Scott Webb (Host): Robots are undeniably cool and they're being used in a variety of ways at Salinas Valley Health and today, orthopedic surgeon, Dr. John Bonano, is going to tell us about robotic assisted knee surgery and how patients are benefiting from the use of robots in the operating room.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb.

Doctor, it's nice to have you here today. I always get excited when I get to talk about robots. I don't know if it's just me or if it's all listeners, but I love talking robots. I love talking about robotic assisted surgery, and that's why you're here today. So great to have you here. Great to have your expertise. And just want to maybe start with a foundational sort of question for folks. You know, how does robotic assisted knee replacement differ from traditional knee replacements?

John Bonano, MD: In both robotic and traditional knee replacement surgery, we remove the damaged cartilage and bone and replace it with the metal and plastic implants, with the goal being to straighten out the knee, restoring alignment to the leg, and recreating normal ligament balance so the knee doesn't feel loose or unstable.

In traditional knee replacement, this is done by pinning cutting blocks in place and using a handheld saw to make the bone cuts. Then we assess how the knee feels, and typically we either have to recut the bone or perform ligament releases until the implants fit and the knee feels stable. Robotic assisted knee replacement on the other hand, involves the use of a computer to create a 3D model of the knee that allows us to plan all the cuts ahead of time.

A robotic arm with a saw blade attached is then used to help make precise bone cuts without the use of any cutting blocks resulting in a perfectly balanced knee without having to do any additional soft tissue releases or recuts of the bone.

Scott Webb: Yeah, it's really interesting. You have a great way of explaining things. I'm sort of picturing this in my head and you know, I, I like, hearing that it's more precise maybe, and I'm sure it all leads to better outcomes for patients, faster recovery, all of that, which we'll get to. But just want to get a sense, how long have you been doing these surgeries at Salinas Valley Health?

John Bonano, MD: Robotic assisted knee replacement surgery has been done at Salinas Valley Health for several years, and they actually adopted a new robot that I have been using there since August.

Host: Well do tell. You can't tease like that and not tell us about the robot. I'm familiar with some of the best robots out there, you know, DaVinci and Rosa. Tell us a little bit more about the robot.

John Bonano, MD: Well, the robot I use is called the Mako. I think the main benefits of this technology is the improved precision and accuracy of the bone cuts. So the robotic arm assistance allows for precise bone cuts within one millimeter of the plan and more accurate target alignment within one degree of your plan.

And it also allows for more predictable ligament balancing, which I believe allows you to put in a tighter feeling knee, a more natural feeling knee. And patients may also have less pain and inflammation in the first few days of surgery because less exposure and soft tissue releases are needed.

Host: Yeah. And I want to hear more about from your perspective, you know, oftentimes we do these podcasts and they're really for the listeners. But I want to hear from your perspective, from the actual, you know, surgeon, when we start talking about this robotic system, the Mako, how does it help to ensure precise implant placement, alignment? I know we don't have the benefit of videos and pictures, but do the best you can.

John Bonano, MD: Sure. So I think the precision of the robot, it hinges on creating an accurate computer model of the knee for planning out all the cuts ahead of time, and then accurate execution of that plan by using the robotic arm to help guide the saw blade. So it all starts with patients obtaining a preoperative CT scan, which is then used to create a 3D computer model of the knee.

We can then create a personalized plan for each patient and determine the optimal implant size and position of the implants based on their individual anatomy. Then during surgery, after registering the patient's bone to the computer, we can adjust the plan based on the patient's ligament laxity, which we determine by stressing the medial and lateral ligaments on each side of the knee.

The robotic arm then guides the saw blade to precisely make the bone cuts based on our plan, and the blade is kept precisely in plane, which I think leads to more accurate bone cuts, and it consistently results in a perfectly balanced knee.

Host: Right. Yeah. So let's talk about from the patient's perspective, let's talk about what they can expect. Typical recovery times after a surgery like this, you know, with the robot, compared maybe to the traditional methods.

John Bonano, MD: Well, I think individual recovery times, they definitely vary and are often related to the patient's preoperative function going into surgery. But robotic knee replacement may allow for a slightly faster recovery due to the less soft tissue trauma and ligament releases needed during surgery, and studies have found less inflammation, lower pain scores, and lower opiate use within the first few days after surgery.

In general, patients begin walking with a walker on the same day of surgery and then they progress to a cane while working with physical therapy and usually are walking unassisted when I see them at their six week post-op visit. And by three months, patients are almost fully recovered and have returned to their normal activities.

But I always encourage patients to continue doing their exercises on their own at home because they can continue to build quad strength up to a year after surgery.

Scott Webb: Right. there some specific patients maybe that are better candidates for robotic assisted knee replacement?

John Bonano, MD: Yeah, I think all patients can benefit from robotic assisted knee replacement, but certainly it can be especially beneficial for the more complex cases. So these are patients with ligament instability or altered anatomy due to areas of bone loss or hardware from prior surgeries. Younger and more active patients may also benefit from the precise bone cuts, which allow us to use newer press fit implants and helps us avoid using cement, which has the potential to loosen over time.

Host: Yeah. Because it makes me wonder, are there any potential risks or complications with this type of surgery?

John Bonano, MD: The risks are similar to traditional knee replacement surgery, and these include infection, injury to the soft tissues, instability, stiffness, and wear, or loosening of the implants over time. And these risks are very rare, so it's hard to prove any significant differences when compared to traditional knee replacement surgery.

But in my opinion, I do think there is less soft tissue damage, as we discussed when using the robotic arm to make the bone cuts. And this increased precision has the potential to improve longevity by avoiding any major outliers in alignment, which may lead to loosening over time.

Host: Right. I want to get an idea from you when you sort of look into your crystal ball, if you will, if you have it there at your desk. Where do you see robotic technology or how do you see it evolving in orthopedic surgery over the next few years, decade? I know things seem to be changing so fast and just in hosting these, you know, it's like I'll talk to somebody and then six months later we're talking about some new advancement that just kind of blows your mind. So where do you see things going?

John Bonano, MD: I think robotic technology will continue to rise and updates will make it even more precise and efficient. Applications will be expanded to different procedures, including complex revision surgeries, and artificial intelligence may even help improve the planning and decision making process based on pattern recognition from all the data that's being collected during surgery. Future studies and studies that are just beginning to come out will continue to precisely define our target gaps and alignment goals, all in hopes of improving knee function and patient reported outcomes. It's definitely a, an exciting time to be starting my career when this technology is available.

Host: Yeah, I'm sure that it is. I get excited and I'm just a lay person who's at least not having that surgery anytime soon. So I'm sure it's exciting for you, patients, families, everybody involved. So, thanks for your time. Appreciate it.

John Bonano, MD: Thank you for having me.  

Host: Dr. John Bonano is accepting new patients. Call 831-757-3041 for more information or to schedule an orthopedic appointment.

And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.