@wcbstv—June 17, 2009
wcbstv: It's Dr. Max in the OR at Hospital for Special Surgery. Dr Steve Haas about to begin a total knee replacement on 55 year-old woman.
wcbstv: OR a beehive of activity. Anesthesia sedated patient and put in an epidural... no general anesthesia.
wcbstv: At same time nurse prepping her right leg... scrubbing with betadine antiseptic... the orange color people emerge from surgery with.
wcbstv: They also put a tourniquet on her leg so that there won't be much blood to get in the way during the replacement itself.
wcbstv: Tourniquet isn't inflated or tightened until the surgery actually starts.
wcbstv: Techs are preparing sterile instruments, tools and the implant itself. Nurses keeping track of meds, equipment etc.
wcbstv: All going on at same time. It's like a football team where everybody knows what they're supposed to be doing.
wcbstv: Drs are now inflating the tourniquet. Then they "milk" the blood out of the leg to minimize blood loss.
wcbstv: Surgeons, techs wear space helmets with a large plastic face shields. That keeps blood and bone bits away from the face but more importantly it isolates surgeons and techs minimizing the risk for infection. Infections in joint replacements can be very difficult to treat.
wcbstv: And often require removal of the implant. Dr. Haas has made incision into knee. Can now see the bones on knee.
wcbstv: Rather than cutting muscle and large tendon from the thigh (patellar tendon) he separates the muscle fibers and pulls the kneecap to side.
wcbstv: That's much less traumatic and makes recovery afterwards much easier and faster. It's called MIS (minimally invasive surgery).
wcbstv: That requires special instruments which Haas helped develop, because the space he's working in is much smaller than conventional replacement.
wcbstv: Dr. Haas using a replacement that has very smooth, hard ceramic on the thigh bone side of knee and special polyethylene plastic on tibia.
wcbstv: There's also a webcast going on at same time so dr is narrating technical details of the surgery. He's now sawing off the top of the tibia.
wcbstv: That's where plastic surface will rest with a sort of metal "keel" that goes into tibia to keep it in place. next: taking off end of femur.
wcbstv: That allows the new ceramic surface to be placed. Dr. now determining what size implant components he'll use. Tries various "dummy" implants.
wcbstv: Alignment of the implants is also critical to a successful replacement. So he takes care to get size and placement just right.
wcbstv: Special instruments help with alignment. I can see the plastic film that covers the skin of her knee, keeping skin germs out of the incision.
wcbstv: For those not used to it, a knee replacement is like a carpentry shop. Hammering, drilling, sawing... but all with great precision of course.
wcbstv: Knee that Dr. Haas is using is "female" in that the size is smaller than those used in men. Each component of the new knee is customized.
wcbstv: He'll also "replace" the kneecap. Actually just puts a new artificial surface on the inside of kneecap so it will ride smoothly on new knee.
wcbstv: Dr. carefully testing the flex and extension of the knee to make sure size of implants will give the right "feel" and range of motion later.
wcbstv: You can watch my story on this knee replacement tomorrow morning at 5:45AM and again at 6:45AM on CBS2 News.
wcbstv: Patient only 55 years-old which used to be considered too young to have knee replacement but replacements now last so long, at least 20-25 years.
wcbstv: That means younger patients don't have to live in pain because their new knee should last their lifetime. This patient moved to new ranch home.
wcbstv: Because she could no longer climb or descend stairs in her old home. She was told to wait for new knee but now wants her life back.
wcbstv: She told me she could no longer do the things she loved: walk, garden, dance. She'll be able to now.
wcbstv: Knee replacements are also safe in older patients. Safer anesthesia (no general) and control of complications means people in 80's and even 90's.
wcbstv: Can have knee replacements as well. Less invasive approach also means recovery is much quicker so patient can get back to normal activities.
wcbstv: Much sooner.
wcbstv: Dr. Haas cementing the implant components in place. Essentially medical grade epoxy mixed at table and put on the implant like a green putty.
wcbstv: Smells just like epoxy you'd use in a workshop. It cures in a few minutes when its placed in the bone.
wcbstv: The epoxy cement sometimes mixed with antibiotics to reduce risk of infection in hi-risk patients. Cement gets placed on bone and on implant.
wcbstv: Still amazed at how little blood there is in this procedure. Thanks to tourniquet of course but for large incision, it's almost bloodless.
wcbstv: Incision in minimally invasive procedure is about a third as long as in conventional knee replacement, so easier to heal the skin too.
wcbstv: Waiting for cement to set before suturing skin. Procedure normally takes less than an hour! But webcast explanations for surgeons watching
wcbstv: is slowing procedure a bit. Instrument table crowded with sterile knee sizing-components of many sizes... that way only the precise size
wcbstv: of the final implants are actually "opened" and used. The metal, ceramic and plastic used in implants too expensive to use them for sizing
wcbstv: right after skin is sutured patient will have knee placed in CPM machine which slowly, continuously moves the knee right after surgery
wcbstv: drs now know that the sooner you move the knee, the quicker the recovery and the greater the range of motion the patient eventually gets
wcbstv: in fact, she'll be up and walking a little tomorrow! The sooner she moves, the fewer the complications and the faster the recovery
wcbstv: turns out the plastic component. Dr. Haas used has a plastic stem or keel rather than the metal one in other replacements.
wcbstv: Dr. Haas now checking knee alignment, tracking of kneecap with all components in place. Knee actually a complex joint, not a straight hinge
wcbstv: Dr. Haas now suturing skin. Patient will be awake in short while. Epidural stays in for a couple days. Just enough to allow her to walk
wcbstv: without pain but not so much as to keep her from using her muscles. Patient will be out of hospital in 3 days. Do home physical therapy for
wcbstv: week or two and then will do outpatient physical therapy 3 times/week for a couple months. She can actually go back to work as soon as 2 weeks
wcbstv: although most patients don't go back for 4-6 weeks.
wcbstv: Patient going to recovery shortly... See rest of the story tomorrow morning...
Learn more about Dr. Max Gomez's tweeting from the OR by reading Healthwatch: Next Generation Knees & Twitter.
Follow us on Twitter @hspecialsurgery for future news updates.