UofL Health Orthopedic Total Joint Surgeons focus on improved patient outcomes with robotics
LOUISVILLE — The first time Arthur Malkani, MD, requested a robot in his operating room, he showed his hospital board the difference robotics would make.
Using images of joint replacement operations, he showed not only how the joints were placed, but how much better the outcome could be with robotic assistance.
“I had to present my case, in order to get approval to purchase a total joint robotic system, to the board of the Jewish Hospital in Louisville at that point and explain why we needed a million-dollar robot,” he recalls. “So several years ago, I showed them slides of how we were doing total knee replacements by drilling a hole in the femur and inserting a rod towards the hip to help align the knee implants along with some eyeballing. I told them we can improve the quality of our patients’ lives and actually showed intraoperative pictures of surgeries that I was doing.”
With photos from his latest hip and knee replacements, he explained how he had to make decisions on the best placement of orthopedic implants during surgery, which at times involved some guesswork. Later, he discussed how the robotic platform takes the guesswork out of surgery by providing the surgeon with real time intraoperative data on the individual patient’s unique native hip or knee joint anatomy based on the preoperative 3D CT scan.
“I told the board we can perform surgery with more accuracy and precision to minimize human errors to match the patient’s native anatomy and get better results for our patient,” he says.
And it worked, with a caveat.
“That night I got a call saying, ‘You got your robot, but don’t ever show pictures of surgeries again. One of the members of the board fainted!’” Malkani says.
Doctor/Fixer-Upper
Malkani is the chief of adult reconstruction at UofL Health, focusing on knee and hip replacements. He also serves as the co-director of the Adult Orthopedics Residency Training at Jewish Hospital and as a clinical professor at the University of Louisville School of Medicine. After more than 30 years in the field, he continues to be impressed by the difference technology, especially robotics, has made in improving the clinical results in patients undergoing total joint hip and knee replacement.
Born in Mumbai, India, Malkani came to the U.S. at the age of ten. Told by his mother he should go into healthcare, he knew his passion was in fixing things.
“I had no idea what I wanted to do, but your mother knows you best. She said, ‘You’re better suited for healthcare. Why don’t you become a doctor?’ I said, ‘Okay, mom.’”
“When I was in medical school, there was a patient in a car accident with a broken bone. It was two in the morning, and they were putting a rod in his thigh bone to fix the fracture. I saw that these surgeons were enjoying doing this type of work, and they were happy. I said to myself, I want to be happy at two in the morning if I have to work.”
From there on, Malkani decided to marry his love for fixing things and using his hands to improve his patients’ quality of life.
“I enjoyed orthopedics a lot because you’re fixing something that the patient needs in order to walk; the patient in most cases can get right up and start walking, which is very gratifying,” Malkani says. “My dad was an engineer and always asked me, ‘What can you do to make the house more efficient?’ He always wanted things better and better, so I got into orthopedics, and I wanted to make things better.”
Malkani attended Columbia University in New York, to obtain his BA before receiving his medical degree from Columbia’s College of Physicians and Surgeons. After an orthopedic residency at the University of Connecticut Hartford Hospital, he did a fellowship at the Mayo Clinic for Adult Reconstruction and then another fellowship for orthopedic trauma at the Hospital for Special Surgery (HSS) at Cornell University in New York City.
“Back in the 1990s, we had problems with first-generation polyethylene in total joint replacements due to increased wear debris, which would lead to particles that would destroy the bone, a condition called osteolysis,” he says. “A lot of patients with hip replacements had this massive osteolysis in the hip area when I first started orthopedics. I did my training at the Mayo Clinic on how to reconstruct the hip and knee in cases of bone loss. There was a well-known doctor at HSS in New York City, Dr. David Helfet, who was restoring bone loss in the pelvis in patients with failed hip replacements. So, I did another fellowship with him, mainly focusing on pelvic and acetabular reconstruction, and how to manage those patients.”
Welcome to Kentucky
After Malkani’s fellowship at Cornell, he was recruited by UofL in 1993.
“My first response was, ‘Excuse my ignorance, where’s Kentucky?’” he says. “I grew up in New York City and my folks moved to California, so it was New York or California for most of my career. When I came here, there was no one doing some of the things I was trained to do, so I was busy from day one.”
When he started, most of his work was level one trauma — car accidents, gunshot wounds, the usual. Now, his career focuses on total joint replacements, something that he says he really enjoys. While the majority of his patients are older, some are younger with conditions like juvenile rheumatoid arthritis or trauma injuries from car accidents. The majority of his older patients are female, he says, because they live longer. While his adult patients in their 40s tend to be male, his octogenarian patients tend to be female.
Advancements in robotics help him ensure even better outcomes for his patients. With the assistance of computer technology, which helps put implants in the best position with less trauma. Most patients feel like the joint replacement isn’t even there.
“If the implants are not in the ideal position, the ligaments about the knee may not function properly and you may feel some discomfort while walking. We call this the ‘forgotten joint score.’ A high forgotten joint score means you don’t even know the knee is there. For years, hips had a higher or better forgotten joint score. Hips are a weight-bearing joint, but the knee is a lot more intricate and a lot more involved, and so the forgotten joint score following knee replacement wasn’t as good,” he says. “Now it’s a lot better because of robotic technology. More patients don’t realize they have a knee replacement when doing activities.”
Patient Satisfaction Is Up
Patient satisfaction for the procedure has gone up as well. Historically, he says, orthopedic surgeons used their best judgement to place parts in the idea position for that patient during surgery, but patient satisfaction was approximately 80 percent for total knee replacement, which was not good enough. Now with the introduction of robotics technology, the individual patient’s 3D CT scan of their knee or hip goes into a computer software platform and during the surgery, the surgeon can determine the ideal placement of the implants and use the robotic system to execute their plan precisely. The use of robotic surgery has led to patient satisfaction of approximately 94.6% in total knee replacements, which is a significant improvement from the past.
“Every patient is different in their shape, angles, size — each one is so unique. For 30 years, we were doing the same operation for every patient — the same kind of knee alignment, no matter who they were or what their individual alignment was because we did not have the tools for precise surgery,” he says. “Robotic-assisted surgery can help me determine what the individual alignment is, what the gap numbers are that you have to match to achieve a stable knee replacement… I can get to within millimeters of where the implants need to be.”
Prior to surgery, joint replacement patients need to be medically evaluated to ensure the best outcome. “We have the best preoperative nurses, anesthesia team, and postoperative nurses,” Malkani says, “But we have to medically optimize patients prior to surgery.” That means cardiac clearance, lower BMI, an acceptable A1C level, and other indicators. Some levels can prevent him from scheduling surgery until patients are in the better shape.
“There are a lot of risk factors in some of our patients in Kentucky, but over the past 20 years I’m seeing fewer patients who come in as smokers… but the obesity has skyrocketed.”
About 22 percent of the patients he sees are morbidly obese with a BMI of more than 40, which can impact the surgery’s success. Another 30 percent are on psychotropic medications for conditions like anxiety or depression, which may cause negative interactions with the pain medications. Another 20 percent may be at risk because they live alone, which can negatively affect the surgery’s outcome. All these factors have to be considered so they can ensure the best results for their patients.
“If you’d asked me 10 years ago, ‘Are you going to operate on an 88-year-old patient?’ I’d say, ‘Are you out of your mind?’ Now, it’s a routine, because that 88-year-old patient wants to go to the bathroom on their own without pain; they want to visit the grandkids,” he says.
But the tools used a decade ago also didn’t involve robotics, either, he says. Technology has changed how he does his job now. It allows him to place implants in the best position for that individual patient. This has resulted in improved patient satisfaction following hip and knee replacements.
The move towards robotics is helping to take orthopedics to the next level, he says. The Robotic Total Joint Orthopedic group at University of Louisville Health System has several champions who contributed to the over 6,000 robotic-assisted total joint replacements. These doctors include Dr. Madhu Yakkanti, Dr. Logan Mast, Dr. Rodolfo Zamora, Dr. James Baker, Dr. Andrew Swiergosz, and Dr. Jarod Richards. Each of them has their own stories about how robotic-assisted surgery has improved outcomes in the lives of their patients. With their expertise, they have built a robotic-assisted total joint center at several of the University of Louisville hospitals throughout our community to provide the best care for patients undergoing total joint replacement.
