Top Six Questions to Determine Seriousness of Knee Pain

June 7, 2013

William A. Leone, Jr., M.D., F.A.C.S.

Knee pain is a widespread complaint affecting people of all ages. It can originate from a sports injury or past trauma, such as a fall. Many medical conditions also can lead to knee pain and arthritis. This includes infection and also autoimmune diseases such as rheumatoid arthritis; childhood diseases such as Rickets or Blount’s disease; or diseases that deposit crystals such as gout. Many types of knee pain can be managed with self-care, such as pain relievers and anti-inflammatory medications. Knee braces and physical therapy also can alleviate knee pain, especially after an injury. In more serious cases of debilitating injury or deformity, surgery may be required.

Sometimes, other medical problems also can cause referred knee pain. Many people who develop osteoarthritis in their hips will experience pain in their knees. Remarkably, some people with hip issues have no symptoms in their hips, only their knees. A variety of problems that people develop in the lower back, such as disc compression or arthritis, often can elicit leg or knee pain. Sometimes, despite their back pathology, these individuals only experience pain in their knees or legs and have no pain in their backs.

If you are experiencing persistent knee pain, here are six of the top questions to ask yourself, and if the answer to one or more of these is yes, I recommend having a conversation with your doctor:

  • Is knee pain habitually keeping you awake at night or do you wake up during the middle of the night with pain?
  • Does your knee pain limit your ability to perform typical daily activities such as walking, climbing stairs, or getting up and down from a sitting position and in and out of your car?
  • Are you afraid that your knee might give way when you pivot or step up or down from a curb?
  • Does your knee pain limit leisure activities such as walking, exercising, dancing, golf, tennis, traveling, or even shopping?
  • Are you experiencing increased frustration that you are losing your quality of life due to impaired mobility?
  • Have you tried other treatments for a suggested period of time, such as exercise, physical therapy, a brace, anti-inflammatory medicines, or injections and still have no relief from pain, or you simply “can’t trust” your knee.

Dr. Leone is a board certified orthopedic surgeon who specializes in treating complex knee problems caused by a broad range of conditions that have led to joint and bone destruction, including: trauma, angular deformity, bad outcomes from prior surgery, infection, rheumatoid or inflammatory arthritis, and childhood diseases. Treatment options include total and partial knee replacement, as well as arthroscopy.

Kneeling Can Bring a Whole New Meaning to Healing – With Partial Knee Resurfacing

November 9, 2012

Scott Resig, M.D.

Walking into an exam room this morning, I was greeted with big smiles and hugs from my 74 year old patient and her husband.  Just 8 weeks ago, I had performed a MAKOplasty partial knee resurfacing procedure on her.

“This knee feels better than my total knee replacement already,” she said as she moves her knee back and forth on the exam table.   She had a total knee replacement on her other knee 2 years earlier.   She told me that the MAKOplasty knee feels more natural and she can kneel yet she still has trouble kneeling on her total knee replacement.

She’s back to farming, gardening and doing activities she could not do before MAKOplasty.   MAKOplasty has changed her life.

“It’s these moments that make me feel so lucky to be an orthopedic surgeon and to have this type of amazing technology at my fingertips.”

Scott G. Resig, M.D. is board certified surgeon at Sky Ridge Medical Center, specializing in complex conditions of the lower extremity with a focus in foot and ankle as well as hip and knee joint replacement. Dr. Resig utilizes many of the most advanced technologies available in orthopedics, including robotic knee surgery, anterior minimally invasive hip replacement and ankle replacement.

An Alternative to Total Knee Replacement for Active Lifestyles

October 23, 2012

David Bartlett, M.D.

My patients tend to be very active enjoying bicycling, swimming, long walks and general physical conditioning.  Many are aware of the shortcomings of total knee replacement and are looking for alternatives to that traditional procedure.  MAKOplasty has provided an alternative solution to their activity limiting arthritic knee pain.

I am continually amazed at the rapid recovery I see in my patient’s after MAKOplasty.  Patients routinely report to the office, one week after surgery, without crutches walking with only a slight limp and demonstrating near normal range of motion.  At three weeks, patients are performing their usual every day around – town activities.  For all practical purposes, they are fully recovered at two months.

I can tell stories – of a farmer who returned to fencing 5 days after surgery, of a dairyman who was milking within 4 days of surgery and climbing a silo at 4 weeks, of a farmer who was back on the tractor within one week of surgery, of a retiree who was on his riding lawn mower with a plastic bag wrapped around his knee (to protect it from flying grass) at 5 days, of a city administrator who returned to desk work 3 days after surgery.  Never in my career, have I been involved in surgical strategy with such a predictable rapid recovery.

Dr. David Bartlett – is a MAKOplasty Surgeon in Madison that practices at Bone and Joint Surgery Associates 340 S. Whitney Way, Madison, WI  53705 T: 608-238-9311

10 Things Your Knees Are Trying To Tell You

September 26, 2012

Andrew D. Pearle, M.D.

Memo From Your Knees:

I am the largest and most complex joint in the human body. The knee has been likened to a biologic transmission. In a car, a transmission is designed to accept and transfer loads between the engine and the wheels. The knee accepts loads from the lever arm of the femur, the longest bone in the body, and transfers the load down to the lower leg and foot. Knees typically work well and can last an entire lifetime. However, they are prone to injury and can wear out over time (20% of knees develop arthritis during the course of a lifetime). Here is some advice from your knees on how to keep your “knee transmission” running strong.

1. “Keep Me Moving”

Blood does not flow to the bearing surface of the knee (the cartilage or the inner portions of the meniscus). Instead, the cartilage and meniscus is bathed in joint fluid that provides nutrients to it. This joint fluid is like transmission fluid and is pumped throughout the joint by moving the knee. Without motion, the cartilage and meniscus is starved of its nutrition as the joint fluid does not circulate. Therefore, keep your knee moving – take walks, bike rides, hikes, etc.

2. “Understand The Loads You Are Putting On Me.”

Different activities impart very different loads across the knee. You should know the following chart:

Cycling = 1.2 times body weight across the knee
Walking = 3-5 times body weight across the knee
Stair Climbing = 5-7 times body weight across the knee
Running = 15 times body weight across the knee

When you go running, the magnitude of load you are subjecting your knee to is 10-15x more than when you go cycling. When your knee hurts, go spinning or swimming and don’t pound your knees into the pavement on a jog.

3. “Lighten My Load”

Now that you understand how loading affects a knee, it is critical that you do not put excessive loads on your knees. The best way to unload your knee is to stay slim. Body weight matters and every pound on you is magnified at the level of the knee. For every pound you weigh, your knee feels it as 3-5 pounds when you walk and as 15 pounds when you run!! Think about it – if you lose 10lbs, you reduce your knee’s load by about 50 pounds when you walk and by 150 pounds when you run. That has an enormous effect on how long your knee will last.

4. “Share My Load”

The muscles around the knee are the motor that drives the knee transmission but also absorb energy and dampen the load that your knee has to transfer. In fact, during normal walking, the muscles around the knee actually absorb more energy than they generate! As such, keep the hamstrings, quadriceps, and lower leg muscles strong – they take load off of the knee and protect it.

5. “Listen To Me”

Your knee can’t speak but it can tell you when something is wrong. Your knee will alert you by swelling, hurting, locking, and buckling. It does this to try to tell you something. Please do not “play through” these things and go see a doctor.

6. “Keep Me Flexible”

Your knee is most efficient when it has a full range of motion. Stretch often to keep your knee limber and fresh. When it loses motion, your knee will have difficulty regaining it and will often lose progressively more motion over time.

7. “Get Me Fixed”

If your knee does break down, it needs to be fixed. Because it is the most complex joint in the body, your knee often does not respond well to injury. It doesn’t perform well when its ligaments are destroyed and they often need to be replaced or to be protected as they heal. Your knee’s menisci are prone to injury and either trimming or repair is often needed. This maintenance can often preserve its function.

8. “Respect Me As I Age”

We can’t reverse the aging process. As your knee gets older, its cartilage and menisci become stiffer and less pliable. It has less capacity to transmit high loads and is more susceptible to injury. As your knee gets older, you need to make sure you take better care of it – keep it moving to keep it lubricated, stay slim and build muscle to unload it, and incorporate low impact activities into your lifestyle.

9. “Pills, Shots, And Physical Therapy When I Break Down”

20% of the US population develops knee arthritis. We don’t know why this happens but it is almost part of the human condition. While the arthritic process is not reversible, anti-inflammatory pills such as NSAIDs (ibuprofen, Naprosyn) can reduce inflammation and ease pain. Steroid shots are often effective at reducing pain and viscosupplementation (gel) shots (such as synvisc, orthovisc, etc) can help lubricate the joint (like adding new transmission fluid). Physical therapy often helps by improving muscle function to unload your knee. Weight loss is often the most effective way to help a damaged knee and can relieve 40% of knee pain.

10. “They Can Rebuild Me”

Sometimes a knee breaks down, and pills, shots, and physical therapy are no longer effective at keeping the knee transmission functioning. Excellent operations to rebuild the transmission are now available such as partial and total knee replacement. Although these rebuilt knee transmissions have less capacity than factory “original” knees that you were born with, they can provide excellent pain relief and restoration of function. Newer techniques such as robotic knee resurfacing provide durable pain relief and rapid return to activity.

 Andrew D. Pearle, MD is a board-certified Orthopedic Surgeon at the Hospital for Special Surgery, specializing in Sports Medicine, Arthroscopy and Robotic Surgery in New York City.

Do I Need A Hip Replacement? Ask your Surgeon These Questions.

September 5, 2012

Benjamin Domb, M.D.

At first, you could control daily hip discomfort with over-the-counter painkillers, but now even that doesn’t work, so you make an appointment to see your doctor, wondering if you need a hip replacement. To maximize the benefits of that appointment, here are several questions to ask your doctor: Do I really need a hip replacement? How accurate is the placement of the components? How minimally invasive is the surgery?

Below are the answers you should hear:

Do I really need a hip replacement?

Although various congenital disorders may lead to hip replacement surgery, the most common reason for undergoing this procedure is arthritis. If a hip has only mild arthritis and no longer responds to non-steroidal anti-inflammatory medication and rest, your doctor may recommend physical therapy and/or injections to reduce inflammation, which may then alleviate stiffness, swelling and pain.

Your doctor should make every effort to treat your condition non-surgically, and to preserve the natural hip for as long as possible.   Surgery should be utilized as a treatment option only when non-invasive treatments fail to work.

Are there any other options?

Another option for many hip injuries is hip arthroscopy. In this procedure, the surgeon inserts a camera into the hip through tiny incisions. Through this technique, the surgeon can often diagnose and correct the problem causing the trouble. Injuries such as a torn labrum, torn cartilage, impingement, snapping hip or muscle tears may be repairable through a hip arthroscopy. In many cases, this option should be explored prior to considering hip replacement.

How accurate is the placement of the components?

Hip replacement surgery can be challenging; precise implant positioning is essential to help avoid complications such as implant wear, dislocation, and to maintain even leg length and normal muscle function. A recent study from Massachusetts General Hospital examined the placement of just the socket component and discovered that only 47% were  in an ideal position. This was despite the surgeries being performed by outstanding surgeons at a renowned institution.

In a study comparing MAKOplasty® Total Hip Replacement performed with robotic arm assistance, to standard hip replacements (those done without robotic arm guidance), the percentage of accurately placed sockets went from 47% to 84%, using the same methodology and 2-D image evaluation as Massachusetts General Hospital used in the original study.  A 3-D image evaluation of the data provided by the RIO® system found that 96% of the MAKOplasty® cases were within this restricted safe zone. In short, almost all of the MAKOplasty® hips were in an ideal position. This is because the MAKOplasty® procedure uses a highly advanced, surgeon-controlled, robotic arm system to help accurately align and position the implants. Best of all, almost anyone needing hip replacement surgery is a candidate for this procedure.

I believe that the robotic arm procedure will eventually replace traditional hip replacement surgery. I also believe the MAKOplasty® hip behaves more like a normal hip, meaning the hip should last longer, thus lengthening the time between hip replacements.

Although many experienced surgeons can do an excellent job performing a hip replacement without the robotic arm or other forms of guidance, the data shows that the hand alone is less than ideal at least 50% of the time, and accuracy can be dramatically improved with the robotic arm.

How invasive is the surgery?

The size of the incision is the area where most patients focus simply because that’s the only part they can see. However the length of the scar is probably least important when it comes to preserving hip function. What’s more important is the approach beneath the skin, and how the soft tissues are handled. The goal is to spare them from being disrupted or traumatized during surgery. This yields less risk of dislocation, a minimal hospital stay, quick recovery and return to function. Fortunately, the MAKOplasty® robotic arm procedure can be performed in combination with a minimally invasive direct anterior approach, providing the advantages of both: improved accuracy thanks to the robotic arm, and faster recovery with minimally invasive surgery.

With many minimally invasive hip replacement surgeries, such as MAKOplasty®, patients can usually bear weight and walk out of the hospital when they leave. Those who work desk jobs can return to work in as little as a week, but even for jobs that involve more activity, such as standing or walking, patients can usually return to work faster than with traditional hip surgery. By six weeks, patients are generally able to walk a mile every day. With the quantum leaps that have occurred in this field in recent years, the aim is a hip replacement that feels so natural, you’d guess it was your own hip.

Benjamin Domb, M.D., is medical director of the Hip Center for Excellence at Adventist Hinsdale Hospital and

Dr. Stefan D. Tarlow on Knees – The Lighter Side

July 19, 2012

Stefan D. Tarlow, M.D.

MAKOplasty Robotic Partial Knee Replacement Best for One Compartment Disease

While MAKOplasty parts can be combined in several different configurations, by far the most common is to resurface only one compartment. The one compartment most commonly resurfaced is the medial compartment of the knee.

Medial Implant (inner) Cartoon of medial implants X- ray of medial implants

Medial knee is the time tested application with predictably great outcomes. This procedure has been dramatically improved upon using robotic arm technology. In my opinion, lateral unicompartmental application works well when your surgeon is able to incorporate accurate implant placement using the robotic arm and computer 3-D image of your CT scan.

Bicompartmental implant Cartoon of bicompartmental x-ray of bicompartmental implants
(patellofemoral + medial uni)

Bicompartmental Knee Resurfacing


In my hands, bicompartmental use is a less desirable construct. If two or more compartments are arthritic, I will usually recommend Total Knee Replacement. Another bicompartmental construct is to resurface the medial and lateral compartments, leaving healthy patella.

Stefan D. Tarlow, MD is a Board-Certified orthopedic surgeon who has focused on the diagnosis and treatment of knee-related problems for 24 years. Stefan D. Tarlow, MD, offers exceptional patient care with individual service.

Robots Take Over The Operating Room!

July 13, 2012

Terry Younger, M.D.

In January 2012, Northwest Community Hospital purchased a new computer-based robotic arm technology for the surgical treatment of knee arthritis.  The RIO® Robotic Arm Interactive Orthopedic System is used by surgeons for a significantly higher degree of accuracy in implanting knee prostheses.

The first several patients who have had the MAKOplasty® procedure are now returning to activities such as exercise, hiking, and stair-climbing, with relief from their osteoarthritis pain.  Partial knee replacement has been around with successful results for many years, but this innovative procedure uses the computer imaging and robotic arm to ensure a customized and accurate surgical result.

The MAKOplasty experience, exclusively performed in the Northwest suburbs at Northwest Community Hospital – begins with a visit to the physician’s office for examination and assessment of x-rays radiographs.  When a patient is a candidate for MAKOplasty® partial knee replacement, a CT scan is performed to provide information to the computer.  A customized fitting of knee components is then planned for surgery.  At the time of surgery, the surgeon accurately programs the robotic arm using the computer program.  The robotic arm is then used to cut the damaged, arthritic areas away and allows the surgeon to position the knee implant in a more exact position.  The implants are cemented in place and ready to walk on.  Patients can typically leave the hospital the morning after surgery.

According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States and the numbers are rising every year.  Many patients can be treated with partial knee replacement, but only certain surgeons have mastered the training for this exciting innovation.

The new, minimally-invasive MAKOplasty partial knee replacement procedure gives patients an accurate, computer-imaging and robotic-arm assisted surgical treatment option to conquer the pain and stiffness of osteoarthritis.

Terry Younger, M.D. is a board-certified Orthopedic Surgeon at Northwest Community Hospital, specializing in Orthopedic Surgeon, Major Joint, and Sports Medicine.


Robotics and Experience: a Winning Combination for Partial Knee Replacement

July 3, 2012

Andrew D. Pearle, M.D.

“Why do you use robotics in the OR?” I am commonly asked this question when I discuss the robotic arm assisted knee resurfacing (partial knee replacement) procedure. My answer: I want to get it right the first time.

A problem with partial knee replacement is that it is technically demanding, and prone to surgeon error. Rather than making perpendicular cuts to remove the entire ends of the knee (as we do in total knee replacement), the surgeon has to preserve the inner ligaments (ACL and PCL) as well as the dimensions of the native knee in partial knee replacement. Technical error is a major source of failure in partial knee replacement. There are two main solutions to this problem: robotics and surgeon experience.

I have pioneered the use of robotics for partial knee replacement (I call the procedure robotic knee resurfacing) because robotics affords a level of precision and reproducibility that cannot be achieved with manual techniques.  I have shown that implant positioning is 3x more accurate and less variable with robotic techniques compared to manual tools and that alignment can be controlled with robotic resurfacing (1, 2).  My colleague in England, Justin Cobb, demonstrated in a prospective randomized trial that robotic partial knee resurfacing achieved accurate placement of the implant 100% of the time compared to only 40% with manual techniques(3). With robotics, I can reliably get it right the first time.

Another major factor in determining surgical outcome after partial knee replacement is surgeon experience. Medical evidence has long shown that the more you do something, the better you get. This is particularly the case for partial knee replacement.  In a recent study looking at partial knee replacement, it was found that high volume surgeons had a revision rate of less than 1% over 5 years. Surgeons who performed 8-12 partial knee replacements per year had a revision rate of 5% while surgeons who performed less than 8 partial knees/year had a revision rate of 6-8% over 5 years(4). Low volume surgeons had a revision rate 6-8x that of high volume surgeons!! I currently perform 150-200 partial knee replacements per year, which is the most of any surgeon in the greater New York area.

Finally, the hospital setting matters. For example, a study out of Sweden demonstrated that there was a direct association between the number of partial knee replacements performed in the hospital and the revision rate. In this study, the greater the surgical volume of partial knee replacements performed, the lower the rate of revision (5).  Surgical volume is one reason to choose Hospital for Special Surgery. No hospital in the world performs more joint replacement surgeries than HSS. We are truly experts at what we do. Because Hospital for Special Surgery is devoted exclusively to orthopedics, every one of our scientists, nurses, and therapists is a specialist in this field and aligned to provide the best possible care.

Coupling robotics with extensive surgeon experience in the world-class environment of the Hospital for Special Surgery is a winning combination.

Andrew D. Pearle, M.D. is a board-certified Orthopedic Surgeon at the Hospital for Special Surgery, specializing in Sports Medicine, Arthroscopy and Robotic Surgery.

  1. Mustafa Citak; Eduardo M Suero; Musa Citak, MD; Nicholas J Dunbar; Scott A Banks; Andrew D Pearle. Unicompartmental knee arthroplasty: Is robotic technology more accurate than conventional technique? CAOS International 2010
  2. Eduardo M. Suero, Mustafa Citak, Innocent U. Njoku, Andrew D. Pearle. Does the type of tibial component affect mechanical alignment in unicompartmental knee replacement? CAOS International 2010
  3. Cobb, J.; Henckel, J.; Gomes, P.; Harris, S.; Jakopec, M.; Rodriguez, F.; Barrett, A.; and Davies, B.: Hands-on robotic unicompartmental knee replacement: a prospective, randomised controlled study of the acrobot system. J Bone Joint Surg Br 2006.
  4. Tregonning R, Rothwell A, Hobbs T, Harnett N. Early Failure of the Oxford Phase 3 Cemented Medial Uni-Compartmental Knee Arthroplasty: An Audit of the NZ Joint Registry over Six Years. J Bone Joint Surg Br 2009
  5. Robertsson O, Knutson K, Lewold S, Lidgren L. The routine of surgical management reduces failure after unicondylar knee arthroplasty. J Bone Joint Surg Br 2001

HOW TO CHOOSE? Partial Knee Resurfacing (PKR) vs. Total Knee Replacement (TKR)

May 25, 2012

Andrew Pearle, M.D.

Here is a list of the issues that are important to my patients and a review of the pros and cons of the two operations.  The choice is personal as different patients have different goals and realities.  Often, either operation would appropriately service the needs of an individual.

Return to Activities

Returning to sport or leisure activities is an important goal of many patients after knee resurfacing and the ability to return to sport is highly variable.  In general, return to sport is easier and more predictable after partial knee replacement than total knee replacement.

Return to Work

Return to work after knee repair is highly variable; indeed, many patients are retired at the time of their surgery.  However, I recommend 2-3 months off prior to return to work after total knee replacement.  Alternatively, I consider partial knee replacement a back to work operation.  I encourage patients to go back to work after 2-3 weeks after a partial knee replacement.

Recovery Time

The recovery time for any operation varies.  Here is a comparison of typical recovery times for partial vs. total knee replacement.

Total Knee Replacement

Partial Knee Replacement

Hospital Stay 3-4 days 1-2 days
In Patient Rehab Stay 1-2 weeks None
Outpatient Rehab 12 weeks 6 weeks
Time using walker or crutches 6 weeks 2 weeks
Need for pain meds 6 weeks 2 weeks
Loss of work 6-12 weeks 2-3 weeks
Complete Recovery 6-12 months 6-12 weeks

Cost to Patient

Insurance covers both partial and total knee replacement.  However, there are hidden costs to the procedures.  Obviously, since partial knee replacement results in much quicker return to work, less need for rehabilitation, and less pain medication requirement, the cost to the patient is significantly lower.

Risks of the Procedure

A recent study demonstrated that the risks associated with total knee replacement are over 3 times higher than partial knee replacement.  These risks are both systemic risks such as heart attack or death as well as local risks such as infection, persistent pain, loss of motion requiring a manipulation, nerve injury and instability.  Infection is particularly concerning after knee replacement; it is estimated that total knee replacement has twice the risk of infection as partial knee replacement.

Direct Comparison

There is only one randomized prospective clinical study comparing long term outcomes of total knee replacement versus partial knee replacement.  In this study, partial knee replacement had better early and long term outcomes in terms of pain relief and function.  Surprisingly, partial knee replacement demonstrated superior survivorship at 15 years than total knee replacement.


Both partial and total knee replacement can provide durable pain relief and improve function in patients with knee arthritis.  Partial knee replacement is not appropriate for all patients with knee arthritis and may only be possible in 10-30% of patients.

Total knee replacement is a very durable operation that can last for 30 years.  It predictably allows patients to walk, hike, ride a bike, and swim.  It is less predictable in return to sporting activity.  The recovery is long and arduous.

Partial knee replacement has a quicker recovery, permits rapid return to work, and often allows patients to expand their sports participation.  In addition, the surgery has fewer risks than total knee replacement and is less costly to the patient.

Andrew D. Pearle, MD is a board-certified Orthopedic Surgeon at the Hospital for Special Surgery, specializing in Sports Medicine, Arthroscopy and Robotic Surgery.

Doctor Greenlaw explains MAKOplasty — hip replacement procedure

May 17, 2012

Paul Greenlaw, M.D.

What is MAKOplasty?


MAKOplasty is the trade name for a specific type of total hip replacement.  MAKOplasty Total Hip Arthroplasty uses RIO, a Robotic Arm Interactive Orthopedic System, to guide physicians during surgery.

Who is a good candidate for MAKOplasty total hip replacement?

Each patient must talk to his/ her own physician to determine if he/she is an appropriate candidate. MAKO is a treatment option for some people with degenerative joint disease, which can cause debilitating hip pain.

How does MAKOplasty work?

If you are a candidate, I will order a CT scan of your hip, which is used to make a 3-D model of the affected hip and surrounding areas. The surgical treatment plan is specific to each person, based on his/her anatomy. In surgery, the physician uses the robotic arm to prepare the hip for placement of the implant.

Is MAKOplasty of the hip really better than traditional hip replacement?

Doctors are always trying to make things better for their patients. I’ve done close to 800 hip replacements, and I believe MAKO is an improvement on traditional hip replacement. The incisions are smaller, the recovery time is shorter and the robotic arm technology that assists physicians provides a more accurate placement of the hip implant and more consistency in leg length.

Paul Greenlaw, M.D., is an orthopedic surgeon with Wilson Orthopaedic Surgery & Neurology Center. He performs MAKOplasty total hip replacements at Wilson Medical Center.