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St. Charles Hospital
Adds MAKOplasty to Osteoarthritis
Treatment Armory
Brian McGinley, MD, orthopedic
surgeon at St. Charles Hospital,
(center) and Douglas Petraco, MD,
Chair of Orthopedic Surgery at
St. Charles Hospital, (far left) use
the MAKO robot to remove bone
in preparation for the implant.
St. Charles Hospital
Adds MAKOplasty to Osteoarthritis
Treatment Armory
By Jennifer Webster
P
HYSICIANS AND LAYPEOPLE alike
understand the basics of osteoarthritis and the effects it can
have on patients’ lives. However,
according to Douglas Petraco, MD, Chair
of Orthopedic Surgery at St. Charles
Hospital, scientists do not fully understand the biological changes that
accompany the condition. The common
outcomes — including pain, disability
and unemployment or other significant
limitations — make it crucial for physicians to take osteoarthritis seriously and
select treatments for optimal results.
MAKOPLASTY PARTIAL KNEE RESURFACING
ALLOWS PATIENTS WITH CARTILAGE
BREAKDOWN IN THE KNEE TO PURSUE
FULLER, MORE ACTIVE LIVES.
“One of the causes is the mechanical
breakdown of cartilage due to injury or
to overall knee alignment,” Dr. Petraco
says. “When a patient has a problem
with alignment or previous injury, such
as a torn meniscus, he or she is more
susceptible to developing arthritis in
the knee.”
Patients who are elderly, obese or have
a family history of arthritis are also more
likely to develop the condition. Those
with imperfect joint alignment, such as
that associated with genu valgum or genu
varum, may experience it as well.
Cartilage breakdown results in rough
surfaces where bones meet. Bone may
even rub against bone, making movement
of the joint difficult and painful. Bits of
broken cartilage may irritate the
synovium, and the joint may become
inflamed, changing shape over time.
Osteophytes may develop.
Osteoarthritis worsens slowly, so many
opportunities for conservative treatment
exist. If the condition progresses to a stage
in which surgery is the best option,
surgeons must offer a safe and long-lasting
alternative to chronic pain and disability.
Treatments for Osteoarthritis
of the Knee
Numerous treatments benefit patients
who have osteoarthritis. At St. Charles
Hospital, physicians conservatively manage the condition, relying on injections
and oral medications as long as they work
well for patients. Weight loss can also
greatly reduce the chance of osteoarthritis
becoming worse.
“We treat most patients with anti-inflammatory medications, such as ibuprofen or
naproxen,” Dr. Petraco says. “When those
are no longer effective, our next step is
injectables, either cortisone or viscosupplements, which are synthetic forms of the
lubricants the joint naturally produces.”
Medical treatments and lifestyle adjustments may remain effective for many
months or years. Nevertheless, some
patients will eventually need surgery for
their condition. Knee replacement surgery
options include total knee replacement and
partial knee resurfacing, both of which
are performed with excellent results at
St. Charles Hospital.
“When conservative measures are no
longer effective and patients’ lifestyles
are being dramatically altered because
of discomfort, we begin to assess surgical
options,” Dr. Petraco says. “If the arthritis
is confined to only one of the three components of the knee, a partial replacement
is often the best choice.”
In addition to those whose arthritis is limited to a single knee compartment, patients
who would benefit from MAKOplasty
partial knee resurfacing include those
who have middle-stage arthritis. Relatively
young patients make good candidates and
Dr. McGinley prepares the bone for implantation using the MAKO robot.
are turning to this option in increasing
numbers, Dr. Petraco says.
“People in their 50s or even 40s often
present with only one compartment of their
knee affected by arthritis,” he says. “We
can help these patients return to normal
function, and they will be able to do things
they could never accomplish with a total
knee replacement. Then, many years down
the road, when they need a procedure to
convert their partial knee resurfacing to
a total knee replacement, it is like a first
replacement for them.”
Those with congenital alignment problems, such as genu varum or genu valgum,
may also benefit from partial knee resurfacing, according to Brian McGinley, MD,
orthopedic surgeon at St. Charles Hospital.
“Patients who are knock-kneed or
bowlegged may experience joint wear and
“At St. Charles
Hospital, we have
been performing
computer-assisted knee
replacement surgery for
12 years. The computerassisted robotic partial
knee replacement, or
MAKOplasty, improves
upon our prior
technology. When, as
scientists and surgeons,
we determine that an
investment is best for
our community, the
hospital partners with
us to provide what
we need to improve
the quality of care
for our patients.”
— Brian McGinley, MD,
orthopedic surgeon at
St. Charles Hospital
robotic surgical
system assists in
t he pro cedu re
a nd provides
immediate feedback to ensure
t he impla nt is
positioned for the
best fit.
“MAKOplasty
involves precision surgery done
through a very
small incision,”
Dr. Petraco says.
The burr is used to remove bone. The visual arrays identify the
location of the femur and tibia.
“ P a r t i a l k ne e
replacement has
tear in a single compartment due to the
been around for many years; however, the
alignment of the joint,” he explains. “In
longevity of the implants was not optimal
the cases of mild knock-knee or bowed
because it was difficult to get the early
legs, resurfacing one compartment may
implants into perfect alignment. With
be a perfect option.”
MAKOplasty, we incorporate preoperaAthletes and others who have had
tive CT scans and robotics, allowing for
prior arthroscopic surgery may also
enhanced precision. We perform the operabenefit from partial knee resurfacing.
tion graphically, seeing exactly where the
“Often, these patients’ meniscus
implant will be, telling the computer exactly
was completely or partially removed,”
where we want the implant to sit. In every
he says. “The joint will wear out at
case, when we look at the postoperative
a faster rate where the meniscus is
X-ray, the implant is exactly where we want
missing. If the rest of the joint is in
it, and that leads to long-lasting results.”
good shape, those who have had partial
“The onset of robotic surgery has changed
meniscectomies may be good candidates
how we perform partial knee replacements,”
for MAKOplasty.”
Dr. McGinley says. “Now, we can create a
preoperative plan and follow it within a
MAKOplasty Partial
millimeter. We are more comfortable that
Knee Resurfacing
the prosthesis will not wear out.”
At St. Charles Hospital, MAKOplasty
is the preferred technique for partial
A Different Kind of Robot
knee resurfacing. This trademarked
Since MAKOplasty is a robotic surgery,
procedure starts with 3-D knee imaging,
patients may associate it with da Vinci
upon which a surgical plan is built. A
procedures. However, MAKOplasty
has many features that set it apart. The
relationship between the robot and the
surgeon-operator is different. In the case
of a robotic prostatectomy, for example,
the surgeon is working at a console, not
manipulating the instruments by hand.
“With MAKOplasty, the surgeon
removes bone using something similar to
a high-speed drill,” Dr. Petraco says. “The
robotic component is actually a safety and
Computer graphics demonstrate the
precision measure. At any given time during
remaining area of intended bone resection
(in green), as well as the area of bone
surgery, an overhead camera looks at arrays
that has already been prepared using the
attached to the bone. The camera and robot
robotic burr.
communicate so the robot knows where the
burr is relative to the bone at all times. If
the surgeon tries to remove bone from an
area that wasn’t indicated for removal in
the preoperative plan, the burr turns off.
And, if you try to push the burr outside the
field of intended bone resection, the burr
will not move.”
The result, Dr. McGinley says, is
unprecedented accuracy.
“I know that my surgical plan will be
replicated to within 1-millimeter accuracy,”
he says. “The end result will be an aligned
prosthesis that will not wear out.”
The emphasis on pinpoint precision
begins with the initial CT scan.
“We download the information from the
CT into the computer, which constructs
a graphic design of the femur and tibia
surfaces,” Dr. McGinley says. “With that
information, we determine the size of
the component we need to use and how
to position it for the best alignment and
stability. While we perform surgery, the
computer helps us place the prosthesis
correctly, assesses stability and checks the
tightness of the ligaments. That way, we
can position the prosthesis and adjust
the ligaments as necessary during the
course of the procedure.”
Devices on the femur and tibia
make this tracking possible. Infrared
cameras beam light to the tracking
markers and report the information
instantaneously to the computer, which
matches the tracking data to the CT
scan used to identify the location of
the bone surfaces.
“We start by touching the bone
surfaces with a tracking probe, which
shows the computer where the surface
is relative to the bone,” Dr. McGinley
explains. “Then, the computer knows
how the bones match the surface map
we have created, based on the CT scan
data. If we do not pick our reference
points well enough, the computer alerts
us, and we make adjustments. As we
perform surgery, the burr recognizes
the location of the bones and bone surfaces and, as a result, its own location.”
Dr. McGinley has been performing
partial knee resurfacing for many years,
he says, and he appreciates the extra
feedback and assurance provided by
the robot.
“I have increased confidence in the
positioning of the component,” he says.
“After a procedure is complete, I am
comfortable that I have matched the
plan well. Also, I can check my work
after surgery with the surface mapping
technique and see that the stability
and alignment are correct, giving me
assurance that the prosthesis will not
wear unevenly.”
Comparisons to Total
Knee Replacement
Just as the indications for partial
knee resurfacing differ from those
for total knee replacement, the
procedures are quite different. At
St. Charles Hospital, b o t h g i v e
pat ient s h igh ly satisfactory outcomes.
Patients who are candidates for total
knee replacement primarily include those
with osteoarthritis in all three compartments of the knee. Patients having
revisions of previous knee surgeries
should also undergo total knee replacement. According to MAKO Surgical, only
about 30 percent of people with osteoarthritis of the knee are candidates
for MAKOplasty.
However, MAKOplasty offers many
advantages over total knee replacement.
Kevin Nissen, physician assistant, performs the registration and calibration of the robot to
ensure precision.
Hospital stays and recovery times are
shorter with MAKOplasty. In fact, people
typically return to work two to three
weeks after MAKOplasty, compared to
six to 12 weeks after total knee replacement. Also, risk of surgical complications
is lower, and patients experience less
postoperative pain.
“With total knee replacement, it takes
a while for patients to experience pain
relief,” Dr. McGinley says. “However,
with MAKOplasty, patients feel better
almost immediately because we can get
Dr. Petraco, (L) lavages the joint with the assistance of an OR tech, in preparation for the
knee implant.
rid of the grinding surfaces of the bone
with only a small procedure.”
Incisions are smaller than for total knee
replacement, Dr. Petraco says. Even better,
a partial knee resurfacing has the same
“feel” as the original joint, he adds.
“One of the best aspects of partial knee
resurfacing, according to patients, is that
“St. Charles Hospital
is the only hospital
on Long Island to
offer MAKOplasty.
Hospital administration
is willing to support
advanced orthopedic
technology as part of
our mission and as an
orthopedic center of
excellence. We have a
very busy orthopedic
service, performing
approximately 500 joint
replacements each year.”
— Douglas Petraco, MD,
Chair of Orthopedic Surgery
at St. Charles Hospital
Dr. McGinley (center right) and Dr. Petraco (second from left) check the stability and balance
of the knee after placement of the new knee implant.
the replacement feels like their own knee,”
he says. “With total knee replacement, even
though patients are quite happy with the
results, they can tell it is a new knee. The
movements do not fully mimic those of a
normal knee. However, in a partial knee
resurfacing, the patient retains the cruciate
ligaments, so stability isn’t affected.”
MAKOplasty patients can perform
almost any physical activity they could
before surgery; often, they can add activities
to their repertoire. With both total and
partial knee surgeries, most patients can
hike, golf and swim after surgery. Typically,
partial knee resurfacing patients can also
return to more rigorous athletic activities —
although, Dr. McGinley warns, the more
friction the prosthesis endures, the sooner
it will wear out.
As with any surgery, MAKOplasty also
comes with risks, including blood clots,
infections, the need for transfusion and
the possibility of future revision surgery,
Dr. Petraco says. However, MAKOplasty
minimizes these risks, compared with
traditional knee replacement.
“The risk of transfusion is close to zero
because we work through a small incision,”
he says.
Also, not every patient with osteoarthritis
in a single knee compartment benefits from
this surgery.
“This surgery will not correct an excessive
deformity, such as extreme knock-knee or
bowed legs,” Dr. McGinley says.
The Patient Experience
After partial knee resurfacing,
patients typically
The preoperative plan has been recreated, and computer
spend only one night
graphics demonstrate excellent alignment and balance of the
knee at the completion of the operation.
in t he hospit a l.
Their posthospital
recovery also proceeds quickly. They
can typically walk
without assistance
the morning after
surgery and require
only about six weeks
of physical therapy.
“We see patients
two and six weeks
p o s top er at ively,
and then we turn
Reprinted from Long Island MD NEWS
them loose until their annual physical,” Dr. Petraco says. “Often, younger
patients only need about two weeks of
the longer physical therapy plan we
recommend for them.”
MAKOplasty has been around for
about five years, so the implant’s longevity has not been demonstrated across
large numbers of people. However,
Dr. Petraco says, all indications suggest
it has excellent staying power.
“Other partial knee replacements
typically had about a 10 percent rate of
revision at 10 years out,” he says. “At 15
years out, 80 percent were doing well.
However, based on early MAKOplasty
data, we expect this form of partial knee
resurfacing will perform much better.
I would estimate more than 90 percent
of implants will last 15 years or more.”
“At St. Charles Hospital, we have
not had any revision surgeries following MAKOplasty,” Dr. McGinley says.
“Nationwide, studies show excellent
results for partial knee replacement
using the MAKO system. In fact, partial
knee replacements prior to MAKOplasty
had about the same longevity as total
knee replacement, so we expect
these implants to do extremely well
in comparison, given the accuracy of
the placement.”
Longevity is also a function of
patient selection, Dr. McGinley says. At
St. Charles Hospital, physicians guide
patients carefully. Patients likely to
experience osteoarthritis in all three
knee compartments at some point in
the future are guided to conservative
management or total replacement,
even if they are temporarily candidates
for MAKOplasty.
“Referring physicians should be
aware that MAKOplasty is a verified,
researched option that can help patients
return to a more active lifestyle than
they could with total knee replacement,”
Dr. McGinley says. “I would undergo
this operation with no hesitation if I
were a candidate, and I would recommend it to my family members.”
To learn more about how St. Charles
Hospital can benefit your patients, visit
stcharleshospital.chsli.org. n