NAVIO Robotic-assisted Total Knee Replacement

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DISCLAIMER: Always speak to your doctor about the options that would be available to you, as
well as the benefits and risks associated with each option. The information in this brochure is
for general educational purposes only, and should not be construed as medical advice, or as
statements relating to suitability of any implant for you, or for other persons.

Introduction
Learning that you have knee pain caused by osteoarthritis can be discouraging. Fortunately,
there are many treatment options to address knee pain. If surgery is the best option, you should
be happy to know your surgeon uses the latest technology and products from Smith & Nephew,
a 150-yearold medical technology company that was recently ranked by Forbes Magazine as one
of the most innovative companies in the world.1 After reading this brochure, we hope that you
have a better understanding of knee pain caused by osteoarthritis, the current treatment options,
and what to expect from a NAVIO™ robotics-assisted total knee replacement procedure.

The knee and osteoarthritis

The knee is a hinge-like joint made up of the femur (thigh bone), tibia (shin bone), and patella (kneecap)
held together by muscles, ligaments, and other important soft tissue. In between the knee is a natural
cushioning called meniscus that is made up of cartilage. This material provides shock absorption during
weight-bearing activities such as walking or climbing stairs. Through wear and tear, the cartilage in your
knee can break down causing a disease known as osteoarthritis. Age, obesity, heredity, gender, and
other factors can lead to the progression of osteoarthritis. Common symptoms include pain, swelling and
stiffness.

Healthy knee Knee with advanced osteoarthritis

Image provided by the American Academy of Orthopaedic Surgeons (AAOS) with consent

1 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

Treatment for knee osteoarthritis
While there is no cure for osteoarthritis, there are multiple treatment options to manage the pain
and potentially delay progression of the disease. options o consider for treatment of the arthritic

knee:
Non-surgical treatment options

Listed below are several non-operative, conservative options to consider for treatment of the
arthritic knee:

1. Lifestyle modification: Losing weight, avoiding aggravating activities, modifying exercise to low
impact activities only
2. Exercises: Specifically prescribed exercises to improve strength and flexibility without
exacerbating your pain
3. Anti-inflammatory medications: Designed to decrease swelling in the joint, and provide
temporary pain relief
4. Powerful anti-inflammatory agents injected directly into the joint (specific medicines injected into
the knee)
5. Joint fluid therapy: A series of injections directly into your knee, designed to improve
lubrication in the joint
6. Dietary supplements
7. Bracing: used to provide external stability to the knee

Surgical treatment options

1. Arthroscopic surgery: a minimally invasive procedure that removes debris or repairs torn
cartilage. Arthroscopic surgery is often less effective as osteoarthritis progresses.
2. Partial knee replacement: procedure that replaces the single damaged compartment of the
knee, generally reserved for early to mid-stage osteoarthritis.
3. Total knee replacement surgery: a procedure that replaces all three compartments
of the knee, when osteoarthritis reaches an advanced stage.

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Reasons for knee replacement surgery

Total knee replacement surgery is considered when all other conservative measures have failed to
provide successful intervention, and may be performed for the following reasons:

1. To relieve pain
2. To improve joint stability
3. To improve alignment and correct bone deformity
4. To maximise quality of life
5. To optimise activities of daily living

Total knee replacement

Total knee replacement surgery is a common procedure performed on more than 600,000 people
worldwide each year. More than 90% of people who undergo total knee replacement experience
dramatic relief in knee pain and are better able to perform common activities.2

Total knee replacement removes and replaces the damaged knee surface with an implant. A total
knee implant is made up of three parts: a metal femoral component (thigh bone), a metal tibial
component (shin bone), and a plastic space that is placed in between. A fourth component made of
plastic is sometimes used to cover the back of the patella (kneecap).

Total knee implant

Image provided by the American Academy of Orthopaedic Surgeons (AAOS) with consent

3 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

Total knee replacement with the NAVIO™ Surgical
System
The NAVIO Surgical System is a tool your surgeon uses to assist them in locating the correct
size and position the total knee implant with computer and robotic assistance.

Computer assistance is used to collect the unique shape and motion of your knee to virtually
plan the procedure. Robotic assistance is used to accurately perform the procedure. The extra
layer of planning and precision provided by the NAVIO system aims to ensure the procedure is
performed exactly as your surgeon intends. The NAVIO system does not perform the
procedure; rather it assists your surgeon in preparing your knee surgical site, and position and
balance your implant - key factors that can drive implant longevity.

Computer assistance
designed to ensure consistent
and accurate results

NAVIO Surgical System

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Advanced planning software allows the surgeon to tailor the procedure to the unique shape
and motion of your knee.

Advanced instrumentation
designed to enforce the
surgeon-defined plan

Robotics-assisted hand piece

designed to enable precise
implant placement

5 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

Total knee implants
The total knee system(s) compatible with the NAVIO™ system are a next-generation knee implant
design that combines the stability and natural motion similar to the human knee with low-friction
materials - called VERILAST™ Technology - and has the potential to last significantly longer than
traditional knee implants.

VERILAST Technology combines the wear reducing properties of a one-of-a-kind, biocompatable

metal called OXINIUM™ Oxidized Zirconium, with a proprietary, highly cross-linked polyethylene. It
is the only such combination on the market today and has more than a decade of clinical data
behind it.

A Total Knee System

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The total knee system(s) compatible with the NAVIO™ system are designed with the same shapes
and profiles as your real knee. Because of this, the soft tissues in your knee may not have to
readjust to the new shapes and forces after surgery like in traditional designs. This is intended to
make your rehabilitation and recovery shorter.

Pairing the Total Knee System(s) with the NAVIO Surgical System allows your surgeon to prepare
your knee surgical site, and position and balance your implant - key factors that can drive implant
longevity.

7 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

Preparation for knee replacement surgery
Once you and your orthopaedic surgeon have decided to proceed with surgery, there are several
activities that must occur prior to surgery, including the following:

1. Initial Surgical Consultation: Pre-operative X-rays, complete past medical history, complete
past surgical history, complete list of all medications and allergies (prescription, over-the-counter,
supplements)
2. Complete Physical Examination: Your doctor will determine if you are in the best possible
condition to undergo surgery
3. Physiotherapy: Instruction in an exercise programme to begin prior to surgery and an overview of
the rehabilitation process after surgery will better prepare you for post-operative care
4. Preparation for the Hospital: You may want to bring the following items:
• Clothing: Underwear, socks, t-shirts, exercise shorts for rehabilitation, pyjamas
• Footwear: Walking or tennis shoes for rehabilitation exercise; slippers for hospital room
• Walking Aids: Walker, cane, wheelchair, or crutches if used prior to surgery
• Medical Scheme and/or gap cover information
5. Preparation for after surgery:
• Move items and furniture in your home so they are easier to access while your mobility
(movement) is limited
• Remove clutter and obstacles that could be tripping hazards
• Have a plan; preparing meals ahead of time and arranging visitors to help with
daily chores will make your recovery smoother.
6. Evening before Surgery:
• Do not eat or drink after midnight or as instructed by the anaesthetist or surgeon
• Prepare your belongings and review total knee booklet

Follow your surgeon’s complete instructions leading up to surgery.

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Pre-operative procedures
This section will give you a brief overview of the activities that will occur on the day of surgery:
1. You will be admitted to the hospital, typically the morning of your surgery
2. A final assessment of vital signs (blood pressure, heart rate, temperature, breathing) will be taken
3. A clean hospital gown will be provided
4. An intravenous drip will be started to give you fluids and medication during and after the procedure
5. An elastic stocking may be provided to decrease the likelihood of blood clots
6. You will be asked to empty your bladder
7. All jewellery, dentures (false teeth), contact lenses, and nail polish must be removed
8. The surgical leg will be scrubbed and shaved in preparation for surgery
9. If possible beforehand, the anaesthetist will discuss the type of anaesthesia that will be used
10.You will be taken into the operating room

What to expect in surgery

You will first be placed under anaesthesia to relax your body for surgery and block pain.

Your surgeon will then make an incision that extends several centimetres above the kneecap
to several centimetres below the kneecap. Using the NAVIO™ system, special trackers are
secured to both the thigh bone (femur) and shin bone (tibia) with four small surgical pins
placed through tiny incisions in the skin. These trackers are crucial to the precision of the
system as they provide a constant reference point to the surgeon throughout the
procedure. Using computer assistance, the unique shape and motion of your knee are
collected by the surgeon. This allows for a three-dimensional model of your knee to be
generated and used by the surgeon to plan the procedure. Proper implant size and position
will be determined at this time.

9 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

 Incision made on the knee The knee implant is positioned virtually using advanced NAVIO™
planning software

Once your surgeon virtually determines the correct implant size and positioning, a robotics-
assisted tool (the NAVIO hand-piece) is used to accurately position bone removal cut guides.
These cut guides enable the surgeon to use a surgical saw to remove your damaged knee
bone, making room for the implant. The extra layer of precision provided by the NAVIO system
is designed to enable accurate cut guide placement. The NAVIO system does not perform
the procedure; rather it assists your surgeon.

Once the implant is in the final position, the incision is thoroughly cleaned and closed,
completing the procedure.

NAVIO cut guides

positioned using robotic
assistance provided by Bone surface prepared
the NAVIO System for the knee implant Implant in final position

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Post-operative care
After your surgery is completed, you will be transported to the recovery room for close observation of
your vital signs, circulation, and sensation in your legs and feet. As soon as you awaken and your
condition is stabilised, you will be transferred to your hospital room or ward. Below is an example of
what you may see when you wake up:

1. You will find a large dressing applied to your incision in order to maintain cleanliness and absorb
any fluid.
2. There may be a drain placed near your incision in order to record the amount of fluid being drained
from the wound.
3. You may be wearing an elastic stocking, and/or a compression stocking sleeve designed to
minimise the risks of blood clots.
4. Your surgeon may prescribe a PCA (patient-controlled analgesia) that is connected to your IV. The
unit is set to deliver a small, controlled flow of pain medication and is enacted when you firmly
press the button on your machine. The healthcare staff will instruct you on how to use it.
5. You may have a catheter inserted into your bladder as the side effects of anaesthesia often make it
difficult to urinate.
6. A Continuous Passive Motion (CPM) unit may be placed on your leg to slowly and gently bend and
straighten your knee. This device is important for quickly regaining your knee range of motion.
7. When your leg is not in the CPM, you may be wearing a knee immobiliser to protect your knees
when you stand up.

Preventing complications
As with all major surgical procedures, knee replacement complications can occur. Below is a list of
potential knee replacement complications and steps you can take to minimise the likelihood of it
occurring, or to minimise the severity of the occurrence.

1. Thrombophlebitis: Also known as deep vein thrombosis (DVT), this problem occurs when the
large veins of the leg form blood clots and, in some instances, become lodged in the capillaries
(i.e. the smallest blood vessels in the body) of the lung and cause a pulmonary embolism (a
blockage of the main artery of the lung or one of its branches).

11 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

The following steps may be taken to minimise the risk of blood clots:
• Blood-thinning medication (anticoagulants)
• Elastic stockings (TED stocking)
• Foot and ankle exercises to increase blood flow and enhance venous return
in the lower leg

IMPORTANT: If you develop swelling, redness, pain, and/or tenderness in the calf muscle, report
these symptoms to your orthopaedic surgeon immediately.

2. Infection: Although great precaution is taken before, during, and after surgery, infections
sometimes do occur in patients following knee replacement surgery. Steps you can take to
minimise this risk include the following:
• Monitor your incision closely and immediately report any redness, swelling, tenderness,
increased drainage, foul odour, persistent fever above 38°C orally, or increasing pain
• Take your antibiotics as directed and complete the recommended dosage duration
• Strictly follow the incision care guidelines your surgeon recommends
3. Pneumonia: Because your lungs tend to become “lazy” as a result of the anaesthesia, secretions
may pool at the base of your lungs, which may lead to lung congestion or pneumonia.
The following steps may be taken to minimise this risk:

• Deep breathing exercises: A simple analogy to illustrate proper deep breathing is to,
“smell the roses and blow out the candles”. In other words, inhale through your nose, and
exhale through your mouth at a slow and controlled rate.
4. Knee Stiffness: In some cases, the mobility of your knee following surgery may be significantly
restricted and you may develop a contracture in the joint that will cause stiffness during walking or
other activities of daily living. The following steps must be taken to maximise your range of motion
following surgery:
• Strict adherence to the Continuous Passive Motion (CPM) protocol as prescribed by your
surgeon
• Early physiotherapy (day 1 or 2) to begin range of motion exercises and walking programme
• Oedema (excess water/fluid) control to reduce swelling (ice, compression stocking, and
elevation)
• Adequate pain control so you can tolerate the rehabilitation regime

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Disclaimer
The NAVIO™ system is not for everyone. Children, pregnant women, patients who
have mental or neuromuscular disorders (e.g. muscular sclerosis) that do not allow control
of the knee joint and morbidly obese (overweight) patients should not undergo a NAVIO
procedure. Knee replacement surgery is intended to relieve knee pain and improve knee
functions. However, implants may not produce the same feel or function as your original
knee. There are potential risks with knee replacement surgery such as loosening, fracture,
dislocation, wear and infection that may result in the need for additional surgery.
Longevity of implants depends on many factors, such as types of activities and weight.
This information, including post-operative care, is provided for educational purposes only.
Smith & Nephew does not provide medical advice. In no event shall Smith & Nephew be
liable for any damages whatsoever arising out of the use of or inability to use the
expressed views. Consult your surgeon for details to determine if a NAVIO robotics
assisted procedure is right for you.

The NAVIO system is intended to assist the surgeon in providing software-defined spatial
boundaries for orientation and reference information to anatomical structures during
orthopaedic procedures. The NAVIO system is indicated for use in surgical knee
procedures, in which the use of stereotactic surgery may be appropriate, and where
reference to rigid anatomical bony structures can be determined. These procedures
include unicondylar knee replacement (UKR), patellofemoral arthroplasty (PFA), and
total knee arthroplasty (TKA). The NAVIO system is indicated for use with cemented
implants only.

1. The World’s Most Innovative Companies, Forbes Magazine, http://www.forbes.com/companies/smith-nephew/, accessed 10/19/16.
2. American Academy of Orthopaedic Surgeon website, http://orthoinfo.aaos.org/topic.cfm?topic=A00389
3. Total Knee Replacement, OrthoInfo. American Academy of Orthopaedic Surgeons (AAOS), online publication,
http://orthoinfo.aaos.org/topic.cfm?topic=A00389, accessed August 5, 2016.
4. Lonner, et al. “High Degree of Accuracy of a Novel Image-free Handheld Robot for Unicondylar Knee Arthroplasty in a Cadaveric Study.”
Clinical Orthopaedics and Related Research. Advanced online publication. DOI 10.1007/s11999-014-3764-x5 American Association
of Orthopaedic Surgeons (2014). AAOS.org.

13 | A patient’s guide: NAVIO™ Robotic-assisted total knee replacement

For more information ask your orthopaedic surgeon, or visit:
www.walkwithoutpain.co.za

Smith & Nephew (Pty) Ltd

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Westville, 3629 www.smith-nephew.com/south-africa
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Tel: +27 31 242-8111 Fax: +27 31 242-8120 © Smith & Nephew March 2018