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Q&A: Developing complete knee restoration technology

Med-Tech Innovation News spoke to Dr. Andrew Star, medical director, Orthopaedic and Spine Institute, Abington – Jefferson Health and Andrew Ekdahl, worldwide president, joint reconstruction, DePuy Synthes about knee restoration technology and how DePuy’s ATTUNE knee system aims to do just that. 

First, tell us about the ATTUNE Knee system. What is it made of and how does it function?

Andrew Ekdahl: The ATTUNE Knee System is the most contemporary knee system on the market today. It is scientifically designed to more closely match the kinematics of the natural knee, allowing for balanced motion and stability to aid in everyday activities such as bending or going up and down stairs. We took this approach because we believe that functional knee restoration could lead to improved patient satisfaction – which is at the core of our work.

With this great foundation, even more advanced innovations are coming. Early clinical use of our ATTUNE Cementless Fixed Bearing Knee with AFFIXIUM 3DP Technology (ATTUNE AFFIXIUM Knee) and our ATTUNE Medial Stabilized Knee System are underway and will launch in the first half of 2022. The 3D printing process in the ATTUNE AFFIXIUM Knee includes a more precise production method than traditional manufacturing, creating a similar shape to natural bone. This 3D Printed Tibial Base is designed to provide enhanced initial stability with a cruciform keel, scalloped pegs, and diamond surface. The AFFIXIUM 3D Printed Porous structure is designed to mimic bone to promote long term biologic fixation. The ATTUNE Medial Stabilized Knee System incorporates anatomic inserts with a raised medial lip, to provide medial stability and a TruARC LateralPath for natural knee function and the versatility to address a range of surgical philosophies.

Can different materials in ATTUNE’s composition be key to its usage?

AE: The material is key such as what I’ve described with our 3D printing process. However, I think the answer is even broader than just the make-up of the ATTUNE Knee, itself. The key lies in our approach, which is focused on restoring the knee. This comes from the combination of three important elements; (i) the ATTUNE Knee; (ii) the VELYS Robotic-Assisted Solution, which offers accuracy and reproducibility; and (iii) patient-specific techniques, which helps target the restoration of an individual patient's knee function and helps preserve the soft tissue envelope of the knee. Everything works in concert with one another, which is aligned with our expectation that if you have a robotic solution without an advanced implant, you likely won’t have a positive impact on patient satisfaction. 

How is this different from other knee “systems” that we’re accustomed to?

AE: We place a strong emphasis on personalisation. That emphasis is evident in our approach, which is focused on restoring the knee. To succeed in our approach, we combine three elements: (i) the ATTUNE Knee, and our foundation for innovation including several patented technologies such as ATTUNE GRADIUS Curve, GLIDERIGHT Articulation and LOGICLOCK Tibial Base locking mechanism; (ii) the VELYS Robotic-Assisted Solution, which offers accuracy and reproducibility; and (iii) patient-specific techniques, which helps target the restoration of an individual patient's knee function and helps preserve the soft tissue envelope of the knee. This combination is addressing one of the most important trends that we are seeing, the trend towards personalisation. In every aspect of our lives, technology customises our experiences, and when it comes to healthcare, our patients expect the same kind of bespoke approach.

Our goal is to work with a patient’s body to return it to the way it was before the patient needed surgery. We try to do this by:

Dr. Andrew Star: As a surgeon, I would echo what Andrew has said. People focus on technology – because it is new and exciting. But I believe this needs to be associated with a better result…and a better life for patients. The innovative approach in many ways rests on the way we approach soft tissue, which is a new concept for a knee reconstruction company, and then having a robotic solution so that the surgeon can do it in a very personalised way.

It used to be that we would place every implant so that it made the leg perfectly straight, and then cut and adjust the soft tissue; ligaments and tendons, to accommodate the implant.

Research over the past few years has shown that these soft tissues around the knee have grown in such a way that they function better with the bony alignment that has been in place throughout the patient’s life. Now we have learned that we need to respect those soft tissues that have cradled the patient’s knee for 50 or 60-plus years. We no longer try to make everyone’s knee look the same when we know that every patient is different. The goal of this personalised approach is to restore the knee to the way that it was before the patient needed surgery. We believe that adjusting the implant rather than the soft tissues (ligaments and tendons) causes less pain, more rapid recovery, and a better result for patients.

How much does data matter when it comes to new innovations in this area?

AE: Data is key to the new innovations and the personalisation that I was discussing earlier. We find that surgeons want the greatest amount of data when they are in the operating room. Our VELYS Robotic-Assisted Solution uses data to help surgeons place surgical components, evaluate range of motion, fine tune cuts before they make them, and confirm balance in implant positioning. At the same time, the VELYS Insights and Patient Path solution is designed to elevate the orthopaedic care experience, pre-, intra- and post-surgery, giving patients and their health care providers the ability to remain in constant communication with each other about the progress of their recovery. And sharing that data with us will enable us to pursue more and different ways to personalise TKA even more for future surgeries.

It is important to note that not only does data create a personalised patient experience – but it personalises the surgeon’s approach as well. Increased data can help surgeons with speed, accuracy, and predictability – which in turn, can help them manage the mental, physical, and emotional burdens associated with the intensity of being an orthopaedic surgeon.

What further advances can be made?

AE: As I mentioned earlier, we plan to soon launch the ATTUNE Cementless Fixed Bearing Knee with AFFIXIUM 3DP Technology (ATTUNE AFFIXIUM Knee). In addition to meeting the needs of active patients, the ATTUNE AFFIXIUM Knee offers enhanced initial stability along with flexibility and efficiency in the operating room by accommodating patient-specific surgical techniques while working seamlessly with the VELYS Robotic-Assisted Solution and INTUITION Instruments. For surgeons, it can provide enhanced capabilities, including the ability to precisely control the implant position and fit for each patient, while adding the precision and reliability of robotically guided bone cuts. Reduced operating room time is an additional feature, because of the cementless procedure.

In terms of patient specific technologies, how much has the landscape changed in recent years?

AS: I’ve been a robotic solution and technology surgeon for over 20 years. Technology-wise, we started out with minimally invasive surgeries, working with computers to better position the implant, which allowed us to make smaller incisions and obtain better pictures. But during that time, while we made progress in robotics, patient satisfaction never really improved. It is ironic that we have known for many years that bony injuries such as fractures around the knee usually heal more quickly than ligament tears. Until recently, we did not fully understand the importance of preserving the soft tissue envelope that surrounds the knee. The bones and cartilage are important as anyone who has arthritis knows, but what makes a knee really function are the soft tissues that surround it.

Taking that into consideration, our approach now is focused on personalising TKA through patient specific alignment which is an idea that has been brewing in orthopaedics for many years but now perfected by DePuy Synthes – and now I am seeing signs that success rates are exceeding 90%.

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