Procedure FAQ

If the pain is not bad enough to undergo surgery, then surgery should not be done. It is important to realize that it is not necessary to live with a painful joint. There are a variety of non-operative treatment options to consider prior to deciding to undergo surgery.

The decision to proceed with a joint replacement is purely a quality of life decision. When a patient routinely experiences pain, giving way, has difficulty sleeping, and/or discontinues desired activities, in spite of appropriate non-operative treatments, surgery can be a reasonable alternative to consider.

This is a sophisticated navigation and robotic joint replacement tool. This involves a 3-part process. First, we obtain a preoperative CT scan. This allows us to perform the surgery “virtually” before the patient ever enters the operating room.  Second, optical computer navigation is performed during surgery. This allows us to customize the implant position to minimize bone loss, and to create ideal soft tissue balance.  Third, we perform controlled resection of bone (accurate to within a millimeter) using a robotic arm to perfectly execute our customized plan.

Fear of any major operation is very natural. Anyone would naturally be concerned about the idea of taking something out of the body and replacing it with something artificial.

This is a big decision, and surgery has risks. We attempt to minimize unpredictability. We optimize our patients as much as possible prior to surgery to help ensure excellent outcomes. The Mako system gives us, as surgeons, the ability to do very precise work, customizing our reconstruction for every patient. This leads to a more anatomic, natural feeling joint and easier, quicker rehabilitation.

Most patients, once rehabilitated, regret having waited so long to have surgery.

Initially designed for partial knee replacement, the first Makoplasty was performed in 2006. Since then, the system has been adapted for total hip and total knee replacement, and can even allow us to do multiple partial knees within one joint.

Every patient is unique. Using the Mako system, the surgical plan is customized to the individual patient, as opposed to trying to perform every surgery exactly the same. This allows precise soft tissue balance in knee replacement and maximizes stability while minimizing leg length inequality in hip replacement. Furthermore, we are able to avoid drilling into the bone marrow, can resect less bone, and can usually preserve the posterior cruciate ligament during knee replacement. This all results in less inflammation, easier rehabilitation, and a more natural feeling joint.

The goal is to resurface the arthritic joint using a metal and plastic prosthesis. This needs to be done precisely, so we can restore the normal mechanical axis and soft tissue balance. This is expected to result in a smooth, pain-free range of motion.

Modern joint replacements are expected to last decades. There are a variety of factors that affect the lifespan of a joint, including the patient’s body weight and activity level. We believe that properly balanced joints, such as those performed using the Mako system, will experience less stress, and should last longer, and feel better while doing so.

Within a few hours of surgery patients are allowed to bear weight and begin physical therapy. The majority of patients are able to return home within 24 hours of surgery.

Planning ahead for post-surgical needs is important. We hold a class a couple weeks prior to surgery. During this class, specifics with regard to pain management, anesthetic choice, and discharge plan will be addressed.

The information gathered from a preoperative CT scan is used so we can understand the shape and 3-dimensional qualities of the individual’s knee or hip. This allows us to anticipate the size and optimal position of implants preoperatively.

During surgery, we temporarily attach an optical array (an antenna that has 4 optical discs that can be “seen” by the robotic system) to the patient’s bone. We then register the joint by moving the leg in specific ways and by touching a variety of points on the bone using a special wand that also has 4 reflective discs attached to it. This allows the robotic system to understand where we are relative to the preoperative CT scan.

We then make adjustments to the position of implants to optimize soft tissue balance in knees, and leg length and stability in hips.

Lastly, we use the robotic arm to carry out our exact, custom plan.

Patients requiring surgery for hip or knee pain usually have some element of soft tissue deformity, too tight, too loose, or a little of both. Our goal is to restore that soft tissue or ligament balance to as close to normal as possible.

 

Before the Mako system, during total knee replacement, surgeons would make arbitrary bone resections and then release soft tissues in an attempt to balance the knee. Using the Mako system we are able to precisely measure soft tissue balance, and adjust implant position to accommodate the patients precise anatomy- before we ever cut the bone. This minimizes soft tissue releases, minimizes the amount of bone removed and results in a very well balanced knee.

 

Before the Mako system, during total hip replacement we attempt to place the socket into an ideal position and then adjust leg length to provide the best compromise between leg length and stability. This was done mainly by feel and assumes the cup position is perfect. Studies have shown cup position is quite variable when done manually even by excellent, experienced surgeons. This can result in increased wear, instability, and/or leg length inequality.   Using the Mako system, we can place the cup precisely according to our plan. We can then adjust leg length according to objective leg length and offset data provided by the robotic system.

 

The better the soft tissue balance and the more anatomic the joint is reconstructed, the better it feels and the easier the rehabilitation.

Non-surgical options for arthritic joints include: weight loss, anti-inflammatory medications (topical or oral), injections (cortisone, hyaluronic acid, platelet-rich plasma), low impact exercises/PT, and braces. Arthroscopy (knee scope) may occasionally be considered for very specific issues. Total joint replacement remains the gold standard, however some patients are candidates for partial knee replacement.

Upon initial evaluation, the patient’s history will be obtained. Physical examination will be performed and X-rays will be evaluated. This information will be used to ensure the subjective complaints are consistent with the severity and location of disease seen. Treatment options as well as risks/benefits of each will be discussed. A patient does not need to make an immediate decision during the office visit.  Follow-up visits are very reasonable and allow gradual escalation of treatment invasiveness as needed.

At some point, a patient may opt to proceed surgically.  At that point, we provide a guidebook outlining the entire process leading up to surgery and the initial postoperative expectations. Our surgical coordinator will work with the patient to pick a surgical date, and work with them to ensure medical optimization by the time of surgery. A class is held prior to surgery where the patient will meet the team, discuss anesthesia options, learn about physical/occupational therapy expectations, and formulate a discharge plan. Our goal is for patients to understand every step of the process before, during, and after the surgical date.

There is no reason to suffer with the pain, stiffness, and instability of a degenerative joint. Not every arthritic joint requires surgery. It is best to see us in the office to discuss options.

Joint replacement surgery provides a very predictable improvement in quality of life.  Modern prostheses and techniques are very safe and reproducible. In spite of this there is some variability in outcomes. The best way to minimize complications is to stop smoking, attain an ideal body mass index, and to have normal blood glucose levels. Our orthopedic wellness approach helps optimize patient’s medical status preoperatively by eliminating sources of infection and by minimizing nutrient deficiencies.

While the vast majority of patients report pain relief after surgery, fewer feel the reconstruction feels “normal.” We use the Mako robot to optimize implant position for individual patients. This means improvement in hip stability and equal leg lengths following hip replacement and a better-balanced knee replacement that is easier to rehabilitate.

While the concepts are the same as traditional (manual) surgery – resurfacing the joint with a metal and plastic prosthesis- technique is different. The three-dimensional planning process, intra-operative soft tissue balancing, precise robot-controlled bone resection and implant placement provide several advantages over manual surgery. We can minimize bone resection and customize implant positioning to provide optimal soft tissue balance. Our surgical plan is executed perfectly using the robot as opposed to approximately, when using manual tools. We can measure soft tissue balance to the millimeter as opposed to relying on “feel.” This all results in a better balanced, more natural feeling joint reconstruction.

After a correct diagnosis, and the decision to proceed surgically, it is important to minimize risks. Patients may be urged to lose weight, improve their nutrition, and to quit smoking. Chronic medical problems, like diabetes and high blood pressure, need to be optimized. Our team will work with the patient’s medical doctor and specialists to ensure the surgery can be done with the minimum risk.

In the operating room, the surgical team performs a “time-out” during which the patients name, date of birth, the procedure, and laterality is confirmed.  The patient receives intravenous antibiotics, and tranexamic acid (which minimizes blood loss). The surgical site is prepped using a powerful antiseptic (chlorhexidine) and completely draped.   All surgical team members are completely encased in operative space suits. Consistency in technique and teams allows maximum surgical efficiency. Several liters of antibiotic irrigation is used during surgery and prior to wound closure. Multiple layer wound closure using absorbable sutures and glue minimized drainage, allows early range of motion and provides excellent cosmesis.

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