Carl Rodgers’ left knee was splayed open like a roast on the butcher’s block.
In fact, there was little about his leg that looked human as it poked out of a tent of blue blankets, draped over him in the operating room at Spotsylvania Regional Medical Center. The flesh that could be seen was sheathed in surgical cloth the color of iodine to keep germs from entering the wound.
Rodgers hadn’t injured himself, per se, but the cartilage in his knee had eroded to the point that bone painfully rubbed against bone. The Spotsylvania County man needed a knee replacement, but after having the same surgery on his right knee in 2015, he had been in no hurry to walk that path again.
“For a long time, I wasn’t ready to do it, after everything I went through with the first one,” the 75-year-old said. “It was quite painful. I had a hard time sleeping and getting comfortable.”
When the left knee deteriorated to the point that it messed up his bowling game, Rodgers knew it was time. He scheduled a total knee replacement with Dr. Greg Tanner on May 28 and was told “they would do something different” this time.
The difference was, a machine with a robotic arm was part of the team that replaced Rodgers’ left knee. Spotsylvania is the only hospital in the Fredericksburg region with the robotic system, which allows for more precise cuts, shorter recovery times and a less invasive procedure—even though doctors still had to yank, push and pull to take out slices of bone from Rodgers’ knee and put in the implant.
All told, the various factors helped Rodgers get back on his feet again quicker. He was walking within hours, discharged the next day and trading his walker for a cane four days after his hospital visit.
By Day 6, when his daughter, Sherrie Bruce, visited from Richmond, Rodgers was telling the physical therapist that his pain had never topped three or four on a scale of 10. He popped up off the couch with such ease that his daughter, a hospital nurse, gasped in amazement.
“Look at him,” she said. “You can’t get up that quickly six days after surgery.”
“I can’t get up that quickly,” said Rodgers’ wife, Judy, “and I didn’t have knee surgery.”
When told the details of Rodgers’ recovery, Tanner smiled and said, “That’s what we like to hear.”
Carl Rodgers was the 12th person at the Spotsylvania hospital to have a joint replaced with the assistance of a Mako robotic arm. The equipment cost more than $1 million, part of Spotsylvania Regional’s $2.5 million investment in robotic surgical systems, said Chief Executive Officer David McKnight.
“When you think about it, just the precision of this is incredible,” McKnight said about the robotic arm that arrived in early May and provides the “extra technology to help guide [the surgeon] and make sure it’s perfect.”
As one video about the system manufactured by Stryker points out, the surgeon doesn’t push a few buttons, then walk out of the room while the robot takes over. Instead, the system helps the surgeon create a knee replacement that’s tailor-made.
Tailor-cut might be a better description.
About a week before the surgery, Rodgers had a CT scan. The Mako system generated a drawing of his knee, which was displayed on a monitor in the operating room.
The image showed Tanner how much he needed to cut to remove the portion of bone diseased by arthritis so he could make room for the implant—which wasn’t one piece, but four separate pieces replicating the kneecap, components of the femur and tibia and the cartilage that serves as a cushion between bones.
There are seven cuts to bones during a total knee replacement, and each one “has its own special science” and can affect other cuts and the surgery outcome, according to the U.S. National Library of Medicine. Traditionally, surgeons have followed an industry standard based on patient averages for the cuts, which are measured in degrees.
For instance, the cut to the upper part of the femur traditionally has been about 3 degrees of external rotation, Tanner said. But as he’s made his cuts, based on the CT scan of the patient’s knee, he’s found the average differs from one person to the next. Sometimes the cut needs to be made at 1 degree and other times 5 degrees.
“This has really shown us … that everybody is a little bit different on those degrees,” Tanner said, adding that more precision means less cutting and pain, as well as a more symmetrical implant, not one that’s lopsided because cuts were too deep or not deep enough. “That really helps the individual, being able to get that balance and not just relying on a number that was published in 1960 and based on an average.”
During his fellowship training in joint replacement, the 31-year-old Tanner did about 500 such surgeries—including about 200 with the Mako system. He’s been the lead surgeon on all the Spotsylvania replacements with the robotic equipment, except for one, when he assisted.
He and two other doctors in the practice, Central Virginia Orthopedics and Sports Medicine, are the only ones using the robotic arm at the Spotsylvania hospital. Others have expressed interest but aren’t credentialed yet, Tanner said.
He has privileges at Mary Washington Hospital and Stafford Hospital, but schedules all joint replacements at Spotsylvania Regional because of the Mako system.
“There are very significant advantages,” Tanner said about the technology that’s “spreading across the country. The major centers and the major joint replacement centers are all doing it, and it’s just now getting to Fredericksburg.”
Each year, doctors replace more than 1 million diseased or damaged joints, including knees, hips, shoulders and ankles, with prosthetic devices designed to simulate natural movement. The American Joint Replacement Registry expects the number to reach 4 million by 2030.
The Mako system has been used in more than 100,000 total and partial knee replacements and hip replacements, according to the manufacturer.
Even though the technology allows more precise cuts than can be done with the naked eye, Tanner said surgeons don’t want to cut any more than necessary.
“Once you’ve cut, you kind of buy that shape,” Tanner said. “It’s kind of like you’re chiseling out a statue, and if you chisel something wrong, you can’t exactly put it back. We want to not make that error, to prevent it before it happens.”
Six days after Rodgers’ surgery, Beth Ashbrook, a physical therapy assistant from Encompass Home Health, knocked on his door.
“Here comes the physical terrorist, I mean therapist,” Rodgers quipped.
He was only partly joking. After the 2015 replacement, his pain was so fierce, he said that PT stood for pure torture instead of physical therapy.
But even after Ashbrook put him through the paces—knee bends and quadriceps sets, leg raises and ankle pumps—she was surprised when he said his pain level was only two out of 10.
“Just a two? That’s amazing,” she said, then joked, “We’ve got more work to do.”
When the two entered the kitchen and Rodgers stood at the sink, doing hamstring curls, only then was it obvious that his affected leg was slightly puffier than the other. It was bruised, too, on the back side, and the incision that ran down his knee was held in place with surgical glue and tape—not the Frankenstein-ish staples Rodgers had in 2015.
During the procedure, surgeons used stitches, which dissolved on their own, to close up the interior wound and to make the chunk of beef look like a knee again.
Tanner also opted against a tourniquet to control blood flow on the leg, saying that can make the operation a little messier, but results in less pain for the patient.
So does bypassing another part of conventional knee replacement: drilling a hole into the femur to attach a guide for use during surgery. That’s not needed with the Mako system because Tanner used probes to mark 40 different spots on Rodgers’ knee that correlated with those on the computer screen.
Tanner checked and double-checked the marks before he made the first cut, just like a carpenter who measures twice and cuts once. The computer drew an outline of the needed cuts, and as Tanner sliced away, green lines on the screen turned white, noting he had finished that area.
The system also established a boundary that prevented Tanner from sawing too deeply.
“If it’s cutting too much bone, it actually stops the saw blade,” he said.
BOWLING AGAIN SOON
Rodgers was told that his recovery would be shorter with the robotic surgery, but even he couldn’t believe the difference—or wait to show the physical therapist assistant all the things he could do.
He literally danced in place until Ashbrook told him to stop showing off before he hurt himself.
“It’s been a piece of cake, it really has,” he said. “It’s been phenomenal.”
His daughter, the nurse, wondered how long he’d even need the cane. He used it for three months after the first knee replacement surgery, but she’s certain he’ll toss it long before then.
He’ll have to, before he goes back to the bowling alley. Rodgers already plans to be part of the September league.