Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

Is Makoplasty Partial Knee Replacement Right for You?

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Makoplasty Robotic Partial Knee Replacement Best for One Compartment Disease

While Makoplasty parts can be combined in several different configurations, by far the most common is to resurface only one compartment.  The one compartment most commonly resurfaced is the medial compartment of the knee.

Medial knee is the time tested application with predictably great outcomes.  This procedure has been dramatically improved upon using Robotic Technology.

In my opinion, lateral uni compartmental application works well when your surgeon is able to incorporate accurate implant placement using Makoplasty Robotics and Computer Balancing  and CT mapping technology.

makoplasty knee
Xray of Medial Mako (most common construct)
Bicompartmental Mako Components for Tibial Resurfacing
Bicompartmental Mako components (No patellar button shown and 2 options for tibial resurfacing shown)
Bicompartmental Mako with no patellar button
Cartoon of Bicompartmental Mako (no patellar button)

Bicompartmental Knee Resurfacing:

In my hands, bicompartmental use is a less desirable construct.  If two or more compartments are arthritic Dr. T. will usually recommend Total Knee Replacement.  Another bicompartmental construct is to resurface the medial and lateral compartments, leaving healthy patella.  This is rarely done and no xray image was able to be found on line to even demonstrate the appearance of this.

bicompartmental knee resurfacing
Xray of Bicompartmental Mako (patellofemoral + medial uni)

Makoplasty Unicompartmental Knee Mimics Natural Knee

Dr. Tarlow attended a course titled “Update on Unicondylar Knee Replacement” this past week at the annual meeting of the American Academy of Orthopedic Surgeons.

The best surgical outcomes are in unicompartmental knee patients. Uni patients have a higher satisfaction score,  lower chance of infection, stroke, heart attack, blood transfusion, blood clot and death rate compared to total knee replacement patients.
makoplasty knee

The appeal of the unicompartmental or partial knee replacement also known as Makoplasty can be summarized in the following thoughts.

Makoplasty replaced knees compared to Total Knee Replacement:

  • Retain more normal knee tissue – including the ACL and PCL ligaments
  • There is less bone resection
  • Smaller incisions
  • Less pain/quicker recovery
  • improved, often times normal knee motion
  • Less expensive
2014 study from Germany showed unicompartmental knee closely preserves natural knee kinematics in vitro.
2015 study from New York showed Unicompartmental knee arthroplasty is an economically attractive alternative in patients sixty-five years of age or older, and modest improvements in implant survivorship could make it a cost-effective alternative in younger patients.
Most studies comparing unicompartmental knee replacement versus total knee replacement find a slight preference in favor of unicompartmental knee.

Makoplasty Partial Knee Resurfacing Shown To Be Best Surgical Method

Study finds MAKOplasty® Partial Knee Resurfacing Offers Lower Post-Op Pain, Improved Knee Function

 The content for this blog post comes from the work by Blyth MJ, Smith J, Jones B, MacLean III AB, Anthony, Rose P entillted Does robotic surgical assistance improve the accuracy of implant placement in unicompartmental knee arthroplasty?
Comments from Dr. Tarlow:  Common sense would lead me to conclude that precise implant placement will result in the best patient outcomes from partial knee replacement surgery.  Makoplasty allows the surgeon to optimize implant size, knee alignment, implant tracking and limp alignment.  My observation is that many patients return to close to normal knee function after this procedure.  Scientific research is lacking to validate my observation.  This is the first in hopefully many studies that corroborate my clinical observations.
makoplasty knee surgery
Summary of Study:  Results of an ongoing study on partial knee replacement surgery provide early clinical evidence that robotic arm assisted MAKOplasty Partial Knee Resurfacing results in improved knee function and less pain when compared to manual procedures using Oxford® implants.1 The study, which started in October 2010, is being conducted in Scotland and will be ongoing for ten years. The initial results looked at early outcomes of 100 partial knee replacement procedures – 50 robotic arm assisted MAKOplasty procedures and 50 manual procedures performed with Oxford® implants. All surgeries were unicompartmental knee arthroplasty (UKA) procedures, which involve only one compartment of the knee.
The researchers found that when compared with conventional procedures MAKOplasty resulted in:
  • Lower post-operative pain from day one up to 8 weeks  after surgery
  • More accurate implant placement
  • Twice as many patients with improved knee functionality (57% vs. 26%) based on  American Knee Society Scores
This study was presented at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons.

Makoplasty Knee Surgery and Home In One Day-Outpatient Partial Knee Replacement

Makoplasty knee surgery with Dr. Stefan Tarlow and his team
Dr. Tarlow team performing Makoplasty

Stefan D. Tarlow, M.D., Knee Surgeon with Advanced Knee Care, P.C. has posted a new video with an overview showing how Makoplasty, a partial knee replacement procedure using robotic technology can be performed as an outpatient. Click here to watch the 4 minute video.

Makoplasty – Partial Knee Replacement – Home the Same Day


Scottsdale Healthcare Thompson Peak acquired a Mako RIO system in Janaury, 2011.  Since that time Dr. Stefan Tarlow has performed over 180 procedures, more than any other orthopedic surgeon in Arizona.   Dr. Tarlow is Arizona’a most practiced and well-versed Makoplasty surgeon. Not content with status quo, he and his team continue to innovate and improve on the technique.Our team of Surgeons, Nurses and Anesthesiologists have continued to refine our delivery of care for our surgical patients.  This is particularly evident in the patients undergoing partial knee replacement using the robotic technology known as Makoplasty.

Today’s standard delivery of care has evolved to outpatient day surgery
due to improved surgical efficiency, saphenous nerve block (little to no motor weakness compared to femoral nerve block), and recovery room pain management with short acting opiods (Fentanyl).  Together  these modifications allow many patients to go home directly from recovery room.

makoplasty specialist

Makoplasty Specialist Brian Fighting Irish

Everything You Need to Know About Minimally Invasive Surgery

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 Minimally invasive surgery photo

Who is a Candidate for Minimally Invasive Surgery?

Here in the Phoenix – Scottsdale, Arizona area I am frequently asked by patients “Can you perform Minimally Invasive (MIS) Total Knee Replacement (TKR) on my knee?”

My answer is I can perform Minimally Invasive Total Knee Replacement on most any patient but I choose to use the technique on the large subset of patients that benefit most from the technique. It is a surgical procedure that is more technically demanding and more time consuming than traditional Total Knee Replacement so I am somewhat selective on choosing patients for this method. By analogy, I would not buy a new Basketball for my 90 year old mother in law but I would for my teenage son who is on the high school basketball team. She would never use the basketball and he would use it frequently.

I always perform Minimally Invasive Surgery on the healthy, motivated, energetic patients who will recover fast because of their good health and motivation to get well fast. I rarely perform Minimally Invasive Surgery on unhealthy patients with multiple co morbidities (Diabetes combined with cardiac or respiratory disease combined with high Body Mass Index is a typical patient profile that comes to mind). The first example patient would take full advantage of having had this technique by discharging from the hospital in 1-2 days, be walking freely without a walker in 5-10 days, be driving in 10 days -3 weeks, be back to work in 2-4 weeks and be golfing or hiking in the beautiful Arizona desert in 4-8 weeks. The second example patient would recover but take 1-3 months to reach similar milestones.

Body mass index is sometimes a factor since some patients with high BMI have low energy. BMI alone is not a reason not to perform MIS Total Knee surgery.

A normal BMI is under 30 and defined as a six foot tall man weighing 215 pounds or less or a five foot six inch woman weighing 182 pounds or less.
Obesity (BMI 30-40) is the six foot man between 215 and 285 pounds or the five foot six woman between 182 and 240 pounds. Morbid obesity (BMI above 40) is above 285 pounds for the six foot man and above 240 pounds for the five foot six inch woman. (BMI tables are available online to calculate your own BMI). Minimally Invasive Surgery can be performed on the higher BMI patients. It always requires a skin incision 2-4 times longer than the incision in under 30 BMI patients. The longer skin incision allows the surgeon to “convert” the high BMI patient into a low BMI patient by retracting away the “extra” skin and subcutaneous tissue. However, the definition of Minimally Invasive Surgery Knee Replacement and the key factor allowing for faster recovery is not the size of the skin incision but the size of the deep or Capsular incision that allows the surgeon into the knee joint proper. Therefore high BMI patient can have Minimally Invasive Total Knee Replacement Surgery and enjoy the benefits of a faster recovery.

Returning to the question posed at the beginning of this post: Who is a candidate for Minimally Invasive Total Knee Replacement Surgery? The answer is that most people are good candidates for MIS TKR as long as they are healthy, have a good energy level and are motivated to recover quickly.

Minimally Invasive Knee Replacement is Safe/Better: Refuting the Wall Street Journal

The October 14, 2008 edition of the Wall Street Journal published an article entitled “New Doubts About Popular Joint Surgery”. The following excerpt from the WSJ raises issues concerning Minimally Invasive Joint Replacement surgery (MIS).

“But patients aren’t always told that minimally invasive surgery is more difficult to perform than a traditional operation. Because of the smaller incision, surgeons have a harder time seeing what they are doing. And because minimally invasive surgery has grown so fast, many doctors don’t have extensive experience performing the complicated procedure.”

As an experienced MIS Knee Replacement Surgeon I completely agree with the above quoted comments. However, the other side to the story is that experienced surgeons using computer surgical navigation have patients with consistently excellent outcomes and complication rates as low or lower than traditional joint replacement surgeons.

I would like to address the three issue raised. First, “minimally invasive surgery is more difficult that a tradition joint replacement”. There is a known “learning curve” of approximately 25 cases, after which most surgeons will have mastered the MIS technique. I have been performing MIS Total Knee Replacement since 2004 and to date have over 500 cases experience. The transition to MIS replacement will occur with time and can be compared to the transition in sports medicine from open “traditional” knee and shoulder surgery in the past to current arthroscopic treatment for most knee and shoulder injuries.

Secondly, “because of the smaller incision, surgeons have a harder time seeing what they are doing”. Using Computer surgical navigation intraoperatively or computer generated surgical cutting blocks preoperatively provides the Minimally Invasive Joint surgeon with the information needed to accurately place the new hip or knee joint using the smaller incision. Computer technology more than overcomes the exposure issue raised in this second point. I personally do not perform MIS Total Knee Replacement unless I have computer navigation or computer generated cutting blocks.

Third, “because minimally invasive surgery has grown so fast, many doctors don’t have extensive experience performing the complicated procedure”. Every major city and some smaller towns have compentent, experienced minimally invasive joint replacement surgeons. As a patient, do your research and find the well trained, experienced minimally invasive joint replacement surgeon and you will often times be rewarded by a faster recovery and a less painful experience while getting all the long term benefits of traditional total joint replacement.

Minimally Invasive Total Knee Replacement Facilitates Recovery

An article appeared in the July, 2007 Journal of Bone and Joint Surgery entitled “Minimally Invasive Total Knee Arthroplasty Compared With Traditional Total Knee Arthroplasty“. The main author is Seth S. Leupold, M.D. from the Department of Orthopedic Surgery at the University of Washington in Seattle.

The conclusion of the article is that minimally invasive Total Knee Replacement seems to facilitate recovery after this operative procedure. The patients who had the minimally invasive approach demonstrated significantly better clinical outcomes with respect to shorter length of hospital stay, higher percentage of patients discharged to home instead of inpatient rehabilitation facility, less narcotic use at 2 and 6 weeks post-operatively and less need for assistive devices to walk at two weeks after surgery.

The Journal of Bone and Joint Surgery is one of the most respected and credible orthopedic surgery publications. The journal was founded in 1903 and is the official journal of the American Association of Orthopedic Surgery. The guiding principle of the JBJS is excellence through peer review. There are high standards, professional review and rigid criteria that have to be met before an article is accepted for publication. This is one of the first unbiased articles to appear in a prestigious orthopedic journal confirming the benefits of minimally invasive Total Knee Replacement. Therefore I believe the appearance of this article in the JBJS is highly significant.

Like the author of this article, I began performing MIS Total Knee Replacement in 2004. And just as the author discusses in the quoted article there is a learning curve of at least 25 cases to become more familiar with the technique. Like the author I perform a number of these operations on a monthly basis so that I got the over the learning process in a 3 month period. Over the last 3 years I have performed Minimally Invasive Knee Replacement on most of the patients I treat surgically for knee arthritis.

The components that are implanted are the same for MIS and Traditional Knee Replacement. I always use Surgical Computer Navigation as I believe this improves the accuracy in component position.

In my experience 1 in 4 patients are discharged home after one night in the hospital and most of the remaining patients go home after 2 nights. It is less common for a patient to be hospitalized 3 nights or to be discharged to an inpatient rehab facility. Similarly 25 % of patients are walking without assist in a week and the 70 % are walking without assist at 2 weeks. Most patients are driving in 2-3 weeks.

The results with respect to mobility, knee motion, pain relief and function for activities of daily life after MIS and Traditional Knee Replacement seem to merge around 3-12 months after surgery, however the return of quadriceps strength seems to occur sooner in MIS patients.

In conclusion I found the publication of the article highly significant and supportive of the beliefs of my colleagues who are currently performing minimally invasive Knee Replacement. Surgeons using minimally invasive techniques for Joint Replacement do so because of the greater patient benefits with this procedure.

 

3 Reasons Computer-Assisted Knee Replacement Is Better Than Traditional Surgery

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Computer Assistance Increases Precision of Component Placement in Total Knee Arthroplasty with Articular Deformity

Computer Navigation is a valuable tool that surgeons use to accurately position components for Knee and Hip replacement surgery. Computer navigation is embraced by patients – it is common sense that technology is helping medicine to evolve and improve. However, there continues to be push back to the adoption of this technology. Not surprisingly, health insurance companies continue to deny payment to surgeons who believe this valuable technology improves joint replacement surgery. Traditional “old guard” joint surgeons refuse to adopt emerging technologies. Insurance claim payment for navigation is denied is based on ” experimental or not necessary” reasoning. However, a large body of medical literature supports the use of computer navigation to aid joint replacement surgeons.

The next wave of technology will combine navigation with robotics which will further revolutionize joint replacement surgery. Look for this technology to be minimized and deprecated by health insurance companies and old guard surgeons.

This is the abstract of a scientific paper demonstrating the value of computer navigation in total knee replacement surgery.

The accuracy of computer navigation applied to total knee arthroplasty (TKA) in knees with severe deformity has not been studied.

Questions/purposes

The purpose of this study was to compare the radiographic alignment achieved in total knee replacements performed with and without navigation and to search for differences in the final alignment of two groups of patients (with and without previous joint deformities) using the same system of surgical navigation.

Methods

The first series comprised 40 arthroplasties with minimal preoperative deformity. In 20 of them, surgical navigation was used, whereas the other 20 were performed with conventional jig-based technique. We compared the femoral angle, tibial angle, and femorotibial angle (FTA) by performing a post-TKA CT of the entire limb. In the second series, 40 additional TKAs were studied; in this case, however, they presented preoperative deformities greater than 10º in the frontal plane.

Results

The positioning of the femoral and tibial component was more accurate in the group treated with surgical navigation and FTA improvement was statistically significant. When comparing the results of both series, FTA precision was always higher when using computer-assisted surgery. As for optimal FTA, data showed the use of surgical navigation improved the results both in the group with preoperative deformity greater than 10° in the frontal plane and in the group with minimal preoperative knee deformity.

Conclusions

Surgical navigation obtains better radiographic results in the positioning of the femoral and tibial components and in the final axis of the limb in arthroplasties performed on both deformed and more normally aligned knees.

Level of evidence

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This study belongs to a project promoted by the Health Research Institute (Carlos III Health Institute) of the Spanish National Healthcare System.

Computer-Assisted Surgery More Accurate for Total Knee Replacement


Medical articles on new technologies are often times conflicting. The the old guard designs research protocols to verify that time tested procedures are the standard. The forward thinking innovators design studies supporting the benefits new technologies represent. Computer Navigated Knee (and Hip) replacement surgery is in the middle of a technological revolution and this is being carried out in the press, the medical literature and in operating rooms across the world. Here is a compelling study citing both the effectiveness and safety of computer assisted Knee Replacement Surgery.According to data presented at the AAOS 2010 Annual Meeting, total knee arthroplasty (TKA) conducted with computer assistance is more accurate than conventional surgery. The authors based their data on the results of 1,000 computer-assisted TKAs conducted at a single center between February 2005 and January 2010. They found that alignment within 3 degrees was achieved in 100 percent of the patients, with an average final, post-surgical alignment of 0.8 degrees. In addition, none of the knees failed early or have required revision secondary to misalignment, instability, or aseptic loosening. In other words, a study of 1,000 consecutive Computer-Assisted Robotic Total Knee Replacements performed over a five year period at Mercy Medical Center in Rockville Centre, NY demonstrates that the computer-assisted procedures result in far better leg alignment, much less likelihood of complicating infection, and a far lower early failure rate than surgeries performed using conventional techniques.

Scientific Article Questions Routine Use of Computer Navigation for Knee Replacement Surgery

A Mayo Clinic 15 year study confirms accurate placement of Total Knee Components does not improve long term results.

One long-held tenet of total knee arthroplasty is that implant durability is maximized when postoperative limb alignment is corrected to 0° ± 3° relative to the mechanical axis. Recently, substantial health-care resources have been devoted to computer navigation systems that allow surgeons to more often achieve that alignment. Better long-term survival of total knee arthroplasty in accurately aligned implants was similar to the group of alignment outliers. 398 Knees were studied.

Results At the time of the latest follow-up, forty-five (15.4%) of the 292 implants in the mechanically aligned group had been revised for any reason, compared with fourteen (13%) of the 106 implants in the outlier group. Revision for specific reasons thought to be related to initial position showed the following: seventeen (5.8%) of the 292 implants in the mechanically aligned group had been revised because of aseptic loosening, mechanical failure, or wear, compared with four (3.8%) of the 106 implants in the outlier group (p = 0.49).

Conclusions A postoperative mechanical axis of 0° ± 3° did not improve the fifteen-year implant survival rate following these 398 modern total knee arthroplasties. We believe that describing alignment as a dichotomous variable (aligned versus malaligned) on the basis of a mechanical axis goal of 0° ± 3° is of little practical value for predicting the durability of modern total knee arthroplasty implants.

This report suggests that for traditional knee replacement surgery with standard instrumentation aligns the knee well enough for an 85 % good result rate fifteen years after surgery. This report suggests that “perfect axial alignment” is not an important variable toward improving the long term result after total knee replacement. The author’s initial bias was to discount the benefit of accurate alignment using the current technology of computer navigation, which the data confirms. Computer navigation use to prevent implant alignment errors in minimally invasive surgery or in the case of unusual leg deformities as a result of trauma or congenital variation is still considered valuable in my opinion. Also, the combination of computer assisted surgery with robotics might be the next “great” advancement in joint replacement surgery. More on robotics and computers later.

3 Frequently Asked Questions About Knee Replacement

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Knee of a runner

  1. How Successful Are Total Knee Replacements in the First Three Years?

    A frequently asked question about knee replacement centers on the success rates of the surgery. A British Study looked in the National Registry to determine revision surgery rates of 80,697 primary Total Knee Replacements between 2003 and 2006. This was an observational study and a revision for any reason (infection, loosening, instability, fracture) was the defined end point of the study. Observational studies have many limitations, but the numbers in this study still have some validity and some interest.

    The overall primary knee replacement revision rate was 1.4% for cemented total prosthesis, 1.5 % for cement less total prosthesis, and 2.8% for uni compartmental prosthesis at three years. Patients younger than 55 years at the time of the primary TKR had the highest revision rate and those older than 75 years at the time of primary TKR had the lowest rates. Overall, this reports shows that revision rates in the first 3 years after knee replacements carried out in the NHS in England since April 2003 were low.

  2. Does Sports Participation Adversely Affect Total Knee Durability?

    The American Academy of Orthopedic Surgeons annual meeting was held in New Orleans last week. Paper 507 by surgeons from Mayo Clinic Rochester (including well respected Mark Pagnano, MD and Daniel J. Berry, MD) reviewed results of knee replacement patients that did not follow doctors orders and participated in heavy labor or high impact sports such as aerobics, football, soccer, baseball, basketball, jogging and power lifting.

    Contrary to accepted doctrine, at an average 7 1/2 year followup the high activity group actually did BETTER than the restricted activity patient group, with higher knee rating scores and better knee function scores.

    The authors were surprised by these findings. “We hypothesized that high-impact activities would not increase the risk of implant failure, but we did not foresee that such activities might actually improve clinical results”.

    These finding are accompanied by, you guessed it, a disclaimer; The industry is not ready or able to revise activity recommendations after knee replacement, but that possibility may exist in the not too distant future. In the meantime, surgeons and patients should continue to follow all industry recommendations relating to recovery following joint replacement surgery.

  3. Does Outpatient Physical Therapy Improve Functional Outcome After Total Knee Replacement?

    One frequently asked question about total knee replacement seems to have been answered in a recent study. Quality of life and functional outcomes after total knee replacement are of great importance to both patients and surgeons. Mockford et al. studied 150 patients after knee replacement to determine the effect on range of motion and functional outcome. Patients in one group received NO physical therapy and the study group received 6 weeks of outpatient PT.

    At one year followup there was no difference in knee function or range of motion.

ACL Surgical Technique

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ACL Surgical Technique – Single and Double Bundle Reconstructions Similar Results

Single bundle and Double bundle ACL reconstruction did not differ in terms of clinical outcomes

“Single Bundle” Hamstring ACL reconstruction

(knee stability exam, functional activity, retear rates) at 3 years according to a Japanese study published in April, 2016 American Journal of Sports Medicine.

A Swedish study published in the same journal in May, 2016 found similar outcomes of the two surgical procedures at 5 year followup.

A well placed single bundle ACL reconstruction using hamstring autograft or patellar tendon autograft will provide satisfactory outcomes.  Choose a skillful surgeon and you can expect a good outcome for your knee.

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