Medical Minute 6-22: Healing Arthritic Knees With a Robot

By: Vanessa Welch Email
By: Vanessa Welch Email

A day playing golf is a day Herb Williams has been waiting a long time for. The lifelong athlete is just getting back into the swing of things after years of grueling pain with osteoarthritis brought him to his knees.

"The pain became more constant and aching, and you just wanted relief," said Herb Williams.

Herb's doctor suggested a new surgery known as makoplasty

"It uses a robotic arm that's connected to a high-speed burr to help remove only the diseased portion of the knee and allow for a quicker recovery with a more natural-feeling knee," said Andrew Noble, M.D., Orthopedic Surgeon.

Doctor Noble invited our cameras in so you can see how the surgery works. Using a three-D screen, the surgeon tells the computer where certain parts are on the knee.

"It basically matches up the CT scan to what we have in real life."

Then -- the robot comes in.

"So the robot is following the plan that we just made for how much bone needs to be removed as well as staying inside the lines."

The green area is the bone the surgeon targets.

"He's making the movements of his hand based on what he's seeing on the monitor. Kind of like a joystick or controller of a video game where you're watching a TV screen, moving the man around on the TV screen, but your hands are actually moving without you watching them."

Putting herb back on the green in five weeks.

"My legs feel good, which is primary. That's what this is all about."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500,


BACKGROUND: Osteoarthritis is the most common joint disorder. It develops as the articular cartilage in the knee begins to deteriorate. When this happens, the joint space between the bones narrows. In severe cases, the bone ends rub against each other and wear away. People with osteoarthritis may have a hard time walking, finding it painful. Stiffness also characterizes the disease. It affects more than 15 million people in the United States alone.
(SOURCE: Academy of Orthopaedic Surgeons)
CAUSES/SYMPTOMS: Aging joints, previous injuries and obesity are common causes for osteoarthritis. Symptoms include joint pain, aching, stiffness, muscle weakness, limping and loss of motion. This “wear and tear” disease can stop people from enjoying life and the activities they love.

NEW MAKOPLASTY TREATMENT: A new surgery technique known as MAKOplasty uses a robot to help surgeons buff out osteoarthritis and custom fit an implant. MAKOplasty uses GPS technology, a 3-D screen and a robot to guide the surgeon’s hand. Before the resurfacing is performed, a 3-D image of the knee is created pinpointing exactly where the arthritis is so that only the diseased tissue is removed. The incision made (4-6 inches) is smaller than that made in a total knee replacement (8 inches), and recovery time is faster. Most patients are able to walk out of the hospital the same day as their surgery.

BEST CANDIDATES: MAKOplasty is best for those living with painful early to mid-stage osteoarthritis of the knee. It suits those who would like a less invasive surgery with a faster recovery time than total knee arthroplasty. Most patients recover in a matter of weeks compared to total knee replacement surgery that can take months to recover.

Ryan Lieber, Tenet Healthcare PR Manager North
Delray Medical Center
Palm Beach Gardens Medical Center
Good Samaritan Medical Center
St. Mary’s Medical Center
West Boca Medical Center
(561) 308-9830


Andrew Noble, M.D., an orthopedic surgeon at Good Samaritan Medical Center/Palm Beach Orthopaedic Institute talks about a new procedure for arthritic knees.

Tell me about the procedure.

Andrew R. Noble, M.D.: MAKOplasty is a robot assisted partial knee resurfacing surgery for patients who have isolated knee arthritis. It uses a robotic arm that is connected to a high-speed burr to help remove only the diseased portion of the knee and allow for a quicker recovery with a more natural feeling knee.
What’s really interesting about this technology is that you can zero in on exactly where the problem is. You can zero in on the arthritis. Can you talk a little bit about that?

Andrew R. Noble, M.D.: This technology only replaces the diseased portion of the knee. The other areas of the knee that don’t have arthritis are not affected by the surgery. A CT is done before the surgery to create a 3-D model of the knee that we can use for sizing and for placement of the components. This allows us to more precisely plan the surgery. During the time of the surgery the robot is used to remove only the diseased portion of the knee which helps the patient experience a more natural feel knee, and have a quicker recovery It also allows for a shorter incision and less blood loss.

Can you talk a little about osteoarthritis and how many people it affects and what it does to the joints?

Andrew R. Noble, M.D.: The problem with osteoarthritis is that the cartilage at the end of the bone starts to wear away. This then leads to increasing pain and stiffness and swelling of the knee. This is why patients come in. We treat them initially with anti inflammatory medications and injections, potentially, using bracing and physical therapy. When these non-operative measures are no longer effective we then look into surgery. The advantage of doing a MAKO plasty is that we can replace only the diseased portion of the knee leaving the other portions behind since they are not affected by the arthritis.

How does this compare to traditional surgery?

Andrew R. Noble, M.D.: Traditional surgery, as in total knee replacement, replaces the entire knee which generally requires a larger incision, longer hospital stay and a longer recovery.

The new procedure enables you to zero in to the diseased portion of the knee?

Andrew R. Noble, M.D.: Right. With this new technology we can zero in only on that disease portion of the knee. It also allows us to more accurately place the components for better long-term outcomes.

Is everyone a good candidate for this?

Andrew R. Noble, M.D.: Not everyone is a good candidate for this surgery. They need to have more isolated arthritis in one particular area of the knee with activities. Their x-rays need to show moderate to severe arthritis in that particular portion of the knee. Also, patients need to have somewhat of a preserved range of motion. They can’t be overly stiff before surgery. Also, they can’t have a significant deformity of their knee.

****Next try: (baby born – lullaby playing in the hospital)

Andrew R. Noble, M.D.: Patients that are good candidates for the MAKO plasty have isolated arthritis in one particular area of the knee. Their pain is localized to that area during activities. These patients have also tried non-operative measures, which are no longer effective. Also, it is important that patients have a good range of motion of their knee without too much stiffness and don’t have a large angular deformity, which would make them a better candidate for a total knee replacement.

Have you seen instances where patients have had the MAKO plasty but had to come back and get the traditional surgery ( a total knee replacement)?

Andrew R. Noble, M.D.: I have not had any patients come back for the traditional surgery. There are patients that I’ve seen that have more traditional non-robotic partial knee replacements that do need a conversion to a total knee replacement. A lot of times this is many years after the surgery was initially done.

The pain comes from the bone grinding against each other without any cartilage or anything to absorb that shock?

Andrew R. Noble, M.D.: Right. It turns out that the pain comes from the nerve fibers in the bone. Cartilage doesn’t have nerve fibers. When the cartilage wears away at the end of the bones patients experience pain when the bones start to rub against each other. The cushion has basically been eliminated through the development of osteoarthritis.

How long have you been doing this procedure?

Andrew R. Noble, M.D.: I’ve been doing this procedure for approximately six months.

What has been the response from your patients?

Andrew R. Noble, M.D.: I’ve had an excellent patient response with faster recovery, quicker return to recreational activities and even work as soon as two to four weeks after surgery. This has become quite a popular procedure. Patients don’t always have arthritis that affects all areas of the knee. Many times patients have arthritis in only one area. So, this is an excellent procedure for that indication.

I hear that the recovery time is so short that people are just getting up and walking out whereas when they came in they were having struggles.

Andrew R. Noble, M.D.: Very true. Patients notice a dramatic improvement early on. At two weeks when I see patients back they are able to walk into the office almost routinely without a cane. I’ve had patients who have returned to golfing as soon as two to three weeks after surgery.

How does that compare to the other surgery then?

Andrew R. Noble, M.D.: Compared to a total knee replacement, the lag time for that is potentially six to eight weeks before patients get back to more normal activities. And the entire healing process after a total knee replacement can be up to six to twelve months. There is still some time after this procedure that patients can have some soreness and we involve them with physical therapy and try to maximize their range of motion.

Do you feel right now this is the best alternative for people who have osteoarthritis in their knees?

Andrew R. Noble, M.D.: I think MAKOplasty is the best alternative for select patients who are good candidates for this surgery. This surgery is not for everybody. It needs to be for that patient who has isolated arthritis and pain in a particular area of their knee.

For the rest, they would have to look at other alternatives.

Andrew R. Noble, M.D.: The other alternatives would be the non-surgical treatments as well as a total knee replacement.

Can u explain the technology to us when we go into the operating room?

Andrew R. Noble, M.D.: Essentially, this is an interactive robotic arm that’s connected to a high-speed burr that the surgeon directs to remove only the diseased portions of the bone in an area where the implant will be placed or seated.

Let me say that another way:

This is a robotic arm connected to a high-speed burr that guides the surgeon to remove only the involved area of the knee arthritis. During the time that the bone is removed real time images are displayed on the monitor which show the areas where the bone has already been removed as well as the areas that need to be removed. The MAKOplasty is analogous to staying inside the lines when you are coloring a picture.

In what way? Because it really directs you?

Andrew R. Noble, M.D.: You determine where you want to remove the bone. We basically, draw a line, which outlines the implant and the robot keeps us within the particular area where the implant needs to be seated. So, in essence, if you are drawing a picture it keeps your hand within the line that the picture has already pre-drawn.

What if you start to go outside the line?

Andrew R. Noble, M.D.: The robot prevents the burr from moving outside the lines. There is an actual resistance to the robotic burr for moving outside the lines. The robot prevents the burr from moving outside the lines by a mechanical block and going beyond that area. In addition there is an audible notification that you are getting close to the edge and if you are going way beyond the lines the burr itself will shut down,

Will we be able to hear that?

Andrew R. Noble, M.D.: Yes, you will. You’ll be able to hear the beeping sound as you’re getting too close to the margins of where the implant is supposed to be placed. What this is doing is the robot is preventing unintentional removal of bone outside of the area where the implant is to be seated.

Mic problem

The robot prevents the unintentional removal bone in the knee that is not supposed to be operated on.

The robot prevents the unintentional removal of bones in areas that are not supposed to be removed. It allows the surgeon only to remove the diseased portion of the knee where the implant is supposed to be seated.

That’s pretty exciting. Just think about how far technology has come.

Andrew R. Noble, M.D.: It is. This robotic technology has elevated surgery to a new level. This has allowed us to precisely prepare the bone and more accurately implant the components.

Is there anything we missed that you think would be relevant? Anything else you want to say about the procedure?

Andrew R. Noble, M.D.: What you need to understand is that partial knee replacements can be done without a robot. And, traditionally, these procedures have been performed without the use of a robot. The issues and problems have been with malpositioning of the component implants, which could then lead to early failure. So, this technology allows for more precise bone preparation and more accurate component alignment, which will, hopefully, avoid the early failures and allow for longer durability and long lasting outcomes.

How long do these replacement usually last?

Andrew R. Noble, M.D.: That’s a great question and something a lot of people ask. In appropriately selected patients a partial knee replacement can last at least ten years.

Appropriately selected?

Andrew R. Noble, M.D.: There are definitely patients that are better qualified for this procedure. We found that patients who are very heavy, more than 200-250 lbs. may have early failures. Osteoporotic bones could lead to some bone collapse. Also it is important to determine where the patient’s pain is localized. If they are having pain throughout the knee then doing a partial knee replacement is not the right procedure to do. A total knee replacement would be the better choice so that you can address all their pain.

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