Fred Kozlo, 61, vice president of Nexus Protective Services in Calgary, Alberta, likes his left knee better than his right knee. He’s OK with the standard right partial knee replacement he had done five years ago in Canada. But he’s ecstatic about the left partial knee replacement he had less than a month ago in Arizona, which involved computer-assisted surgery with robotic technology. For Kozlo, short-term recovery has been much smoother the second time around.
Partial or Total Knee
The knee joint is made up of three separate areas, or compartments: the medial or inside part of the knee, the lateral or outside part of the knee and the patellofemoral compartment at the front of the knee, beneath the thighbone. If you have damage from arthritis confined to just one compartment of your knee, along with significant pain and disability despite medical treatment, you might be a candidate for partial knee replacement.
Yet orthopedic surgeons say too many people who could get a partial replacement — which spares healthy surrounding bone and tissue — receive a total knee replacement instead.
There are “distinct” advantages to opting for partial knee replacement if you’re a suitable candidate with osteoarthritis, says Dr. Andrew Pearle, founder of the Computer-Assisted Surgery Center at the Hospital for Special Surgery in New York City. “It tends to be a more natural-feeling knee,” he says. “It tends to be a more athletic knee — you can play more sports on it.” Partial knee replacement involves a “much quicker return to work and is a lot less expensive to go through,” he adds.
Longevity or Satisfaction
Pearle just published a cost-effectiveness analysis comparing partial and total-knee procedures in the Journal of Bone and Joint Surgery. For patients 65 and older, partial knee replacements led to lower lifetime costs and higher quality of life. However, because of the need for eventual revisions, partial knee replacement was less cost-effective in patients under 65.
Having the longest-lasting implant isn’t always top priority for patients, Pearle says. “In most studies, about 10 to 20 percent of people who had a total knee replacement are not satisfied,” he says. While implant longevity is important, he says, quality of life and activity after surgery also matter — and people with partial knee replacements tend to have higher satisfaction scores.
Standard or Robotic Surgery
Standard partial knee replacement uses X-ray images and relies on the surgeon’s visual assessment of the knee and direct manual surgery.
The robotic partial knee procedure used for Kozlo, called MAKOplasty, involves CT scanning, which allows the surgeon to build a virtual model of the patient’s knee and make a preoperative plan. With computer assistance, the surgeon guides the programmed robotic arm in resurfacing the damaged part of the knee.
In both methods, the surgeon places metal components on the ends of the thigh bone and tibia (the larger leg bone below the kneecap). These metal pieces are cemented in place. Then, the surgeon places a plastic insert between the metal pieces to allow smooth movement of the knee.
Partial knee replacement is increasingly being performed as an outpatient surgery.
Do Patients Notice?
Dr. Stefan Tarlow, an orthopedic surgeon with Advanced Knee Care in Scottsdale and Mesa, Arizona, performed Kozlo’s recent knee replacement. Tarlow switched entirely over to the robot-assisted method in 2011. With traditional surgery, “there are many factors we can’t control when we use our eyes and skill,” he says. “For a partial knee replacement, the precision in which we can adjust how that implant is placed in the patient’s knee is, I think, critical.”
While surgeons agree that robot-assisted surgery increases the precision of bone cuts to within a single millimeter or less, the issue is whether patients experience an appreciable benefit. For his part, Dr. Sharat Kusuma, director of adult reconstruction at the Grant Medical Center in Columbus, Ohio, isn’t sure.
“The question is — does it make a difference?” Kusuma says. “Is it clinically relevant?” It might be, he says. But without more and longer-term data to back that up, it’s too soon to tell. Kusuma did a study of both methods, published in the September 2014 Journal of Arthroplasty, comparing results with manual and robotic techniques. He found no significant differences in patients’ outcomes, which were “excellent” for both groups.
My Favorite Knee
Kozlo, with his dual knee replacements, only represents one patient. His standard procedure was done five years ago by a different surgeon in another country. It’s just been a month since the robot-assisted procedure — too soon to say how his new left knee will feel a year from now. Given all that, here’s how his experiences compare:
With the standard knee replacement, Kozlo stayed in the hospital for three days. He used a walker as an inpatient and another week at home, then moved on to crutches and a cane. The pain was “much worse” the first time, he says, requiring a morphine drip during his hospitalization.
With the robot-assisted procedure, Kozlo says, he was in and out of the clinic within four hours, and out to dinner the next night. He was given oxycodone pills for pain but didn’t need the full supply. As for mobility, Kozlo used a cane for a single day, and returned the crutches he’d bought unused. He’s already been out and about — walking and riding his mountain bike.
With “health care up in Canada, the wait time is very, very long,” he says, which is why he opted to have surgery during his annual “snowbird” stay in Arizona. He paid for the procedure himself, to the tune of about $20,000. It was money well spent, he says. “It’s surpassed any expectations I had. This one is far and away better than the other one.”
Consider Your Options
Hospitals lay out upward of $1 million for the equipment to perform robotic joint replacement. What concerns Kusuma is that the new technology might draw patients to nearby centers that perform relatively few joint replacements — or to surgeons who are less experienced and rely more on the robotic assistance to boost their technique.
Kusuma says while many Americans aren’t willing to travel several hours to seek out the best possible health care, an elective procedure like knee replacement “shouldn’t be a local product. It really should be a center of excellence.”
His advice to patients — whether they need a knee replacement or cardiac bypass surgery — is “you’re better off going to a person who’s done quite a few of them. You should be looking for a place that has high volume and good outcomes, and not just go to the first place in your locality.” And patients “absolutely” should ask whether they need a partial or total knee replacement, Kusuma says.
Pearle agrees. About 10 percent of patients with knee arthritis currently get a partial rather than a total knee replacement, he says. However, “it’s been estimated that the number could be 20 to 40 percent of people,” he adds. “About 10 percent of the U.S. population has knee arthritis. It’s a big issue.”
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Knee Replacement: What to Consider originally appeared on usnews.com
