Location, location, location: Its importance can't be underestimated for
"The precision you can get with this preplanning with a 3-D model is important for range of motion," he said. "What I hope to see is that this is another technique to improve the long-term functional results for patients."
Carter first used the technique in December and expects that it will drive up the demand for partial knee replacements over full knee operations. Of 600,000 knee replacements performed nationally in 2008, only 50,000 were partial, he said, attributing the discrepancy to patients' fears that a partial might not last as long. "It's dependent on the position," he said, emphasizing the super-precision of the robotic-arm assisted surgery.
It's not the first procedure that Carter, who practices with Hampton Roads Orthopaedics and Sports Medicine, has pioneered in Hampton Roads. In 2006 he introduced the "jiffy hip" procedure for
"A lot pooh-poohed it, but patients wanted it and now they've all switched," he said. He has since taught his techniques to surgeons from the University of Virginia, Emory and Dartmouth. "It's neat. We teach the teachers," he added. While the "jiffy hip" took three years to catch on locally, other surgeons in Hampton Roads have already adopted MAKOplasty. "They're not going to get behind the eight ball on this one," Carter said.
Prepping for surgery
Back in November, the osteoarthritis in his right knee was causing Larry Ritch so much pain that he had to stop working.
"It was like bone on bone when I moved at a certain angle, a deadening sharp pain," he said.
For almost four years the 56-year-old
He criss-crossed the region, from Chesapeake to Virginia Beach to the Peninsula, looking for appropriate treatment that would bring lasting pain relief and restore mobility. His wife, Cindy, had heard Carter talk about his techniques for joint replacement at a retirement home in Norfolk. They made an appointment in December and started the necessary preparation process for the surgery, following instructions to the letter. Larry attended the surgery class that explained the procedure and what to expect in rehab. He cited the advantages of sparing the ligaments, the precision from the CT scan and presurgery modeling, and the possibility of full knee replacement later, if needed. He quit smoking and lost 15 pounds.
On the Thursday of the surgery, scheduled for 9:30 a.m., Larry and Cindy arrived at Mary Immaculate at 6:30 a.m. As the wait stretched to 11 a.m., they whiled away the time with a steady stream of jokes and banter, mixed with concerns about Larry's general health and ability to return to work. He owns a trucking company but also drives, which he hasn't been able to do since Thanksgiving.
In the OR
For 75 minutes, the surgical team proceeded to illustrate the focus and coordination involved in resurfacing a knee for an implant, a curious mix of high-tech wizardry, delicate calculations, trained know-how and sheer strength.
At 11:38 a.m.: The team called a "timeout" to go over the patient information and the procedure. Seven people — including Carter, surgical techs, nurses, a physician's assistant, and a MAKOplasty specialist — huddled around Ritch's draped form. The information from the earlier CT scan and plan for the sizing and positioning of the implant were fed into the computer. Larry's leg was fitted into a boot with a small metal ball on the end, ready to slide into a fixed track to keep it stable and aligned.
At 11:41 a.m.: Carter made the incision across the length of the knee. An assistant used a fork-like instrument to retract the tissue to allow access to the joint. Steam rose from the cauterization used to minimize the bleeding. As the surgeon drilled, a fine spray of spittle-like fragments flew up in an arc, and he paused occasionally to pick out bits and pieces of detritus.
As part of the MAKOplasty procedure, Carter then inserted "guides," metal rods known as bone pins, to attach "arrays," black antenna-shaped reflective surfaces, one to the tibia and another to the femur, to interact with the infrared camera. Using triangulation from the two fixed points above and below the knee, Carter held a green probe with similar reflective surfaces to touch landmarks on the upper and lower bones to give the computer the general orientation of the patient. "It takes a little bit longer — about 15 minutes. We have to map the knee and get the computer registered," Carter explained afterwards.
A trio of helpers bent Larry's leg up and down as the infrared reader sent data points to match up with the CT image, rotating in 3D on the computer's divided screen. "Flip it so I can see it," Carter instructed. "You really need to have a good working relationship with the person running the computer. You have to confer, make sure you're on the same page," he said later. Though most of the decision-making took place in the pre-op planning, the system allowed for several minor adjustments during the operation.
Then, over the course of about 4 minutes as Carter touched multiple points on the bones with a probe, the blue dots on the screen turned white as the data matched up, like hitting targets in a computer game. The team moved the leg through the full range of motion. "It's loose on deflexion. We want to take a couple of cartilage points," Carter said in response. As he brought the robotic arm up to the operating table, an assistant placed a large tool box with the different size color-coded temporary implants at the ready. Carter registered the "burr," the tip used for sculpting the bone instead of sawing, and the computer gave the familiar electronic "da-ding" sound on completion of the process.
At 12:16 p.m.: After conducting another placement check, the actual modification of the bones started. The surgeon used two hands to hold the robotic wand as he eased it back and forth, glancing back and forth from the knee to the screen as the green area changed to the desired white. "If it's off by more than one millimeter, it cuts off," said the MAKO computer operator. A couple of red marks on the screen showed where Carter approached the allowable 1/2 millimeter margin on a couple of occasions.
At 12:37 p.m.: Carter has completed the preparation of the femur and tibia and drilled out a groove for the placement of the implant. "The technique is far and away the most critical rather than the metal," said Carter. "There's no data that would suggest one implant is better than another." He called for the #7 — the standard sizes run from one to eight — and then hammered in a trial one to test its placement and the knee's range of motion.
After its removal, an assistant mixed up some powerful-smelling "cement," and the permanent parts were unsealed from their delivery boxes and hammered into place.
At 12:56 p.m.: Carter's work on his 10th MAKOplasty partial knee replacement surgery was done.
A few days later
In rehab at Lake Taylor Hospital in Norfolk, Larry Ritch spends four hours a day on a knee machine (bending and straightening) and has physical therapy twice a day. He's walking with a walker and moving from the bed to a chair. "Every day he's a little better," said Cindy, citing the first 48 hours as the toughest. "I'm hanging in there. Everything is going as planned," Larry confirmed.
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With Video by Joe Fudge
What is MAKOplasty?