Procedures

Following experience with Robodoc at HC International Hospital (Marbella) in the 1990s, the CORI (Smith & Nephew) Robotic-assisted Surgical Joint Replacement System is the latest technology in Joint Replacement Surgery at HC.

CORI is an image free system which does not require CT images or virtual implant positioning before surgery. With CORI the I can 'register' the dynamic leg and knee anatomy at the start of your operation. The system allows for precise recognition of individual knee shape, ligament length and tension and leg alignment.

Before the actual knee bones are cut I can virtually determine implant size, implant position in all six planes-of-freedom along with ligament laxity/tension.

The removal of residual cartilage and bone close to the joint is then carried out with the hand-held robotics-guided CORI burr. I can follow this on the monitor.

Excess bone removal is prevented by the super-fast retraction of the burr tip in a fraction of a second. The result is a super flat bone surface that is cut within an error margin of less than 0.1 mm.

The bone preparation of the femur and tibia is followed by trial implantation, using a mock implant with an identical shape and size to the definitive implants followed by cementation of the definitive implants. A standard set of conventional mechanical instruments will always be available as back-up.

A more precise implant position resulting in exact ligament balance throughout the range of knee motion is thus achieved.

Similarly, increases in accuracy of patella-femoral joint position are achieved. The patella-femoral joint remains a typical problem area in conventional mechanical knee replacement surgery and accounts for a proportion of the reported patient dissatisfaction.

Leg alignment can be predicted at the planning stage and modified if required.

The more accurately balanced knee and aligned leg is expected to bring about improved final function of the knee, reduced residual symptoms, enhanced reliability with activities such as mounting stairs etc.

Navigation and Robotic-assisted joint replacement systems are especially relevant and advantageous for patients with unusual leg alignment or knee anatomy.

Most often the inside of the knee is arthritic with bone grinding on bone. Due to the loss of cartilage on the inside, the leg becomes bowed and increased weight is transferred to the arthritic side of the knee. The result is ever-increasing pain with activity. Partial Knee Replacement aims at replacing only the arthritic, worn out part of the knee.

An inside (medial) partial knee replacement can typically be carried out through a small incision on the front of the knee just to the inside of the kneecap tendon. The surgery is carried out under regional anaesthetic with sedation.

Bilateral Surgery
Many patients have arthritis in the inside of both knees. Consequently, Dr. Boerger often replaces both knees during the same operation. The rational for bilateral surgery is the need for only one hospital admission, one anaesthetic, one exposure to surgery related risk factors and one period of rehabilitation and inconvenience. Patients suitable for partial knee replacement typically have mobile knees.

Assessment
Dr. Boerger assesses all potential knee replacement patients carefully. This includes a functional review including gait assessment, lower limb joint examination and extended radiological investigation.

Typical x-ray images taken include both knees standing frontal view, Rosenberg view, true lateral view in flexion with calibration marker, axial patella view and a patient-led valgus stress view.

Following validated inclusion criteria Dr. Thomas Boerger can formulate an indication for partial knee replacement. All joint replacement patients undergo a pre-operative review with Dr. Boerger’s Nurse Assistant, Tanya Keble, and a review with a HC International Hospital anaesthetist.

Preparation
Basic investigations include screening blood tests and ECG. To minimize the risk of a peri-operative joint infection multiple skin and nose swabs are taken for MRSA and MSSA. Patients testing positive for skin colonisation are treated with body washes and ointment at home until repeated test results are negative.

If deemed necessary, a medical review will be scheduled. If cardiac problems are known or anticipated, a full cardiac work-up including stress test and heart catheterisation can be performed at HC International Hospital.

Smokers must stop for 6 weeks before and after surgery in order to minimise the risks of post-operative complications such as cardio-respiratory problems, delayed wound healing, infection, and blood clot formation.

Most patients are maintained on anti-coagulation for 4 weeks after surgery.

Before surgery, patients will meet a physiotherapist at HC International Hospital, and will be taught how to use crutches, transfer in and out of bed safely and perform basic daily tasks.

Advantages of Partial Knee Replacement over Total Knee Replacement:
- Less invasive operation with less trauma to knee and patient
- Smaller incisions and less post-operative pain often resulting in quicker and easier rehabilitation
- Avoidance of bone cement with even better bone preservation
- Lower risk of significant complications, e.g. stroke, cardio-pulmonary failure and infection
- Minimal blood loss making blood transfusions very unlikely
- The possibility to perform the surgery in older or less fit patients that are no longer suitable for total knee replacement
- The option of bilateral partial knee replacement in one procedure requiring only one pre-assessment, one anaesthetic intervention, one post-operative period of pain and discomfort, full rehabilitative effort not hindered by the remaining arthritic knee
- Normal knee biomechanics leading to a more natural knee feel and higher patient satisfaction
- Lower treatment costs

Partial Knee Replacement Prosthesis
The Oxford partial knee has been used clinically for over 45 years and is by now the most used partial knee. The Oxford design philosophy remains unchanged though minor changes to implant and instrumentation have taken place over the years. Implant survival rates have been documented with 94% at 15 years and 91% at 20 years. The implant survival rates equal those of total knee replacement.

Dr Boerger has used the Oxford partial knee prosthesis for over 18 years. He has a large and growing case series with up to 100 Oxford procedures per year. The Oxford knee can be implanted with or without cement, depending on preference and bone quality. Cementless implantation is likely to improve the long-term bone fixation and can potentially further extend the life expectancy of the Oxford partial knee.

Dr Boerger has used non-cemented implants almost exclusively in the last 6 years.

A Partial Knee Replacement typically requires a hospital stay of 2 or 3 nights. The time in hospital is used for pain relief and physiotherapy. Some patients, however, feel well enough to go home the same day. Patients are able to get up on the day of surgery.

Procedures are performed in a private hospital with very comfortable private rooms. From your initial consultation, a comprehensive, personalised treatment plan is created. In preparation for your recovery, there is a specific pain-relief plan established for you to minimise post-operative discomfort.

Rehabilitation is of course an essential part of your patient treatment plan. In addition to our expert physiotherapy offered during your hospital stay and as an out-patient, we are also happy to liaise with your preferred rehabilitation professional to design a recovery plan.

Rehabilitation for a Partial Knee Replacement is quicker than with Total Knee Replacement. Most patients walk without crutches at around 4 weeks, sometimes earlier. It takes 6 - 12 months until the partially replaced knee fully ‘settles’ and patients are able to forget about their previously painful knee.

Rehabilitation of partially replaced knees is more about walking short distances and controlling swelling, rather than physiotherapy and range of motion exercises. Dr. Boerger’s advice is to avoid knee exercises after Partial Knee Replacement in favour of frequent short walks.

Partial Knee Replacement surgery is less invasive than a Total Knee Replacement so you can expect a lower risk of complications, and a faster recovery. Patient satisfaction for Partial Knee Replacement is very high.

The old established belief that Partial Knee Replacement is an interim procedure for younger patients until Total Knee Replacement becomes necessary is not correct.

Partial Knee Replacement is also very effective in older patients with single compartment arthritis. Clinical review studies for the ‘Oxford’ Partial Knee Replacement demonstrated functional survival for over 20 years in some patients. Individual implant survival can be shorter.

However, it is important to remember that even the best knee replacement cannot ‘turn back the clock’. A replaced knee is never as good as a normal healthy knee.

Complications
Recognised risks and complications after knee replacement surgery include post-operative pain, bruising, swelling, bleeding, knee stiffness, reduced sensation near the wound, infection, deep vein thrombosis with potential progression to pulmonary embolism, implant mal-position, implant wear and failure and the need for further surgery in the future.

General risks include cardio-pulmonary collapse and stroke. Partial Knee Replacement surgery is smaller than Total Knee Replacement surgery. The recognised incidence of complications for Partial Knee Replacement surgery is lower than that for Total Knee Replacement surgery. Dr. Thomas Boerger uses operative techniques that minimise risks and complications, including surgery performed in a laminar flow theatre and the use of astronaut-style helmets with all joint replacement surgery.

Aftercare
Dr. Boerger personally follows up all his patients at 2 weeks, 6 weeks, 6 months and 1 year with new x-rays.