Case Study: Robotic Bilateral Total Hip Replacement

in a 65-year-old female with Arthritis

A 65-year-old former New York City Fire Department (FDNY) employee and a September 11 survivor presented to our office with complaints of worsening bilateral groin pain. The patient had sustained multiple injuries during the collapse of the north tower in 2001.

As a member of the FDNY, responded on 9/11/2001 immediately upon the first plane striking the North Tower of the World Trade Center. During the subsequent collapse of the North Tower, she was thrown down a flight of stairs and was covered in a large pile of debris.

Despite her injuries, she worked to free herself, an elderly woman she was carrying down and a co-worker who was assisting her in the removal. She and her colleagues were trapped in the stairwell of the North Tower for some 5 hours prior to self extricating themselves from the confines of the collapsed building.

She continued to work directly on the Ground Zero pile without being treated for her injuries, despite constant pain, for months in the immediate aftermath of the attack. She had previously received cortisone injections in the right hip and physical therapy along with heat pads. She had minimal relief with all forms of conservative management.

The pain was described as a dull ache in both groins, which radiates down the knees medially and anteriorly. The severity was mild to moderate initially which had increased to severe recently. She was unable to perform her daily activities without pain. Activities such as walking, navigating stairs, bending and getting up from a chair exacerbated her pain.

She was a nonsmoker and her medical ailments included hyperlipemia, asthma, and hypertension. She previously had arthroscopic meniscal debridement of the right knee. Open reduction and internal fixation of the left humerus. Left inguinal hernia repair and right rotator cuff repair.

On physical examination, she walked with an antalgic gait and used a cane for ambulation. There was no evidence of exaggerated lumbar lordosis. There was no spinal scoliosis and both the shoulders, iliac spines, and patella were at the same level.

There was no leg length discrepancy and the bilateral trochanters were at the same level. There was no fullness or induration in bilateral groins. There was no inguinal lymphadenopathy. There was no thickening or broadening of the trochanters. The range of motion was restricted terminally with painful rotatory movements.

There was no fixed deformity in the coronal, sagittal and axial plane. The bilateral lower extremity pulses were 2+ and comparable. There was no distal neurological deficit. Imaging revealed severe osteoarthritis of both hips with subchondral cysts, sclerosis, and osteophyte.

In view of the patient’s medical conditions and lifestyle limiting groin pain, she was advised bilateral total hip replacement with robotic assistance. Risks, benefits, and alternatives were discussed at length with the patient. She agreed with the plan.

Preoperative X-ray of the patient’s pelvis with both hips

Preoperative X-ray of the patient’s pelvis with both hips.

OPERATION: Bilateral hip replacement using the robot.

IMPLANTS USED: Cup size 56 with acetabular liner 36-mm inner diameter with a 127 degree neck angle size 6 stem with ceramic femoral head 36-mm plus O on both sides with a 6.5-mm bone cancellous screw.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining the informed consent, signing on the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient as well as with her husband prior to the procedure.

The patient was brought to the operating room and anesthesia was obtained by the anesthesiologist The patient was then definitely positioned with the right hip up and the right hip was then draped and prepped in the usual sterile manner.

The external fixator pins were then placed in the iliac crest and the tacking device was then set up. An incision was then made over the hip joint, centered over the greater trochanter, and the skin and subcutaneous tissues were then incised.

The fascia was then divided and the hip was then placed into internal rotation and the posterior soft tissue structures were then taken down and tagged for future repair. The acetabular was then exposed. The tracker was placed over the greater trochanter before the neck resection that was done before exposure of the acetabulum.

After exposing the acetabulum, the acetabular tacking device was then placed into position. The remainder of the labrum was then divided. The acetabulum was then reamed and the final shell was placed into position in the correct abduction and anteversion. A screw was placed for additional fixation. The liner was then placed over the shell.

The alignment was found to be satisfactory. Attention was then turned towards the femur. The remainder of the tissue and undersurface of the greater trochanter was then removed, and the femur was then sequentially broached. The final broach was left into position. The trial trunnion and the head were.then placed into position.

The lesser trochanter with the central distance was measured and was compared to the lesser trochanter to distance prior to the hip dislocation. The lesser trochanter to the center distance was found to be correct. The hip was then reduced and then trialed through a full range of motion.

The hip was then dislocated and the trial femur was then removed. The final femur with the femoral head was placed into position. The hip was then reduced, thorough lavage was given. The tracking devices were then removed.

The fascia was closed with Ethibond, cutaneous tissues were closed with 2-0 Vicryl, subcutaneous tissues were closed with O Vicryl, subcuticular tissue was closed with 2-0 Vicryl, and the skin was closed using staples.

Sterile dressing was then applied over the wound. The patient was stable under anesthesia and it was decided to proceed with the other hip joint.

An x-ray was obtained before proceeding to the other hip joint and the hip joint was found to be in satisfactory position.

The patient was then placed with the left hip and the left hip was then draped and prepped in the usual sterile manner. A curved incision centered over the greater trochanter was used for the arthrotomy, skin and subcutaneous tissues were incised, fascia was then divided.

The hip was then placed under a trial rotation and the posterior soft tissue structures were then taken down and tied for future repair The hip was then dislocated. The lesser trochanter with center distance was then taken and the neck dissection was made at the correct level.

The head was then removed as the acetabulum was exposed and the labrum was then debrided. The acetabulum was then reamed and the final cup was then placed into position and the correct hip reduction in anteversion. The poly was then placed over the shell.

Attention was then turned towards the femur. The remainder of the tissue and the undersurface of the greater trochanter was removed, and the femur was then sequentially broached. The final broach was left into position. The.trunnion and the head were then placed over the femur the hip was then reduced.

The hip was then trialed through a full range of motion and the hip was found to be stable. The hip was then dislocated. Trial components were then removed. The final components were then placed into position. Thorough lavage was given. The soft tissue structures were then tagged to the greater trochanter through transverse tunnels.

The fascia was closed with Ethibond, cutaneous tissues were closed with 0 Vicryl, subcuticular tissues were closed with 2 0 Vicryl, and the skin was closed using staples. Sterile dressing was then applied over the wound and the patient was then placed in the supine position.

An x-ray was then obtained for confirmation of the placement of the prosthesis and for confirming proper alignment and limb length. The x-rays were found satisfactory. The patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray of the patient’s pelvis with both hips

Postoperative X-ray of the patient’s pelvis with both hips.

Post-op her vitals remained stable and there was no distal neurological deficit. Hip precautions were advised to the patient at length. She was started on aspirin for deep vein thrombosis prophylaxis. The sutures were removed uneventfully. Physical therapy and rehabilitation were started with gait training and fall prevention education.

Three months post-op, she demonstrated an excellent range of motion and zero pain. She was able to walk without support and was able to carry on her daily activities without pain. She follows up as needed.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
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15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
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21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
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17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
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19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.