Arthur Frederick, 71, said he hadn’t been in the crushing pain before he needed knee replacement surgery. His legs were tired and he woke up feeling like his left kneecap was “dislocating”.
In the fall of 2020, things got significantly worse for the Leroy resident.
“One morning I rolled out of bed and my left leg was twisted. I could barely walk for almost a month,” Frederick said.
An appointment with Dr. Nolan Malthesen and an X-ray technician revealed that his knees had been affected. They were much worse than Frederick thought, and he wondered why. He worked as an electrical engineer at Motorola, so his knees hardly got beat.
Malthesen said many factors can put a strain on the knees: excessive impact, such as that possibly produced when running; the height of a person; long-standing injury; and natural alignment, being bow legs or knock knees.
“The end result is arthritis,” Malthesen said. “The problem may start with injury or long-term use, but it causes the cartilage to wear down.”
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Knee replacement is not state of the art. The first knee replacement surgery was performed in 1968. More than 600,000 people undergo the procedure in the United States each year. But a robotic surgery system called Robotic Surgical Assistant has become a valuable addition to Ascension Providence.
An explainer provided by the hospital system indicates that ROSA causes less bleeding and less scarring, and provides more precision in “tuning” the knee, which can shorten recovery and physiotherapy times. Frederick enrolled in ROSA and was able to have surgeries to replace both knees two months apart.
Frederick said he accepted the surgery with mixed emotions. His father received new knees in the 1980s, “and he was never happy with them”.
Steroid injections gave Frederick temporary relief, and the COVID-19 pandemic put elective surgery on hold for several months. Frederick stayed in touch with his doctor, who persuaded him to go robotic when conditions allowed.
“My knees are pretty much fully serviceable now,” Frederick said over the phone. “I’m still building muscle. I can’t kneel on it. There’s popping when I’m tired, but I think it’s going to subside.”
Malthesen said that despite the name, the robots never touch anything sharp during surgery. Instead, patient-specific data points are fed into a computer, allowing the surgeon to make precise cuts, including saw cuts down to the bone.
Surgeons traditionally rely on experience and feel when ready to proceed. The computer provides objective feedback on the positioning of the knee relative to the cutting instrument and the surgeon’s hand, Malthesen said.
But the surgeon does not play second fiddle to the machine. Malthesen said the computer is only as good as the information that is entered into it.
If everything goes as planned, the new knee can more easily resume its functions. There is less scar tissue. The implanted knee does not “fight” against its environment. There is less chance of the implant being too tight or too loose, a condition usually corrected by therapy, but still not ideal.
“As always, we’re trying to perform better and more reproducible surgeries, with fewer outliers,” Malthesen said. “I know that attempts to implement robotics in knee and hip replacement surgery have been going on for a long time. I’m not sure why it’s more applicable now, but there are advances in medicine all the time. If you have the ability to use them, use them.”
Robot-assisted hip replacement surgery still has some way to go, even as it progresses towards national acceptance. Patients rely more on soft tissue to maintain balance after hip replacement surgery, Malthesen said.
He said Ascension Providence gets knee implants from Zimmer Biomet, which also provides the robotic system he uses. He said the robot was on loan at the moment, but could not speak about future financial arrangements.
Using robotics can add 10 to 15 minutes to a knee replacement, although Malthesen said he saves time with repetition. The procedure takes less than 90 minutes and Ascension Providence can take an inpatient or outpatient approach. Malthesen said patients using robotics don’t pay higher medical bills, and rehabilitation time is reduced if affected. Rehabilitation usually lasts six weeks, and driving with a knee implant is possible in four weeks.
Total knee replacement costs $35,000 or more, according to health.costhelper.com. Frederick benefits from health insurance, while his wife receives retirement benefits as a former teacher. He said he was pleasantly surprised by his total bill, having paid less than $1,000 per knee.
The timing of knee replacement surgery can be difficult.
Cut too early in life, and the patient may require another medical intervention down the road, Malthesen said. Wait too long and the patient suffers.
“There are people who put up with things for years and years. The deformity is so bad, the pain is so bad… you’d be amazed,” he said.
He said he and other Ascension Providence doctors shared the workload, performing knee replacements on Mondays, Wednesdays and Fridays. The operation begins as early as possible in the day and requires the presence of a surgical team and an anesthesiologist, Malthesen.
Down the road, Baylor Scott & White Hillcrest performed its first robot-assisted orthopedic surgery in April 2021 and has performed more than 400 such procedures since then, spokeswoman Megan Snipes in an email message.