Written by Kim O’Brien Root
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[dropcap]After injuring her knee four years ago, Tonya Higgins tried just about everything in order to avoid replacement surgery.[/dropcap]Arthroscopy helped some, and injections of cortisone and hyaluronic acid, which can serve as a lubricant to help buffer the knee, were only temporary fixes. Doctors even tried injecting plasma from her own platelets into the knee to try and heal it.
But Higgins’ knee kept getting worse. It kept the 59-year-old Gloucester veterinarian from going on walks and hindered her volunteer work with homeless animals. Bone ground against bone with every painful step she took.
Then along came MAKOplasty—a type of partial-knee replacement surgery that uses computer- and robot-assisted technology to resurface the joint and install implants in the most precise manner possible. The technique means better results, quicker healing times and sometimes a way to avoid a more complicated total knee replacement.
The surgery was approved by the FDA in 2005, but only recently became available in Hampton Roads thanks to the purchase of new equipment at hospitals on the Peninsula and in South Hampton Roads. A handful of orthopedic surgeons in the region are now performing MAKOplasty surgeries at Mary Immaculate Hospital in Newport News and at Sentara Virginia Beach General Hospital.
There are two kinds of MAKOplasty surgery—partial-knee resurfacing and total hip, which is 10 to 15 percent more precise than traditional total hip replacements. Doctors are being trained in one or both areas. Last year, more than 10,200 MAKOplasty procedures were performed in the United States.
Dr. Peter Jacobson, an orthopedic surgeon with the Virginia Institute for Sports Medicine in Virginia Beach and one of three physicians trained to perform MAKOplasty at Virginia Beach General, calls the technology for the knee procedure in particular “cutting edge.”
“We’re excited about it,” says Jacobson, adding that people were ready to sign up on the spot at a recent informational session on MAKOplasty at Virginia Beach General. “It’s going to offer something new to patients.”
MAKOplasty uses a robotic arm and three-dimensional imaging of a patient’s knee to assist surgeons in resurfacing the diseased part of the knee as accurately as possible. The use of the robot arm and real-time feedback on a computer screen allows doctors to watch what they’re doing—and ensures that no mistakes are made.
The surgery still requires the skill and expertise of a trained surgeon, but it takes out any guesswork. For surgeons who might not do as many knee surgeries as others, the robotic assistance can be hugely beneficial, says Dr. Boyd Haynes, an orthopedic surgeon at the Orthopaedic & Spine Center in Newport News.
“For me, I’m very comfortable doing the old style or the MAKOplasty—it doesn’t matter to me,” says Haynes, who’s been an orthopedic surgeon for 28 years. “With MAKOplasty, you can’t put [the implant] in the wrong place. The robot says, ‘You’ll only go there.’”
“It’s a great adjunct tool for making a good operation better,” Haynes adds.
The surgery requires only a four- to six-inch incision over the knee, along with small incisions in the femur and tibia to secure probes. The probes, attached to devices that look like small satellite dishes, are then synched with the robotic arm and a computer program that has the patient’s surgery “plan” stored and ready to put into action. Healthy tissue and bone are preserved while an implant is put in the joint to allow the knee to move smoothly.
[quote]… it still feels like your knee. It’s less expensive, it’s more efficient for the hospital, requires less Physical therapy…[/quote]Higgins heard about the new surgery after attending an open house at Mary Immaculate Hospital, and on Jan. 8, she went under the knife of Dr. Anthony Carter, one of three surgeons on the Peninsula using MAKOplasty.
The day of Higgins’ surgery, Carter worked with a team of assistants at the operating table while keeping in constant contact with a representative from MAKO Surgical Corp., who stays in the OR to assist from behind the computer.
Once Carter finished chiseling off the irregular bone on the femur and tibia—using an instrument similar to what a dentist might use—he worked trial implants into place to make sure they were the right fit and then manipulated Higgins’ knee, bending it back and forth to make sure she had the range of motion he wanted.
“Perfect,” he declared.
The procedure took just about an hour—about twice as long as a traditional partial-knee replacement. But doctors say the results are worth it. Ten days after the operation, Carter told Higgins he was very pleased.
“It’s got so many benefits all around for the patient,” said Tony Cravin from the MAKO Surgical Corp. “This lets it still feel like your knee. It’s less expensive, it’s more efficient for the hospital, requires less PT—so better off for health care.”
More than 4.5 million Americans have had knee replacements, according to a research study presented to the American Academy of Orthopaedic Surgeons last year. And replacement surgeries have more than doubled in the last 10 years, with younger people getting surgeries due to osteoarthritis.
Osteoarthritis, a degenerative joint disease, results in the wearing away and eventual loss of joint cartilage. Without the cushion of cartilage, bones begin rubbing together—when it happens in the knee, walking can be excruciating.
The need for technology in knee surgery is higher than perhaps ever before, doctors say. Studies show there could be a 200-fold increase in the need for knee replacements over the next 10 years, according to Dr. Colin Kingston, an orthopedic surgeon at Tidewater Orthopaedic Associates. Much of that is due to the Baby Boom population reaching their 50s to 70s.
For people in their 40s and 50s, doctors have usually been conservative to do a total knee replacement until the knee was bad enough, choosing instead to try injections and braces in patients who have arthritis in one or two parts of their knees—called uni- or bi-compartmental. Doctors now think MAKOplasty will allow them to treat patients in the earlier stages of the disease.
The procedure also leaves options—although it’s likely a patient will need a total knee replacement down the road, MAKOplasty should let them enjoy life for longer until they get to that point. But with MAKOplasty, all the ligaments remain intact, unlike a total knee replacement that removes the anterior cruciate ligament (ACL) and sometimes the posterior cruciate ligament (PCL).
“It might not be their last operation, but it’ll be the only one they need for many years,” Jacobson says.
Sometimes, however, a surgeon will begin the operation only to discover that the knee is more damaged than X-rays and CAT scans showed. If the damage extends beyond one or two parts of the knee, then surgeons likely will have to do a total knee replacement. Higgins had agreed and was prepared for that before she entered the OR, and said she was relieved upon waking from anesthesia.
Jacobson said he sees MAKOplasty being beneficial for two population groups—those in their 40s and 50s who have been dealing with an old injury but aren’t ready for a total knee replacement, and older patients who want something done for their pain without a lengthy recovery time. A total knee replacement can take three times longer to heal than a MAKOplasty replacement.
Last month, Haynes performed MAKOplasty knee surgery on an 80-year-old woman at Mary Immaculate. The woman was kept overnight because of elevated blood pressure, but by the next day, “the knee wasn’t bothering her,” Haynes says. “She cleared physical therapy the same day.”
Haynes estimates that he performs 50 to 60 partial knee replacement a year and about 300 total knee replacements. He says he’s hopeful that about half of the people a year who would otherwise face a total knee surgery can instead have the MAKOplasty.
“With every year, there’s more innovation, more things to make things better,” Haynes says. “We’re doing better things for the patients to make better outcomes.”
As for Higgins, the day after her surgery, she was using a walker. She would have been on her feet the same day, but a reaction from her anesthesia kept her in bed overnight. Within a week, she graduated to a cane. After three weeks, she was driving. Since the day of surgery, all she’s needed for pain is Tylenol.
Two months later, “I’m pretty back to normal,” says Higgins, the veterinarian in charge of the Animal Resource Foundation’s Spay/Neuter Clinic in Gloucester. She thinks working with sometimes unruly dogs while volunteering at the nearby pound may have led and then exacerbated her knee injury in the first place.
Her knee wasn’t just injured—it was deformed to the point the knee bowed out. She spent four years “walking very awkwardly,” she says.
Now, her knee is straight. It looks better; it feels better. And she can walk—often with her husband, Gary Rice, and two of their rescue dogs, Cheeser and Carrie—around their neighborhood without pain.
“I’m trying to walk a mile a day,” Higgins says. “Before, if I walked a tenth of a mile I could have done it, but wouldn’t have chosen to.
“Now, I can choose to go for a walk.”