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Medial Partial Knee Replacement

What is a Partial Knee Replacement?

X-rays of partial knee replacement

X-rays of partial knee replacements by Dr. Buechel. Left to right: 1. Medial 2. Medial after ACL reconstruction 3. Lateral 4. Patellofemoral 5. Medial and Patellofemoral.

  • A partial knee replacement, also called a “resurfacing or arthroplasty”,is a surgical procedure that replaces (“resurfaces”)one or two of the painful, damaged, knee joint compartments.
  • Partial Knee replacements decrease or eliminate knee pain and swelling during weight bearing activity from the worn-out or damaged surfaces.
  • The compartments that can be replaced are:
    • Medial (inner side and most common)
    • Lateral (outer side and second most common)
    • Patellofemoral (the kneecap compartment and least frequently performed)
  • The new surfaces called “implants”and they are made of cobalt chrome and titanium alloy metals, and a polyethylene plastic insert.These implants replace the damaged cartilage surfaces and the meniscus.
  • Partial Knee Replacement with Dr. Buechel’s Mini-incision Mako Robotic assisted technique is dramatically less invasive,preserving all the healthy functioning structures of the knee and allowing for a rapid return to activity.

What are the keys to a successful Partial Knee Replacement?

  • Choose an experienced orthopaedic partial knee surgeon to perform your surgery. One who has done several hundred at least in the compartment you are looking to replace.
  • Choose an experienced surgeon to optimize and minimize your skin incision, be meticulous with the handling of your tissues, avoid cutting into the muscle, and provide a multilayered watertight closure with a cosmetic skin closure.
  • Choose a surgeon who uses advanced technology to optimize the preparation and installation of you implants. This is critical to success.
  • An experienced Mako Robotic Partial Knee surgeon would be optimal to achieve the reported low revision rates seen in the joint registry data for medial partial knee replacement (only 0.8% failure rate in the Australian Joint Registry Data, best in the world). Dr. Buechel was the launch surgeon for Australia providing all Mako Robotic Partial Knee training to the Australian surgeons starting in 2015.
  • Optimizing implant alignment, sizing, tracking, ligament balance, and bone preparation are keys to success and are possible using the Mako Robotic System on all cases.
  • Choosing a surgeon who uses Multi-Modal Pain management during and after the procedure to minimize the discomfort
  • Your surgeon should educate you on why, or why not to do a partial knee replacement, so you are clear this is best choice for you.
  • Make the decision to optimize your health before and after your surgery to help healing
  • Be dedicated to your recovery program protocol to optimize a successful and rapid return to activity.
  • Dr. Buechel’s 11-year robotic experience with thousands of partial knee procedures, meticulous attention to all details, use of robotic technology, comprehensive presurgery education and post-surgery protocols will optimize the chance of your successful partial knee surgery.

What is a Medial Partial Knee Replacement?

X-rays of medial sided osteoarthritis that is bone on bone

X-rays of medial sided osteoarthritis that is bone on bone. A front view of a medial partial knee replacement. A side view of a medial partial knee replacement. The skin appearance of the mini-incision Dr. Buechel uses to install the partial knee.)

  • Medial Partial Knee Replacement is performed on the inner side of the knee, called the medial side. This is the most common of the three compartments of the knee that can wear down. This is also the most
    common partial knee replacement performed.
  • Medial Partial Knee Replacement provides new surfaces that restores smooth painless motion on the inner side of the knee and can last for decades.
  • Medial partial knee replacement will restore and maintain the natural tension to the 4 main ligaments (ACL, PCL, LCL, MCL), correct some or all of the angular deformity of the leg, and allows for a return of near normal knee motion and kinematics.
  • A well installed partial knee replacement allows patients to return to life’s normal activities, including walking, hiking, biking, swimming, dancing, running, climbing stairs, tennis, golf, deep knee bending and more.
  • Dr. Buechel has used the Precision Mako Robotic Partial Knee System to install his partial knees for more than 11 years and nearly 2,000 cases in the USA and internationally.
  • Dr. Buechel’s Medial partial knee replacements are performed with the Mako Robotic Arm System to provide every patient a consistently, reproducible, precision installation through a minimally invasive approach.
  • Dr. Buechel uses the Mako Robotic System to:
    • Pre-operatively plan your surgery with precision sizing and initial anatomic implant positioning and alignment.
    • Intra-operatively, Dr. Buechel optimize the ligament tension, implant tracking and implant to cartilage transitions in the software.
    • The Robotic arm is guided by Dr. Buechel to prepare the bone surface exactly to plan within 1mm and 1 degree. This ensures optimal implant alignment, tracking, ligament balance, and bone preparation.

Who is a candidate for a Medial Partial Knee Replacement?

X-rays of medial partial knee replacement candidates. The left 4 images are mildto severe medial compartment osteoarthritis. The right two images are osteonecrosis of the medial femoral condyle.

X-rays of medial partial knee replacement candidates. The left 4 images are mild to severe medial compartment osteoarthritis. The right two images are osteonecrosis of the medial femoral condyle.

Deciding to have a partial knee replacement requires that your clinical history, physical symptoms, physical exam and imaging (x-rays and sometimes MRIs) point towards partial knee replacement. This synthesis of information requires a skilled partial knee surgeon,like Dr. Buechel, to ask the right questions, perform a properpartial knee exam, and understand the imaging to confirm where the problems are in the knee, and then provide you with the correct recommendations.

The clinical history indicating a person is a candidate for a medial partial knee replacement can include one or several of the following:

  • Younger active adults,generally in the later 30s and beyond, that want to remain very active who have painful weightbearing knee arthritis or osteonecrosis.
  • Adults that have had a prior medial meniscus tear,with or without surgical repair that have gone on to degenerative arthritis in the medial compartment.
  • Adults who have had a prior knee fracture/break on one side,such as a tibial plateau fracture.
  • Active older adults into their90’s who have painful weightbearing knee arthritis or osteonecrosis.
  • Older patients that are too unhealthy to undergo the stress of a total knee replacement and its recovery.
  • Adults with a prior ACL reconstruction that have gone on to develop arthritis in the medial compartment.
  • Patients that have failed one of the cartilage repairing operations on the medial side of their knee joint.
  • Patients that no longer respond to injectable treatments like PRP, Stem Cells, Hyaluronic Acid or cortisone.

The symptoms many people experience indicating they are a candidate for a medial partial knee replacement are:

  • Pain Medially in the knee when walking
  • Pain getting up from seated position
  • Pain walking stairs
  • Dull aching pain, Sharp Pain
  • Swelling of the knee Joint
  • Stiffness in knee
  • Loss of motion in the knee
  • Walking distance has decreased
  • Limping
  • Reduction in fun activities
  • Decreased or stopped playing their sports
  • Failed Injection Therapy (Cortisone, HA, PRP, Stem Cells)

 

The physical exam findings people have indicating they are a candidate for a medial partial knee replacement are:

  • Pain on examination with pressure on the medial (inner) compartment of the knee
  • No pain or tenderness in the lateral or kneecap compartments
  • The ACL and PCL ligaments should be stable on exam.
  • The collateral ligaments must be intact and have stable end points when corrective tension is applied to the knee on exam.
  • Range of motion for best candidates should have no more than 15 degrees loss of extension (straightening), and at least 90 degrees of flexion (bending).
  • Varus (bowlegged) limb alignment deformities should be less that 15 to 20 degrees.
  • Opening up of the medial side of the knee space when a stress is applied to the knee joint.

The x-ray findings people have indicating they are a candidate for a medial partial knee replacement are:

  • A decrease or total loss in the medial joint space of the knee on the Anterior Posterior (AP View) and Flexion Weightbearing views (Rosenberg View).
  • The lateral compartment joint space is preserved. There may be some small bone spurs.
  • The patellofemoral joint space is normal, or mild to moderate space loss with no pain. There may be bone spurs around the kneecap edges.

What are the Benefits of having Dr. Buechel perform your Partial Knee Replacement?

multiple knees with small scars after partial knee replacement

  • Dr. Buechel has Unparalleled Experience with nearly 2,000 Mako™ Partial Knees Performed since 2009. Most surgeons do less than 10 per year.
  • He has published on his excellent partial knee patient satisfaction and outcome results
  • He developed the 1st Advanced Mako™ Partial Knee Bio-Skills Course in USA
  • He is an international advanced Mako Partial Knee Instructor
  • He was the Mako Launch Surgeon & Proctor more than 10 countries including the USA, Hong Kong, Thailand, Singapore, Greece, Turkey, Italy, Taiwan, Vietnam, China and Australia.
  • Performed the First Mako Surgeries in Asia in 2012 and Europe in 2013
  • He has been a Mako Surgeon Instructor at more than 75 Mako Bio-skills Cadaveric Courses (Knee & Hip)
  • He uses a Mini-Incision
  • He cuts No Muscle
  • No Tourniquet is used
  • All his Partial Knees are Outpatient Procedures
  • Less Pain, Faster Recovery
  • All Ligaments are preserved
  • Less Bone is Removed
  • He performs a beautiful Cosmetic Skin Closure
  • You can Shower the next day
  • Your Motion will Improve with a more Natural Feel
  • You will have a Predictable Precision implant installation

How does Dr Buechel perform his Medial Partial Knee Replacement?

Dr. Buechel has developed a comprehensive process to achieve high levels of patient satisfaction and great outcomes for his medial partial knee replacement patients. It begins with educating his patients in the office, providing best in class surgical techniques, using the most advanced and precise surgical technology, and being there always after surgery to help you regain your highest level of satisfaction possible.
The following is a summary of the major steps that Dr. Buechel goes through to ensure your knee is done perfectly.

  • He is a master pre-operative and intra-operative software planner on the Mako Partial Knee software which allows him to optimize your implant size and initial positioning.
  • He uses an Innovative Medical Products DeMayo leg holder that allows him to optimally position the knee during each part of the surgery.
  • He uses a small 2-3-inch skin incision over the medial compartment to provide direct access to the area to prepare and resurface.
  • He does not cut into the vastus medialis quadriceps muscle during the exposure.
  • He does not use a tourniquet during surgery which reduces pain and dramatically reduces the chance of a blood clot.
  • He uses the medication (TXA) Tranexamic acid to reduce blood loss, and none of his patients require transfusion.
  • He uses custom instruments and retractors to be gentle on the skin and provide excellent visibility
  • He is very detailed about cauterizing any bleeding during the surgery to reduce swelling and pain.
  • Once the Robotic system is setup and connected, Dr. Buechel properly inputs all the kinematic data from your knee motions and ligament tensions, and then makes the final implant positioning adjustments in the software.
  • The Robotic arm is then brought into the field where it is controlled by Dr. Buechel’s hands to prepare the bone surfaces to receive the implants.
  • The trial implants are installed and then all the bone edges are trimmed and smoothed around the implants.
  • Stability is checked and the computer data is evaluated to help make the final choice on insert thickness to provide the optimal tension on your medial compartment.
  • The final implants are then opened and attached to the bone surfaces with a bone cement. This is a critical step to ensure optimal fixation of the implants.
  • The knee is irrigated with bacteriostatic and antibiotic solutions prior to closure to reduce infection risk.
  • PRP (Platelet Rich Plasma) is injected into the joint and tissue planes to reduce bleeding and aid in tissue healing.
  • The final skin closure is done with a skin adhesive Dermabond that acts as a barrier for 3 weeks over your skin incision. This allows for daily showering and results in a pleasing final scar.
  • A light dressing and ACE wrap cover the knee to go home.
  • A Cryotherapy machine is started immediately to reduce pain and swelling.
  • The next day a Reparel compression leg sleeve is provided in the office.
  • A Nutritional support program is recommended as part of the protocol to ensure optimal healing.

What is the normal recovery time for Robotic Partial Knee Replacement Surgery?

  • Recovery for a Medial Compartment Robotic Partial Knee Replacement surgery by Dr. Buechel is significantly less difficult than patients expect.
  • You are full weight bearing right from the operating room on day one. You will start off with a cane, crutches or walker. You can eliminate any or all of these devices once you feel stable and confident with your balance. This is generally within the first week. But there is no rush, I want you to feel safe and use these devices until you feel ready to discontinue them.
  • The mild to moderate pain is generally limited to the first week starting day 2-3. Swelling control is the main goal in the first 2 to 3 weeks.
  • Once the swelling has resolved, the range of motion generally returns to the pre-op motion. Most patients by 6 weeks have all their pre-op motion back. By 3-6 months, many patients have increased their motion by 8-10 degrees.
  • Physical therapy for robotic partial knee replacement surgery is not an aggressive painful process like most total knee replacement therapy can be. I start with simple patient home exercises the first week to allow for wound stabilization and swelling reduction. Then I begin formal physical therapy the second week focused on improving the quadriceps strength and proper return of a normal, or near-normal gait cycle.
  • Stationary bike exercise can begin right away using the non-operative leg only, to get your cardiac conditioning going and release the good endorphins into your system.
  • At the end of the second week,you can use both legs on the bicycle if the swelling has subsided and the wound has stabilized.
  • Driving is generally okay by the end of the first week for most patients with the understanding that you are not allowed to drive ever if you are taking narcotic pain medication.
  • I limit high impact exercises like jumping or running, and high torque twisting like a strong golf swings and singles tennis until the 8-weekmark. This allows the bone to stabilize where the tracking pins were inserted during your surgery, to reduce the risk of a bone fracture at the pin sites.
  • Return to most activities is common by 12 weeks. However, the knee improves for 18-24 months which means you have lots of time to get it great.

Pain Management for Medial Partial Knee Replacement

Partial Knee Replacement Surgery performed by Dr. Buechel with the Mako Robotic System is significantly less painful for several reasons. Dr. Buechel has developed a comprehensive process to control and manage pain from over a decade of robotic partial knee experience in the USA and Internationally. His protocols are designed to make the recovery process as comfortable as possible. An important part of managing pain is communication. Dr. Buechel and his staff are always available for our post-operative patients directly by mobile phone or text.

  • The multifaceted approach to pain control and swelling reduction includes medications, supplements, surgical techniques that include mini-incisions, no tourniquets, no muscle cutting, layered skin closures and skin adhesives, personalized software enhanced ligament balance restoration, robotic bone preparation & tissue protection, cryotherapy during recovery, personal leg compression sleeves and rapid mobilization.
  • Dr. Buechel has developed several techniques and uses special instruments that allows him to make a very small incision, put very little stretch on your skin and tissues, and still have great visibility to precisely install your implants with minimal tissue injury.
  • His anesthesiologists provide you with a spinal anesthesia or general anesthesia, along with two nerve blocks (1. Adductor Canal Block, 2. IPACK block) that give you great pain control after the surgery for 36 to 48 hours. The anesthesia team uses Dexamethasone IV steroids to reduce swelling after surgery which provides increased pain control and comfort.
  • Dr. Buechel injects a local anesthetic mixture into the wound to provide you with even more immediate pain control that allows you to walk out of the surgery facility and back into your home or hotel that day.
  • Dr. Buechel does not use a tourniquet to stop blood flow while operating. This eliminates the thigh pain after and during surgery, allows for better bleeding control, reducing swelling and lessening pain after surgery. This also dramatically reduces your chance of a blood clot from knee surgery.
  • Dr. Buechel injects PRP (Platelet Rich Plasma from your own blood draw during surgery) into your wound during the closure to reduce bleeding and reduce swelling, lessen pain and improve wound healing.
  • A Breg Polar Care Kodiak Cryotherapy cool wrap is provided after surgery. It is simple to use and critical in making you comfortable, reducing pain and reducing swelling.
  • A Reparel sports compression leg sleeve will be placed on your operative leg in the office the day after surgery to reduce swelling and pain.
  • Elevation after surgery when you’re not walking is part the protocol to reduce swelling, which reduces pain and improves healing.
  • Avoiding aggressive physical therapy early in the first week allows the wound to seal and swelling to reduce. Simple walking and home exercises are all that are needed for the first week for most.
  • With this regimen, most patients only require ibuprofen and acetaminophen after surgery. Some patients will take a few low-level narcotic pills for a few days the first week after surgery.

How does the Mako Partial Knee System work?

What are Mako Robots:

  • Mako™ Robots are computer programmable machines that help surgeons accurately
prepare bone surfaces for implants
  • They provide Tactile Feedback to the surgeon during bone preparation
  • They create virtual boundaries or walls that the surgeon cannot violate with the cutting
tool.
  • They Provide Precision, Safety & Accuracy During Bone Preparation
  • Dr. Buechel has been a pioneer using and developing the Mako Partial Knee System by
Stryker since he began using the system in 2009. As one of the early adopters of this
revolutionary technology, Dr. Buechel has been a part of the development team and
training team since the beginning. Dr. Buechel is a super user of the technology and
uses all the features available to optimize each of his patient’s knee replacements.

The following are the steps of performing a Mako partial knee
replacement

CT Scan:

  • The process starts by obtaining a low dose CT Scan of the
operative leg from the hip to the ankle. This scan is then
digitally sent to our team and loaded into the Mako
software.

Pre- Operative Planning:

  • Dr. Buechel then reviews and optimizes the plan prior to surgery choosing the initial size
& setting the initial position of the knee implants.

Intra-Operative Planning:

  • Dr. Buechel collects live knee motion data during
surgery, then the software is used to optimize the
implants final position.
  • The data then allows Dr. Buechel to make subtle
position changes to optimize the partial knee implant
position prior to using the robot to prepare the bone surfaces.
  • to allow for real time communication between the
computer, the robot and the patient, tracking devices
are temporarily attached to the thigh bone and shin
bone
  • To create the correct data, the knee deformity is
manually corrected to apply proper tension back to the
ligaments while the knee is brought through a full range of motion that the computer
system can see and document.

Robotic-Arm Precision Bone Preparation


  • The robot is then brought next to the
patient and communication is verified prior
to using it to prepare the bone surfaces.
  • The robotic arm communicates with the
optimized computer plan which creates
virtual boundaries, providing safety and
precision during the bone preparation with
the cutting tools.

Software Confirmation of Implant Positioning

  • Once the bone is prepared, the “Restoris MCK” Implant trials are tested and can be
checked for placement accuracy with the system probes.
  • Final implants are then cemented and verified with the software prior to closure.

When is the right time to have a Partial Knee replacement?
• The decision on when to have your partial knee replacement performed is quite straight
forward.
• It starts by having a proper exam and imaging that confirms you’re a candidate for the
procedure.
• Once you know you’re a good candidate, the timing is really up to you.
• It is never an emergency to have the procedure.
• The only problem with delay is a reduction in your quality of life, and continued pain.
• Therefore, when the pain is no longer tolerable, when your quality-of-life decreases, or
when you can’t enjoy the things you like to because of your knee pain, then this would
be the right time to move forward with your procedure.

When is the right time to have a Partial Knee replacement?

  • The decision on when to have your partial knee replacement performed is quite straight
forward.
  • It starts by having a proper exam and imaging that confirms you’re a candidate for the
procedure.
  • Once you know you’re a good candidate, the timing is really up to you.
• It is never an emergency to have the procedure.
  • The only problem with delay is a reduction in your quality of life, and continued pain.
  • Therefore, when the pain is no longer tolerable, when your quality-of-life decreases, or
when you can’t enjoy the things you like to because of your knee pain, then this would
be the right time to move forward with your procedure.

When Shouldn’t a Partial Knee Replacement be performed? (The
Contraindications)

There are some good reasons that patients should not have a partial knee replacement. For
some of these patients, a precision robotic total knee replacement is the better option. The
following conditions should be considered contraindications for partial knee replacement.

  • Inflammatory arthritis such as rheumatoid arthritis is not a good indication for partial
knee replacement because the entire joint lining is involved in this disease process, not
just one or two compartments. This is a good indication for total knee replacement.
• If the entire knee joint hurts on exam, this is not a good indication for partial knee
replacement, this is an indication for total knee replacement.
  • If the knee deformity (angle of the knee) is too severe, generally more that 15-20
degrees
  • If the knee has poor motion with less than 80 degrees of flexion (bending), and flexion
contracture (it won’t straighten) more than 15-20 degrees
• If the knee is too loose in extension. The knee hyper-extends more than 10 degrees on
exam
  • Having an ACL tear that is unstable on physical exam. Some ACL tears that are chronic
are stable on exam and can still have a medial partial knee replacement without
reconstructing the ACL
  • Having a prior joint infection is a contraindication to a joint replacement and runs the
risk of becoming infected again after the joint replacement surgery.

What Dr. Buechel Does to Improve your Partial
Knee Outcomes

Exposure and safety

  • Dr. Buechel uses a Specialized Padded leg holder designed to support your leg safely
during the partial knee procedure (IMP Leg Holder)

Infection control

  • Dr. Buechel wears a Joint Replacement Space Suit with lighted helmet for optimal
visualization and protection
  • Adhesive Drapes are used to seal skin during surgery
  • Antibiotics are in the Bone Cement
  • Antibiotics are given to you in your IV
  • Preoperative and postoperative Nutritional Supplementation is recommended to
optimize your healing and immune system

Muscle avoiding incision

  • Dr. Buechel precisely draws the anatomy for optimal incision size and position
  • 2-3-inch skin incision is used for most medial partial knee procedures
  • Avoiding Muscle allows for faster return to activity during the recovery process

Blood Loss Control

  • The medicine Tranexamic Acid is given intravenously to reduce blood loss
  • Lidocaine 1% with Epinephrine is injected into the incisions to reduce bleeding
  • Meticulous hemostasis during exposure reduces blood loss
  • No Tourniquet is needed to control bleeding
  • Platelet Rich Plasma Application into joint and would closure reduces bleeding
  • Proper knee positioning and use of the leg positioner during surgery reduces blood loss.

Anesthesia

  • A multimodal approach to your pain control provides an optimal recovery
  • Spinal Anesthesia is recommended, General Anesthesia is just fine if better for you.
  • Regional pain block #1: I-PACK Block
  • Regional pain block #2: Adductor Canal Block
  • Periarticular Local Block: Marcaine, Ketorolac, Morphine

Blood Clot Reduction

  • No Tourniquet
  • No instruments in the canals of the bones to cause emboli
  • Spinal Anesthesia reduces blood clot risk
  • Walking within hours of the surgery reduces clot risk
  • Aspirin 81mg twice a day for 4 weeks
  • Efficient surgical process reduces risk
  • A compression Sports sleeve is used after surgery for 4-6 weeks

Suture Choices

  • Micro-barbed sutures
  • Avoids knot abscesses
  • Antibacterial material lowers infection risk
  • Provides a Watertight closure

Skin Adhesives:

  • Dermabond Skin Adhesive seals the skin edges
  • Allows Showering the Day after surgery
  • Provides a Barrier to Infection
  • Provides better scar appearance
  • Removes easily at 3 weeks

Biologic Treatments

  • Platelet Rich Plasma Application into the knee joint and would closure enhances healing
and the cellular repair process.

Skin Dressings

  • Silicone Boarder Dressings are used
  • Reduces skin irritation
  • Waterproof for showering
  • Remain on for 5-7 days
  • Anti-bacterial
  • Protects the skin glue from clothing rubbing it off

Cold Therapy Wrap / Cooling Devices:

  • Wear continuously as tolerated after surgery
  • Reduces swelling
  • Reduces pain
  • Reduces medication requirements
  • Improve motion
  • Commonly used for 4-6 weeks daily to optimize swelling reduction early

Compression Sleeve:

  • We provide a Reparel Compression Knee Sleeve after surgery
  • These Reduce swelling
  • Provides comfort/support
  • Improves blood flow
  • Used for 4-6 weeks to optimize recovery

Medications

  • Decadron IV Pre-incision & Post Op given in Operating room (Steroid to reduce
inflammation)
  • Aspirin 81mg twice a day for 4 weeks (Reduce Blood Clot risk)(Pain reducer)
  • Acetaminophen (Pain and Inflammation reduction post op) as needed
  • Ibuprofen (Pain and Inflammation reduction post op) as needed
  • Hydrocodone (Moderate pain reduction medication, if needed)

Instruments

  • Specialized custom retractors and tools are used to minimize tissue injury
  • Specialized instruments to optimally prepare the bone and soft tissue surfaces
  • Dr. Buechel is gentle with tissue retraction to optimize wound healing

Physical Therapy

  • We provide a comprehensive post op therapy program for home and your therapist
  • Gentle therapy starts the day of surgery
  • No high impact activity 6-8 weeks

Nutritional Support

  • Protein Supplementation is recommended to enhance wound healing
  • Vitamin C: (to enhance wound healing and infection reduction)
  • Probiotics: (to support your microbiome to optimize healing and to minimize the
negative the effects of the antibiotics on your GI Tract)