Saturday, January 12, 2002

Better new-joint surgery done here

By Peggy O'Farrell
The Cincinnati Enquirer

        Surgeons at Jewish Hospital are the first in the nation to use imaging technology for total knee replacement surgery.

At the Jewish Hospital Friday, Dr. Michael Swank demonstrates an implant technology that uses guided imaging. Behind him is physician assistant Jon Grote.
(Brandi Stafford photo)
| ZOOM |
        The technology could mean fewer second surgeries for the quarter-million Americans who get knee replacements every year, orthopedic surgeon Michael Swank said Friday.

        It gives surgeons a three-dimensional view of the patient from the hip to the ankle — a big improvement, since, without the VectorVision technology, they can see only the surface of the knee itself, Dr. Swank said.

        The improved view lets doctors more accurately place and align knee implants, which means the implants last longer and patients have better quality of life.

        “We've had nothing even close to this in the past,” Dr. Swank said.

        Dr. Swank performed the image-guided total knee replacement on Ann Taulbee, 84, of Silverton in mid-December, and he's performed two more procedures using the technology since then. And on Monday, he'll do the nation's first image-guided hip replacement.

  • A CT (computerized tomography) scan of the patient's knee is taken to give surgeons a 3-D image of the knee.
  • The CT scan is fed into the VectorVision system. Based on anatomical information contained in the scan, the system suggests which joint implant is the best match for the patient, and maps out a plan for placement of the implant. This step can be performed before or during the surgery.
  • In the operating room, markers are placed on the patient's bones and a special probe is used to highlight those markers on the VectorVision screen, which is set up at the patient's bedside. Using the markers, the surgeon can compare the alignment of the patient's bones and the placement of incisions and implants with the CT scan and the previously drawn surgical plan.
        Mrs. Taulbee is walking with a cane and has four more weeks of physical therapy before she's fully recovered. She had suffered with knee pain for more than 10 years before the surgery, and it was “becoming unbearable.” Her right knee was replaced in December, and her left knee needs to be replaced.

        Image-guiding has been used for several years for brain and spine surgery and ear, nose and throat procedures. The VectorVision technology has been used for orthopedic procedures in Europe for about 1 1/2 years.

        The Food and Drug Administration approved its application for orthopedic procedures in this country in August, said Marc Mackey, business development manager for BrainLAB, the German company that manufactures VectorVision.

        “A few more” U.S. hospitals will begin using the technology for orthopedics this year, Mr. Mackey said Friday.

        Image-guiding doesn't change how surgeons replace knee joints, Dr. Swank said Friday. But it does make the procedure more accurate.

        Orthopedic surgeons use the same rule as carpenters, Dr. Swank said: Measure twice, cut once. “Once bone is cut, you can't un-cut it,” he said. Better cuts mean a better fit — whether the job is a new wall or a new knee.

        In conventional knee replacement, there's an acceptable margin of error of 2 millimeters in making incisions in bone and placing the knee implant — the replacement joint.

        In image-guided surgery, that margin can be trimmed to eight-tenths of a millimeter.

        Trimming that millimeter can add years of life to the implant. Ninety percent of knee implants last 20 years, said Paul Lotke, an orthopedic surgeon with the University of Pennsylvania Health System in Philadelphia.

        But an implant that's off by a few degrees will need to be replaced within five to eight years, Dr. Swank said.

        If the leg bones aren't properly aligned when the implant is placed, the misalignment puts additional strain on the new joint — the same reason the patient's original knee failed — and the implant has to be replaced. Image-guided surgery helps surgeons get the bones aligned as well as possible.

        Nationally, about 267,000 total knee replacements are performed every year. That number rises every year, and Dr. Swank and other experts expect a further increase for many reasons:

        • Baby boomers are getting older, but they expect to remain active, so more are demanding knee replacements.

        • Americans are getting fatter. Excess weight puts strain on knees, so those extra pounds will translate into knee replacements.

        • Women are becoming more active in sports and fitness, and they're more prone to knee injuries. So in about 15 years, lots of active women will need knee re placement surgery.

        • Americans are living longer, which means their knee implants are wearing out and need to be replaced.

        Knee replacement surgery is a highly effective procedure that adds years to patients' lives, Dr. Lotke said. But he cautions that enthusiasm for image-guided knee replacement surgery “might be commercially driven.”

        The technology is new enough for orthopedic procedures that there are no data to show how effective it is, Dr. Lotke pointed out, and technology is no substitute for a surgeon's skill.

        Dr. Swank said the technology just provides surgeons with a better guide. And the imaging technology used is already standard in most modern operating rooms, he said, so the additional cost to patients is minimal.


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