Robots are the future of orthopedics. If a hospital in a state in the USA buys a robot and others don’t, 30 percent of their patients move to where the machine is used for operations. We’ve seen one of such robots in… Ostrów Mazowiecka

Less than 100 kilometers away from Warsaw, on the outskirts of Ostrów Mazowiecka, a city of twenty thousand inhabitants, surrounded by pine trees stands an inconspicuous provincial hospital. This seemingly small center is known for its excellent orthopedic department. You must have heard about it if you have ever had any problems with aching knees. Apart from different orthopedic procedures, the hospital performs over three hundred knee replacement operations a year. The pace hasn’t slackened even after COVID-19 outburst.

What is knee arthroplasty? It’s a surgical procedure performed to replace a destructive joint with an artificial one. Knee problems are very common and are mostly caused by injuries or degenerative changes in the tissue due to old age. They lead to edemas and pain which over time makes it impossible for patients to walk or even bend and straighten their legs. Sometimes they can’t even sleep. When all other treatment methods prove ineffective, implanting an endoprosthesis is the only solution. A joint can be fully or partially replaced. In short, a doctor first prepares soft tissues surrounding the knee joint and trims the femur and the tibia. Then, metal plates are attached to the bone ends between which a prosthesis is implanted. This is how an artificial joint is made.

The operation is far from simple – the knee joint is a very complex organ. The most difficult part is to achieve the so-called prosthesis balance; here, everything depends on surgeon’s tactile skills and experience… but not anymore. Two months ago the hospital in Ostrów Mazowiecka acquired American robot Navio, which provides utmost precision and accuracy in knee replacement operations. It’s the first and so far the only robot of this kind in Poland.

High precision robot with rotary cutter

Our patient has been anesthetized from the waist down, so she is aware of what is going on. However, she can’t see the operating theater because the upper part of her body is separated from the room with a shield. Maybe it’s better this way… On the operating table scrub nurses have been placing trays full of instruments the sight of which might petrify anyone who has never seen an orthopedic procedure before: chisels, hammers, drills and saws… They may be sterile and have all medical certificates but it doesn’t change the fact that they are very similar to the tools we know from a carpenter’s shop, which, given the context, makes us realize how fragile and material the body to be operated on is.

We’re witnessing the eighth robot-assisted operation planned for today. Navio is patiently waiting for everyone to get ready. The machine consists of a robotic arm with a cutter, a high resolution camera and a computer.

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We have seen Navio in action

The operation begins. The operating team includes Assistant Professor Artur Stolarczyk, Head of Traumatology and Orthopedics Department of the Hospital in Ostrów Mazowiecka, Head of Orthopedics and Rehabilitation Clinic of the Medical University of Warsaw, and doctor Krzysztof Modzelewski, Orthopedics and Rehabilitation Clinic of the Medical University of Warsaw. The latter cuts the skin on the knee. With the skin flaps unfolded, doctors have now access to the knee joint. First, the surgeon cuts out osteophytes or calcified parts of bone tissue. With the knee cleared, the robot can begin the mapping procedure. The handle of the machine is fitted with sensors responsible for coordinating the arm movement and for maintaining the contact with the camera. Moving the tip of the robot across the knee generates a 3D image of the knee joint which is displayed on the computer screen hung above the patient’s body. No prior magnetic resonance imaging was necessary; the image is created during the operation. The surgeons are closely analyzing the virtual knee that is being drawn on the screen.

The robot is calculating the exact size of the thigh and shin components and of the implant. The surgeon repeatedly bends and straightens the patient’s leg to find the right prosthesis balance in the virtual space. There it is – the team is now sure that the implant will be placed in the best possible position. The surgeon grabs the handle of the robot. The cutter fixed at the end of the arm cuts through the bone. The whole process is being displayed on the monitor. Everything that needs to be cut out is marked in purple; as the operation goes on, the color changes to green and finally to white. The machine won’t allow for any errors; if the surgeon’s hand slips or presses harder and cut out more tissue than needed, the cutter will retract instantly.

It’s been two hours now, but that’s nothing unusual. To get a good feel of what the robot can do, you need to perform 30 to 40 procedures. It doesn’t matter much for Navio as it never gets tired. Precision, working overtime… Will robots soon be better surgeons than humans?

Flock of patients in Ostrów

Robots are the future of orthopedics. You can clearly see that in the United States. If a hospital in a city buys a robot and others don’t, 30 percent of their patients move to where the machine is used for operations. Navio, which is manufactured by Smith&Nephew, has been available on the American market for three years. Globally, there are 157 robots of this type, including 57 in Europe and 100 in the USA. In America all leading centers have switched to robotics.

The benefits are obvious: since operations are more precise, revision surgery is rarely needed which costs six times more than the original replacement procedure. Patients recover more quickly. In the case of standard knee arthroplasty operations as many as 20 percent of patients are not satisfied with the results. According to manufacturer’s data, only 3 percent of patients operated with the use of Navio report any problems.

For years European specialists used computer navigation, i.e. a technique used by the computer to create personalized plates fixed to the tips of femurs and tibias. It allowed for higher precision but at the same time resulted in longer operation times and in the risk of exposing the wound to infections. It also required a prior computed tomography scan. The advantages of the robot had gone unnoticed until two years ago when it was first imported to Europe. Today, most Navio machines operate in the UK.

Average age of an orthopedist in Poland? 58. Soon we will have nobody to perform operations. I hope that when young specialists discover what Navio and similar solutions can do, they will see our job from a different perspective

Artur Stolarczyk

The first Navio robot came to Poland in July; it’s the only machine of this type in our country and the fourth in Central and Eastern Europe. It was purchased by the provincial hospital in Ostrów Mazowiecka.

“Why did you decide to have the robot in this particular hospital?” I ask Artur Stolarczyk.

“You didn’t expect such a solution in a provincial hospital, did you?” he replis smiling. “We have a great working atmosphere here. I joined the team in 2015. Before that I had worked in Bródnowski Hospital in Warsaw. I had been full of energy, wanted to operate but often heard I had been bringing the hospital into debt as I had been performing too many procedures. That’s why I came here. Here nobody scolds me for trying to do my job. Last year we performed about 350 knee replacement procedures. In such a small hospital, having only one operation theater at our disposal! This year we’re shooting for 450 or maybe even 500 operations. People are coming to our facility from all corners of the country.”

That shouldn’t surprise anyone. If you want to have your knee operated in a public hospital, you must wait for a very long time. This is why desperate patients decide to go to a private clinic; the cost of the knee replacement procedure is 30 thousand zlotys. Here, in Ostrów Mazowiecka, operations are not only financed by the National Health Fund but also performed by a renowned specialist with the use of the most technologically advanced orthopedic robot in the world.

Looking through the window

Provincial hospitals are usually perceived as modest healthcare centers. They sure provide their services to local inhabitants but are never suspected of being too ambitious.

“We certainly can’t complain about having too few orthopedists,” says jokingly hospital director Artur Wnuk. “They are not craftsmen; they are artists who always want to go the extra mile. To keep them motivated and passionate I need to give them a chance to show to the world what they can do. I always compare them to fettered people – you need to free them from their shackles to allow them to spread their wings. Buying the robot was a natural consequence of their talent and determination to further develop their skills. There are hospitals that want to act but their managers are reluctant. There are others where the managers would love to take the initiative but the doctors are hesitant. And finally, there are hospitals where all the staff is full of energy and good intentions but they don’t have enough money. We have everything. And that’s the reason why we’re the only hospital in Poland that has bought Navio.”

“Why have you decided to go for Navio?” I ask.

“It was invented by Artur Stolarczyk, who is keeping up to date with all the latest news on knee and hip arthroplasty, travelling around the world and looking for innovation. He was the first specialist in Poland that started implanting anatomical knee endoprostheses.”

dr Krzysztof Modzelewski and Artur Stolarczyk

“Two years ago I went to a convention to the United States,” recalls Stolarczyk. “When I saw Navio, I realized that there wasn’t any better solution on the market,” he says. “The robot combines computer navigation and precise bone cutting by using a real-time generated knee joint model, a feature that is not available in any other competitive robot.” Choosing the right implant is equally important. Navio is compatible only with the best top-ranked automatic endoprostheses.

“But it costs over 2 million zlotys. How did a public hospital manage to get that much money?” I ask surprised.

“We had some savings and we borrowed the rest,” explains the director. “But it’s not about money. It’s about making a decision. If you are really committed to achieving your goals, you will always find a way to get the money. Take a look outside…” the director continues as he approaches to the window in his office. “Some people will see just a parking lot and trees. Others will see the sky and a plane that has not yet been constructed. That’s what it’s all about. You need a vision of what may be. With this robot, we are setting new standards in the domain of orthopedics. We are creating the orthopedics of the future.”

No more worries

Patients come to consult a hospital specialist after four weeks from the operation. They don’t use a crutch.

“They don’t need a crutch in their armpit because they feel no pain,” says Artur Stolarczyk. “Usually, soft tissues need some time to adapt; sometimes it takes six months and sometimes one year. In the case of our method you don’t have to wait that long because everything is balanced perfectly. We cut off smaller parts of bone, we make lesser alterations to the joint. This means less painkillers, anti-inflammatory and blood circulation improving drugs for patients. But there is one more issue that is not often raised in Poland: patients’ mental condition. Pain reinforces the occurrence of depression and depression lowers the pain threshold. Chronic pain is extremely hard to tackle with. You may have your knee operated but you can still feel the pain – in your head. We’ve confirmed that in the case of our patients antidepressants can be administered for shorter periods of time,” he says.

But Navio is still a novelty. Even in the US it has been used for only two years.

“So far I have performed eleven operations; only when I perform 400, will I be able to really tell you what I think about it. For now I can tell you this: intraoperatively speaking I wouldn’t be able to do it better myself even though I have performed thousands of such operations,” he stresses.

“And one more thing,” doctor Stolarczyk stops me as I was about to leave the room. “Do you know what the average age of a Polish orthopedist is? 58. Soon we will have nobody to perform operations. Why ? Because it’s a really hard job. There are very few people who would want to specialize in it. I hope that when young people discover what Navio and similar solutions can do, they will see our job from a different perspective.

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