Robotic-Arm Assisted

Unicompartmental Knee Arthroplasty 111

(MAKO)

Frederick Buechel Jr, Frederick Buechel Sr, and

Michael Conditt

Contents Coronal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1286

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1282
Robotic-Arm Assisted Partial Knee Arthroplasty
Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1283
Features of the MAKO Robotic-Arm Assisted
Partial Knee Replacement System . . . . . . . . . . . . . . . 1283
Indications for PKA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1283
X-Ray and Imaging Indications . . . . . . . . . . . . . . . . . . 1284
Medial Compartment X-ray Indications . . . . . . . . 1284
Lateral Compartment X-ray Indications . . . . . . . . 1284
Patellofemoral Compartment X-ray
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1284
CT Imaging Preoperative Planning . . . . . . . . . . . . . . 1284
Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1284
Preoperative Planning Overview . . . . . . . . . . . . . . . . . 1285
Preplanning Screens: Optimal Starting Position
Medial and Lateral PKA . . . . . . . . . . . . . . . . . . . . . . . . . 1286
Tibial Planning Screens . . . . . . . . . . . . . . . . . . . . . . . . . . . 1286
Transverse View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1286
F. Buechel Jr (*)
Robotic Joint Center at The Stone Clinic, San Francisco,
California, USA
e-mail: ffbjr@me.com
F. Buechel Sr
South Mountain Orthopaedics, South Orange, NJ, USA
e-mail: fbuechel@me.com
M. Conditt
Holy Cross Hospital, Fort Lauderdale, FL, USA
e-mail: Michael.Conditt@stryker.com
Sagittal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287
Femoral Planning Screens . . . . . . . . . . . . . . . . . . . . . . . . 1287
Sagittal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287
Transverse View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Coronal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Patellofemoral Planning Screens . . . . . . . . . . . . . . . . . 1288
Preplanning for the Patellofemoral Replacement:
Three Basic Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Steps 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Steps 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Steps 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290
Surgical Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290
Robot Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290
Patient Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1290
Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
Checkpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292
Tracking Arrays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292
Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1293
Osteophyte Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Pose Captures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Cartilage Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Medial and Lateral PKA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Patellofemoral PKA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
Examples of Reasonable PKA Alignment Goals
in Specific Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
Intraoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 1297
Balancing Graph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1297
Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1298

# Springer International Publishing Switzerland 2016 1281

G.R. Scuderi, A.J. Tria (eds.), Minimally Invasive Surgery in Orthopedics,
DOI 10.1007/978-3-319-34109-5_122
1282 F. Buechel Jr et al.

Bone Preparation (Robotic-Arm Assisted Introduction

PKA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1298
Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300 Robotic-arm assisted partial knee arthroplasty
Kinematic Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301 (RA-PKA) is the designation for the
unicompartmental knee arthroplasty (UKA) pro-
Clinical Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1302
Clinical Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1302 cedures performed using the MAKO robotic
orthopedic system currently available for use in
Accuracy of Component Positioning . . . . . . . . . . . . . 1302
the USA and internationally. Arthroplasty proce-
Accuracy of Joint Balancing . . . . . . . . . . . . . . . . . . . . . 1302 dures performed using this system have been
Survivorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1303 commonly referred to as “Makoplasty ®” proce-
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1303
dures. The first procedures for the knee were
performed on the medial compartment in June of
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1304
2006 [1]. Over the last 10 years, the procedures
being offered using this platform have expanded
to include the lateral compartment [2–5],
patellofemoral compartment, and total hip
replacement, and now total knee replacement.
Successful minimally invasive surgery still
requires a surgeon to perform appropriate place-
ment of limited skin incisions and deep expo-
sures, while attending to the soft tissues. While
this robotic precision tool can assist surgeons in
bone preparation through small windows into
the body, it is the surgeon’s responsibility to
plan the procedure and protect the patient’s tis-
sues from injury with appropriate handling and
retraction. The MAKO robot allows surgeons
using minimally invasive approaches to achieve
precision bone preparation and implant installa-
tions customized for each patient [1, 3, 6–8]. Pre-
operative detailed evaluation of the effected
knee imaging allows surgeons to precisely plan
their implant starting position and prepare for
the anatomical variations each patient presents.
Intraoperative computer adjustment based on
live kinematic data collected during surgery
allows for subtle implant position corrections
prior to bone resection to achieve a fully bal-
anced, properly tracking, and optimally placed
implant. Published results have confirmed posi-
tional accuracy, greater patient satisfaction,
improved short-term survivorship, and func-
tional improvements over previous nonrobotic
techniques. [3, 6–17]
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
Robotic-Arm Assisted Partial Knee
Arthroplasty Solution
Robotic-Arm Assisted PKA provides solutions
to the problems associated with manual PKA. A
computerized 3D planning software package cre-
ates a preoperative starting implant position and
sizing plan, to later be adjusted intraoperatively.
Optimizing the intraoperative plan is logical and
allows the surgeon to use kinematic data in the
OR to optimize final implant position before
bone preparation. Full range of motion femoral
on tibial tracking and gap distance equalization is
achieved while live surface mapping of the fem-
oral cartilage allows the transition of the implants
to the cartilage to be optimal. The final
intraoperative implant plan provides highly
accurate sizing, tracking, and balance for the
knee implants. The intraoperative plan commu-
nicates with the robotic-arm, which provides tac-
tile feedback to the surgeon during bone
preparation. The surgeon then guides the
robotic-arm over the area of bone to be removed
while the system provides tactile, virtual bound-
aries only allowing bone removal at the planned
location and virtually stops the tool from going
further. In essence virtual cutting blocks are cre-
ated for each patient specific to his or her
intraoperative customized plan.
Features of the MAKO Robotic-Arm
Assisted Partial Knee Replacement
System
The MAKO robotic-arm assisted PKA system
package:
• A sophisticated preoperative and intraoperative
planning CT-guided software package
• Computer navigation with infrared sensors and
arrays
• An intraoperative kinematic data acquisition
process that allows for real-time intraoperative
adjustment of the preoperative plan according
1283
to: full range of motion gap analysis, tracking
data, and cartilage surface mapping
• A true robot, with a robotic-arm that has a
6 mm bone preparation burr at its end that
communicates with the software plan and
assists the surgeon by using virtual boundaries
to accurately prepare the bone
• Robot specific implants anatomically designed
on the femoral articular surface, while the bone
surface side takes advantage of the 6 mm round
burr, requiring less bone removal
• A verification process before, during, and after
implant installation that allows confirmation of
cutting depth, trial component position, and
final component position in the cement mantel
• A kinematic analysis option in the software to
allow comparison of the femoral-tibial gap
planning through the range of motion before
bone cutting, again with the trial implant
installed with the gaps achieved, and the final
gaps achieved with the implants cemented that
match the plan, before closure
Indications for PKA
Critical to the success of PKA when deciding on
which patients should or could receive a RA-PKA
is understanding the indications for the patient and
the goals for the surgeon. Considerations in the
decision process include the patient’s medical and
surgical history, specific locations of pain in the
knee, physical exam findings, radiographic find-
ings, psychological issues, and social situations
[18–21].
The patient history for those properly selected to
undergo RA-PKA should include knee pain from
osteoarthritis, osteonecrosis, noninflammatory
arthritis, or posttraumatic arthritis no longer
responsive to nonreplacement interventions. Tradi-
tional indications provide a solid framework for
surgeons beginning with robotic-arm assisted par-
tial knee replacement however, as they become
more skilled with the computer pre-planning and
intraoperative planning adjustments the system
1284
allows, more challenging cases can be handled
satisfying more patients.
Patients that require isolated medial, lateral, or
patellofemoral compartment procedures generally
will point directly to the compartment. Patients for
medial or lateral only PKA should not complain of
anterior knee pain at the location of the patella or
patella tendon with stair climbing or rising from
chairs. Patients considering patellofemoral
replacement should not have a history of signifi-
cant malalignment or patella instability.
X-Ray and Imaging Indications
A standard weight bearing AP, weight bearing 45
PA flexion view, lateral, and sunrise patella view
are all needed to properly evaluate the knee. If the
weight bearing 45 PA flexion view is not
obtained or poorly angled, a significant percent-
age of patients with moderate to severe posterior
medial or lateral femoral cartilage loss will be
missed and the diagnosis will not be made cor-
rectly. A sunrise or Merchant view is important to
assess the tracking and joint space of the
patellofemoral compartment.
Medial Compartment X-ray Indications
Mild, moderate, or severe bone on bone medial
compartment joint space loss are indications for
medial RA-PKA. The lateral side should be well
preserved. There can be some small osteophytes
on the lateral femur or tibia but there should be no
pain there. The patellofemoral space can have
some mild or moderate wear but not bone on
bone. There can be large superior, medial, or
inferior patella osteophytes as long as there is no
significant pain on exam.
Lateral Compartment X-ray
Indications
Mild, moderate, or severe bone on bone lateral
compartment joint space loss are indications for
lateral RA-PKA. The medial side should be well
F. Buechel Jr et al.
preserved. There can be some small osteophytes
on the medial femur or tibia but there should be no
pain there. There should be no significant lateral
subluxation of the patella on lateral compartment
patients.
Patellofemoral Compartment X-ray
Indications
The patellofemoral space can have some mild,
moderate, or severe wear. There should be good
tracking of the patella in the trochlear groove, and
there should not be severe lateral subluxation of
the patella. There may be large superior, inferior,
lateral, or medial patella osteophytes. The medial
and lateral compartments should be well pre-
served on x-ray. Poor tracking is not alleviated
with resurfacing alone [18, 19].
CT Imaging Preoperative Planning
Once the patient is indicated to proceed with a
robotic-arm assisted partial knee arthroplasty
from the office exam and x-rays, a low dose
CT scan of the extremity is performed for the
planning and execution of the procedure.
Detailed 1 mm slices of the knee are taken
with 5 mm slices of the hip and ankle. The
robotic company in-services the CT facility,
provides the protocols and a motion detection
rod for use during the scans required for the
procedure.
The scan is then manually “segmented” to
create the 3D models seen by the surgeon for
preoperative implant planning. This is done
“behind the scene” and is not part of the surgeons
planning but allows the images for the surgeon’s
planning screens to be created. This segmentation
process takes approximately 30 minutes for PKA.
Preoperative Planning
This is the initial preoperative placement of the
virtual implants onto the tibial, femoral, or troch-
lear bone surfaces depending on the procedure.
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
Fig. 1 Basic planning for medial PKA
The company representative performs the initial
planning. The surgeon locally evaluates this plan
and fine adjustments to the preplan can be
performed in the clinic or in the operating room
prior to the start of the procedure. Preoperative
planning allows selection of the sizes and position
of the implants that best fit the patient (and stores
alternative size plans the surgeon creates). Pre-
plans allow planning of the implant depth, sagit-
tal, coronal and transverse rotation, posterior
slope, coronal plane alignment, and initial track-
ing position from the patient alignment lying
supine during the CT scan (Fig. 1).
Preoperative Planning Overview
Planning both preoperatively and dynamically
intraoperatively is the key to the robotic-arm
assisted partial knee surgery process. The cutting
will always be accurate to the planning with the
robotic-arm, so it is up to the surgeon to
1285
understand proper planning, data acquisition,
and final goals.
Intraoperative plan adjustments are finalized to
guide bone preparation. After tracking arrays are
attached, the bones are registered to the CT bone
models, the osteophytes have been removed, and
kinematic data is collected with the knee passively
corrected to the stable endpoint of the collateral
ligaments through full motion.
There are both tibial planning screens and fem-
oral planning screens used by the surgeon.
The surgeon’s preoperative size choice will
almost always be obvious from the rules I will
provide. Occasionally patients may be between
sizes, so surgeons can plan two implant sizes
and choose the right one intraoperatively using
probes to precisely identify the best size and fit
in these few cases. The system will store all sizes
preplanned for the surgeon to test virtually during
surgery.
Later during the surgery, a calibrated handheld
probe with a pointer tip can be used after registration
1286
Fig. 2 Arrows point to the specific key regions to evaluate during preplanning
to identify any position on the patient and display it
on the virtual preplan. This will confirm and display
the bone edge locations, the position of the virtual
implant on the real patient, and identify the location
of the ACL fibers in relation to the virtually planned
tibia. This probe technique is used to help make a
proper size or position choices for the implant on
those in-between sizes.
Preplanning Screens: Optimal Starting
Position Medial and Lateral PKA
The tibial and femoral preplan screens each have
four windows on the left side. The three CT bone
windows allow coronal, sagittal, and transverse
views that can be reviewed as individual 1 mm
slices and allow surgeon-controlled adjustment of
the virtual implant. The top right window is a
virtual 3D reconstruction of the patient’s tibia,
femur, or both created from the segmentation pro-
cess. It can be used as a guide to see the location of
the CT slice being adjusted in one of the three
bone windows, and it can be rotated to look at the
knee from any angle and is used to evaluate track-
ing intraoperatively.
The arrows at the top left of each window allow
for 0.2 mm movements of the implant, and rota-
tion in 1 increments from any user chosen point.
On the right side of the screen are several menus,
options, and functions used by the surgeon and
representative during implant planning.
F. Buechel Jr et al.
Tibial Planning Screens
Transverse View
Medial
• Maximize cortical coverage without overhang
on any slice.
• Keep the medial edge of the implant right on
the tibial cortex but no over hanging on any
slice.
• Fit the implant into the best position to cover
the surface (Fig. 2).
Lateral
• Internally rotate the implant 8–15 (I choose to
start at 10 and adjust as needed). This will be
the usual final rotation for lateral tibias to
accommodate for the screw home mechanism.
• Medially shift the implant 2 mm from the cor-
tical edge to start.
• Ensure there is good anterior and posterior
cortical coverage, as this position is usually
needed to get central femoral contact on the
bearing and provides cortical rim load bearing
to avoid subsidence
Coronal View
Medial
• Keep the medial edge of the implant right on the
tibial cortex but not overhanging on any slice.
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
• Avoid ACL intrusion and do not undermine the
medial tibial eminence with the lateral side of
the implant by staying medial to “half way up
the tibial eminence’s sloped lateral edge.” You
can sometimes go slightly more lateral but
check intraoperatively with the probe to ensure
you are not too far lateral and invading the
ACL during surgery. (If so, go to the next
smaller implant.)
• Set coronal alignment 1 varus.
Lateral
• Adjust lateral edge of the implant 2–4 mm
medial to cortical edge.
• Set coronal alignment 1 valgus.
Sagittal View
Medial
• Match patients tibial slope.
• Starting implant composite height should be ½
above ½ below the cortical bone surface seen
as the magenta bone outline.
• AP cortical coverage does not have to be com-
plete on medial side if the implant is invading
too far into the tibial eminence and ACL on the
coronal view. The medial cortex will support
the implant.
Lateral
• Match patients tibial slope.
Fig. 3 Arrows point to the specific key regions to evaluate during preplanning
1287
• Keep the implant as high as possible while still
making contact with the posterior tibial bone
surface, do not overhang anteriorly.
• Contact on the posterior and anterior cortex is
mandatory, as the lateral edge is often not mak-
ing contact over the cortex for proper tracking
since we medialize it 2–4 mm.
Femoral Planning Screens
Sagittal View
• Plan with the CT slice going through the mid-
dle anterior tip of implant.
• Reproduce anatomic femoral shape with the
implant position.
• Size and shape match femoral component to
condyle.
• Place implant’s posterior condyle at or just
within the subchondral bone outline.
• Keep the anterior tip of the implant ½ in ½ out
of the bone outline.
• Place anterior tip at or just posterior to sulcus
terminalis to start.
• If between sizes, choose the smaller size to
start, especially on the lateral components.
• To make sure the femoral component is large
enough, the anterior tip should to be at or in
front of the anterior tibial bearing edge with the
tibial implant view on (Fig. 3).
1288
Transverse View
• Positions the posterior femoral condyle of the
implant for optimal tracking in deep flexion.
• Stay inside the condyle’s cortical edges on all
views.
• Try to approximate the posterior condyle sur-
face angle, but medials are often in a more
internally rotated and lateralized position.
Medial
• Keep implant lateralized close to the notch
cortex but not in notch on any slice.
Lateral
• Laterals center the implant in the posterior
condyle.
• The condyle is always small and just fits the
implant centered.
Coronal View
• Positions the anterior tip and distal part of the
femoral component.
• Ensures the distal implant is out of the notch
and contacting on bone.
Medial
• Position anterior tip at the junction of the mid-
dle and medial third of the condyle.
Lateral
• Place anterior tip on the lateral cortical edge,
keeping the posterior implant centered in the
condyle on the transverse view.
• Choose the smaller size if you are between
sizes.
Patellofemoral Planning Screens
Preplanning the trochlear component for isolated
patellofemoral or bicompartmental procedures
are both performed the same way. This sets the
parameters for an inlay trochlear component
avoiding a proximally proud component or a
proud edge where the implant transitions onto
F. Buechel Jr et al.
remaining cartilage. With the bicompartmental
planning, the software allows independent posi-
tioning of both components and avoidance of
contact between the two metal implants.
Preplanning provides a starting position for all
of the main transitions and 3D aspects of the
trochlea. The intra-operative planning steps
allow for final accurate mapping of all the
implant to cartilage and bone transitions, and
the cartilaginous trochlear groove location, so
adjustment can be made to optimize trochlear
position prior to bone preparation (Fig. 4).
The trochlear groove of the virtual implant has
a black line showing its path on the planning
screen. The implant’s virtual tracking line will
later be matched to the patient’s trochlear groove
reproducing the correct angle for each patient.
During the intraoperative planning the native
trochlear groove is mapped with a probe and
visualized on the software virtually, allowing for
translation of the virtual implant plan to the true
trochlear groove position.
Preplanning for the Patellofemoral
Replacement: Three Basic Steps
Steps 1
Using the “PF Primary Screen” the size is chosen
on the transverse view leaving about a millimeter
of remaining bone on either side, rotation is set,
and position is matched to the native shape. The
implant’s proximal lateral flange is set just into the
anterior cortex on the sagittal view, and on the
coronal view setting the pink “wings” equal dis-
tance from the distal femur as a transition guide
from implant to cartilage or onto the medial fem-
oral component in the bicompartmental cases
(Fig. 5).
Steps 2
The “Verify 2 Screen” adjusts component in the
AP plane so that mid-proximal tip is split midway
between the cortex. The distal tip is positioned
anterior to Blumensaat’s line, and the distal tip is
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO) 1289

Fig. 4 Starting view for preplanning a patellofemoral replacement

Fig. 5 Step 1 for preoperative planning trochlear component position

1290
Fig. 6 Step 2 for preoperative planning trochlear component position
split midway between bone. Then adjust the flex-
ion extension of component and AP position to be
approximately 2 mm proud of trochlear groove
bone (Fig. 6).
Steps 3
The “Verify 1 Screen” is used to adjust AP com-
ponent position so that the medial proximal flange
is just on the surface of the anterior femoral cortex
(Fig. 7).
Surgical Process
Using the Mako robotic-arm assisted PKA system
with a minimally invasive approach, patients can
be consistently discharged to home on the same
day, with an overnight stay option for some due to
regional differences. A well-rehearsed team
approach to managing this procedure will make
the experience efficient, safe, and comfortable for
the patient, the surgeon, the anesthesia team, and
the operating room staff.
F. Buechel Jr et al.
Robot Setup
The robot is brought into the OR prior to the
patient and surgeon, and the representative and
the scrub nurse perform the startup process. This
turn on and “honing process” validates the func-
tioning of the robotic-arm and registration tools.
The robot is draped sterilely and the cutting burr
and irrigation system is connected. The patient’s
CT data file is loaded into the computer station
and the preplan is brought up on the screen for
the surgeon to review and adjust if necessary
(Fig. 8).
Patient Setup
Standard setup with sterile drapes applied to the
leg with preferably an impermeable stockinet
from the toes up over the top of the tourniquet
is seen in the photo. A wrap secures the stockinet
from the toes up to the mid-tibia. The patient’s
leg is secured in a padded adjustable foot holding
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO) 1291

Fig. 7 Step 3 for preoperative planning trochlear component position

Fig. 8 Honing Robot and Draping Process

device that allows assistant free positioning at

any angle or rotation during the procedure and
ample stability for robotic bone preparation
(Fig. 9).
Exposures
The incisions and exposures used for single com-
partment surgery are different from total knee inci-
sions and require proper soft tissue handling to
1292 F. Buechel Jr et al.

Fig. 9 Standard Patient Set-up in sterile leg holder for Robotic Partial Knee Replacement

Fig. 10 Exposures for

medial, lateral,
patellofemoral, and
bi-compartmental robotic
PKA

avoid traumatizing the skin, which can cause
delayed tissue healing problems, skin edge necro-
sis, and infection. It is best to perform the
arthrotomy first, and then attach the bone tracking
arrays to avoid shifting the arrays or having them
interfere with the exposure process (Fig. 10).
femoral condyle just superior and anterior to the
medial epicondyle. These are removed at the end
of the case and are used for verification of the
tracking array accuracy at the time of robotic bone
preparation and to ensure the arrays have not been
moved prior to bone preparation (Fig. 11).

Checkpoints
With the arthrotomy completed, a small checkpoint
is pushed into the tibial anterior cortex 2 cm below
the plateau at the base of the arthrotomy, and a
second is placed in the medial side of the medial
Tracking Arrays
Tracking arrays are placed in the femur and tibia.
These navigation tracking arrays are each
clamped to two bone pins in the tibia and femur
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO) 1293

Fig. 11 Checkpoints are

placed in each bone
temporarily to verify array
position accuracy before
bone preparation

Fig. 12 Tracking arrays

are attached to the bones to
allow for communication
between the planning
software, the patient, and
the robotic cutting tool

with 4.0 mm or 3.2 mm threaded pins. The fem-

oral pin placement 4 fingerbreadths above the
patella in the direct anterior position works well,
just touching or penetrating the posterior cortex.
The tibial pin placement 4 fingerbreadths below
the tibial tubercle works well in the center of the
subcutaneous border. Deeply engaging the ante-
rior cortex is all that is needed without penetrating
the posterior cortex (Fig. 12).
Registration
Once the arrays and checkpoint are installed, reg-
istration of the bones to the computer CT scan can
be performed. This creates the real-time live bone
models seen on the display for our intraoperative
planning process and guides our robotic bone
preparation (Fig. 13).
1294
Fig. 13 Registration is the
process by which the patient
and the virtual CT plan are
linked during the procedure
Registration starts with rotating the hip to
establish hip center. The ankle center is registered
with a probe placed at the subcutaneous center
position of both malleoli. The two checkpoints
are registered by placing the probe into the check-
point divots. Thirty-two points on the femur are
registered and 32 points on the tibia are registered.
This provides three surface planes to accurately
match the CT data, within a millimeter, to the
patient. Once registration is completed, the
femur and tibial are communicating with the com-
puter software models. Real-time contact posi-
tions of the implants and the gap distance
between the implants can then be collected for
intraoperative planning adjustments.
Osteophyte Removal
Before collecting kinematic data, the large
osteophytes that are tenting the medial or lateral side
of the knee soft tissue envelope need to be excised to
gain proper tensioning during data collection.
Pose Captures
Pose captures or “position captures” are data
points collected and captured in the software
when the surgeon passively corrects the knee’s
coronal plane deformity and ranges the knee.
F. Buechel Jr et al.
The surgeon passively corrects the varus knee to
the MCL’s stable endpoint and puts the knee
through motion from extension through flexion
stopping momentarily along the way as the data
is collected.
The software collects the live implant position
data virtually from the planned femoral and tibial
implants. A gap distance calculation is registered
and a contact point is created at each pose
captured.
On the computer display the center of the tibial
bearing is represented at each pose captured as a
red dot on the virtual femoral component anima-
tion. The femoral component can then be trans-
lated and rotated to line up on these tibial center-
tracking points. The tibia can also be adjusted to
optimize tracking.
The gap distance data between the planned
femoral component and top of the planned tibial
bearing is displayed in millimeters on a bar
graph showing the gap at each position captured
from extension through full flexion (Fig. 14).
Cartilage Mapping
Medial and Lateral PKA
Cartilage mapping is the final data collection
step. Since the CT data on the computer screen
shows the bone and not the cartilage level, virtual
cartilage mapping with a blunt tip calibrated
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
Fig. 14 Knee deformity is passively corrected to collateral ligament stable endpoint while knee is put through ROM as
system collects data to optimize implant position
hand probe allows the surgeon to trace the carti-
lage at the transition zones on the patient, and
this actual cartilage surface level data is overlaid
on the display. The surgeon can see the plan of
the femoral component and the true cartilage
surface level to allow any adjustments to the
anterior tip position of the femoral component
needed to ensure a proper transition occurs, and
the implant is not proud of the cartilage surface,
which could contact the patella during flexion
(Fig. 15).
Patellofemoral PKA
During patellofemoral replacement, cartilage map-
ping is extensively used. Since there is no gap
analysis in the patellofemoral procedure, this is
the primary adjustment tool used for final
1295
placement of the trochlear component. This feature
allows the surgeon to virtually map and display
Whiteside’s line of the native trochlea on the virtual
plan. It also allows one to virtually map and display
all the actual cartilage to virtual implant transition
zones. Once virtually mapped, the implant is trans-
lated and rotated to match Whiteside’s line and to
transition from the native cartilage smoothly onto
the implant distally, medial and laterally, and prox-
imally onto the shaft (Fig. 16).
Examples of Reasonable PKA
Alignment Goals in Specific Scenarios
Varus Goal, Mild Deformity
• Passively correct to stable MCL endpoint.
• If 6 varus to start and corrects to 3 , good.
• If 4 varus to start and corrects to 1 , good.
1296 F. Buechel Jr et al.

Fig. 15 This allows the

cartilage level to be
virtually superimposed on
the CT scan plan allowing
adjustment of the femoral
component avoiding a
proud implant

Fig. 16 This allows the

true cartilage and bone level
to be virtually
superimposed on the CT
scan computerized plan
allowing optimization of the
trochlear component

Varus Goal, Fixed Deformity • Perform small medial sleeve elevation with
• Best to start with a 10 or less fixed varus. moderate fixed varus.
• Trim all medial osteophytes before pose • 30–50 % improvement common in some
captures. but not all.
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
• Severe fixed varus knees that start over
10–15 of varus often remain in significant
varus.
Extension Goal, Mild Deformity
• Document starting extension, try to
improve it, or reproduce good extension.
• If start is 1–2 flexion contracture on com-
puter, try to achieve full extension to 0 .
If the knee starts in 4 hyperextension, the goal is
around 2–5 of hyperextension close to the
patient’s start but not more.
Extension Goal, with Flexion Contracture
• Best to start with a 10 or less fixed
contracture.
• Larger starting flexion contractures will
retain more noticeable residual
contractures.
• 30–50 % improvement is common on fixed
contractures with proper planning and
osteophyte removal.
• Graph planning should increase the gap dis-
tance in early extension to allow for reduc-
tion in contracture and the ability to stretch
more over time.
• Removing larger posterior osteophytes off
femur and tibia can improve extension.
• Removing anterior tibial osteophytes that
impinge in the notch improve extension.
• Many of these contractures will stretch
and reduce over 6–12 months with
removal of the osteophytes and balancing
the knee.
Lateral Goal, Mild Valgus
• Flexible deformities that do not overcorrect
to varus and start at less than 10 of fixed
valgus are acceptable.
• Avoid the valgus knee alignment that cor-
rects into varus and will overload the medial
natural side.
• Severe valgus >10 that is fixed is not a
case for PKA at this time.
• Lateral releases are not recommended as the
gaps can become significant on the lateral
1297
side with releases, and the polyethylene
bearing options are limited to 5 mm
thickness.
Patellofemoral Goals
• The goal for the trochlear component is to
reestablish the native trochlear groove by
mapping the native trochlea and placing
the implant trochlear groove in the same
location.
• Make sure the implant transitions smoothly
to cartilage surfaces from the medial and
lateral femoral condyles and the anterior
shaft, by cartilage mapping the transitions.
• Remove peripheral patellar osteophytes,
properly resect the patella articular surface
and choose the best size implant to cover the
resected surface.
• Avoid leaving the patella un-resurfaced in
this design as it can potentially leave
patients with painful flexion from 20 to 60 .
Intraoperative Planning
An optimized plan has a balanced graph, central-
ized implant tracking, and an optimized implant to
cartilage transition at the tip of the anterior femo-
ral component that is achieved through cartilage
mapping (Fig. 17).
Balancing Graph
The balancing graph allows surgeons to opti-
mize the gap distance between the virtually
planned femoral component and tibial bearing
at each part of the range of motion that data is
captured. The graph represents a gap as a blue
vertical bar going up on a millimeter scale seen
on the left “y axis.” Bars go from left to right
(extension to flexion) and represent the gap
exactly where the surgeon stopped to take a
pose capture through the range of motion, on
the “x axis.” The vertical bars define the
1298
Fig. 17 Each patients
implant positioning plan is
optimized intra-operatively
from real-time interactive
data during surgery
virtual space remaining between the virtual
implants with the MCL tensioned at each
position.
As we optimize the graph, our goal is to allow a
slight gap to be possible between the implants
when the knee is passively corrected allowing
for some elasticity in the MCL. In the past, this
was performed by placing a spacer or tongue
depressor into the gap after the bone cuts were
made and the implants were installed. With
MAKO robotics, we move the tibia and the
femur independently to predictably achieve a
well-balanced knee (a symmetric gap throughout
the arc of motion) on a virtual planning graph,
optimizing the position before we cut the bone
with the robotic cutting tool.
The gap between the implants at each part of
the range of motion can be optimized for each
patient’s dynamic movements and ligament ten-
sions by moving the virtual implants up or down,
right or left, or rotating them. The adjustments are
seen real-time on the graph as the implants are
independently moved. The implants can be
rotated in 1 increments and can be moved up
and down, right or left in 0.2 mm increments
(Fig. 18).
F. Buechel Jr et al.
Tracking
A key feature of this system is its ability to allow
surgeons to optimize the tracking of the femoral
component on the center of the tibial component.
This is based on the kinematic tracking contact
data collected during the pose capture step taken
during range of motion. Performed by flexing the
knee and holding the foot pointing straight for-
ward with consistent corrective tension applied to
the knee, the surgeon passively corrects the varus
on medial OA knees or passively corrects the
valgus on lateral OA knees (Fig. 19).
Bone Preparation (Robotic-Arm
Assisted PKA)
Once the final intraoperative plan has been opti-
mized, the information is locked into the computer
plan that guides the robotic-arm during bone prep-
aration. The 6 mm burr connected to the end of the
robotic-arm assists the surgeon in removing the
planned volume of bone resection. The robotic-
arm provides the surgeon audible and tactile
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO) 1299

Fig. 18 Intra-operative
implant adjustment allows
for fine-tuning of each
patients ligament balance
throughout the range of
motion from kinematic data
collected

Fig. 19 Optimized
tracking prevents edge
loading that can lead to
early wear or loosening

feedback limiting the area of resection to the plan.
The system creates virtual boundaries like an
“invisible wall” that limits the movement of the
cutting burr only to the volume planned.
The surgeon then pushes the burr tip across the
bone, and on the monitor the green bone area to be
removed begins to disappear as the final white
bone level is achieved. When the green has
all been removed, the preparation is complete.
The system provides an audible sound when the
robotic burr gets close to the boundary of
the planned resection. If pressure is continued,
the color will turn to red. If an attempt is made
to go beyond a millimeter past the plan, the cutting
1300 F. Buechel Jr et al.

Fig. 20 Robotic-Arm
assisted bone preparation
provides accuracy and
safety

tool (burr) will be shut down and the surgeon is

physically stopped from going further.
Bone preparation is the easy part of the proce-
dure, as the robot will not let you remove the bone
anywhere except where you plan. Planning is
therefore the critical part of the procedure. The
surgeon’s responsibility during the robotic part of
the procedure requires an awareness of the soft
tissues to ensure the tool is being introduced into
the soft tissue window safely, avoiding injury to
skin, tendon, or ligaments, by using proper retrac-
tors where appropriate (Fig. 20).

Implantation

See Fig. 21.

With the trials in place, the surgeon will assess
the knee for stability and range of motion. The
final metal components are cemented in standard
fashion inserting the tibial tray first, then the fem-
oral component.
The final polyethylene insert is chosen after
the metal implants have stabilized in the cement
and any excess cement is removed posteriorly.
Stability is then checked with the trial inserts
Fig. 21 Trail Implants installed and all bone edges and
soft tissues trimmed flush to implant to avoid impingement
or irritation
while simultaneously evaluating the motion
achieved on the computer, prior to choosing the
final polyethylene insert thickness. (Fig. 22).
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO) 1301

Fig. 22 Lateral PKA tibial bearing seated in tray on left ready to be impacted into the locking mechanism which is seen
on the right fully seated

Fig. 23 Kinematic analysis compares the preplanned pas- trial installation is seen here on the graph as the horizontal
sively corrected virtual implant gaps to the final passively yellow line between the planned and actual gap, at each
corrected gaps with the trial implants installed and the final data point collected
implants installed. The difference in the planned verses the

The final intraoperatively planned gaps are

Kinematic Analysis
See Fig. 23
The software provides an option for surgeons
who wish to validate that what they planned on
the balancing graph has actually occurred once
all the trials and final components are installed
[15]. This is called the kinematic analysis.
overlaid with the final gaps taken with the trial
implants installed and can also be shown with
the final cemented implants. The different color-
coded bars on the graph show the difference
between the planned gap, trial gaps, and the
final installed gaps. The knee is closed in the
standard fashion.
1302
Clinical Summary
Clinical Outcomes
Several studies have shown significant improve-
ments using robotic assistance for UKA postop-
eratively (compared to preoperative levels) in
ROM, Knee Society Scores, WOMAC scores,
and SF-12 scores [8, 16, 22, 23].
Accuracy of Component Positioning
In a study by Roche et al. [23], postoperative
radiographs of 43 robotic UKA patients were
examined for outliers. Of the 344 individual radio-
graphic measurements, only four (1 %) were iden-
tified as outliers. Coon et al. [8] examined a cohort
of 33 robotic and 44 standard UKA patients. The
coronal and sagittal alignment of the tibial compo-
nents were measured on postoperative AP and
lateral radiographs and compared to the preopera-
tive plan. The root mean square (RMS) error of the
tibial slope was 3.5 manually compared to 1.4
robotically. In addition, the variance using manual
instruments was 2.8 times greater than the roboti-
cally guided implantations ( p<0.0001). In the cor-
onal plane, the average error was 3.3  1.8 more
varus using manual instruments compared to 0.1 
2.4 when implanted robotically ( p<0.0001). A
study by Lonner [13] retrospectively compared
the postoperative radiographic alignment of the
tibial component with the preoperatively planned
position in 31 consecutive patients who underwent
UKA using robotic-arm assisted bone preparation
and in 27 consecutive patients who underwent
UKA using conventional manual instrumentation
to determine the error of bone preparation and
variance with each technique. Radiographically,
the RMS error of the posterior tibial slope was
3.1 when using manual techniques compared
with 1.9 when using robotic-arm assistance for
bone preparation. In addition, the variance using
manual instruments was 2.6 times greater than the
robotically guided procedures. In the coronal
plane, the tibial components using manual instru-
mentation exhibited an average error of 2.7  2.1
F. Buechel Jr et al.
more varus relative to the mechanical axis of the
tibia. This compared with an average error of 0.2
 1.8 using robotically guided technology. Fur-
thermore, the varus/valgus root mean square error
was 3.4 manually compared with 1.8 robotically.
Pearle et al. [9] compared robot-assisted and tradi-
tionally instrumented UKA in six bilateral pairs of
cadaver specimens. In all knees, a CT-based pre-
operative plan was performed to determine the
ideal position and orientation for the implant com-
ponents. Postoperative CT scans were obtained
from all knees, and the 3D placement errors were
quantified using 3D-to-3D registration of implant
and bone models to the reconstructed CT volumes.
Femoral component RMS placement errors (posi-
tion and orientation along any single axis) were on
average of 3.0 times more accurate ( p<0.05) and
3.1 times less variable ( p<0.05) with robotic guid-
ance. Similarly, tibial component RMS placement
errors were on average of 3.4 times more accurate
( p<0.05) and 2.6 times less variable ( p<0.05)
with robotic guidance. Roche et al. [11] utilized
the same postoperative CT technique to prospec-
tively assess the accuracy of the first 50 patients
who underwent unilateral medial UKA with
robotic-assisted bone preparation with a dynami-
cally referenced system. Complete pre- and post-
operative records, pre- and postoperative CT scans,
and archived surgical plans were available for
20 knees (19 patients, 1 bilateral). RMS errors for
femoral component placement were within 1.6 mm
and 3.0 in all directions of the planned implant
position, respectively. Average RMS errors for tib-
ial component placement were within 1.6 mm and
3.0 in all directions. Of note, this study was
performed on patients receiving robotic-assisted
UKA in 2006–2007 with the TGS, the first gener-
ation robotic technology. The RIO robot currently
available today is the third generation of the tech-
nology (Fig. 24).
Accuracy of Joint Balancing
Poehling et al. [15] conducted an investigation to
assess whether robotic-arm assisted UKA accu-
rately produced ligament tension according to an
111 Robotic-Arm Assisted Unicompartmental Knee Arthroplasty (MAKO)
Fig. 24 Component
position accuracy has been
clinically validated to be
more reproducible and
precise than manual
techniques. X-rays show all
four FDA approved
procedures using the
MAKO robotic system
intraoperative balance plan devised before com-
ponent implantation. Fifty-two consecutive
robotic medial UKA cases were utilized for this
study in which a dynamic ligament balancing of
the knee was obtained under valgus stress prior to
component implantation. This was then compared
to final ligament balance with the components
cemented in place. The study found that 83 % of
the cases were within 1 mm of the plan. Planned
dynamic ligament balancing was found to be
accurate to within 0.52 mm when compared to
the operative plan.
Survivorship
Successful clinical outcomes following
unicompartmental knee arthroplasty (UKA)
depend on component positioning, soft tissue bal-
ance, and overall limb alignment which can be
difficult to achieve using manual instrumentation.
A multicenter study by Pearle et al. examined the
survivorship of robotically guided medial UKA
coupled with a novel, anatomically designed
implant at 2 years postoperative [10]. A total of
959 patients (1,080 knees) in an initial series and
part of an IRB approved study underwent roboti-
cally guided surgery to receive a medial UKA
1303
from six surgeons at six separate institutions.
The average follow-up was 24  2.5 months.
Nine knees were reported as revised for an overall
2 year survivorship rate of 99 %. Ninety two
percent of patients reported feeling either “very
satisfied” or “satisfied.” This robotically guided
procedure shows improved early survivorship
rates for UKA compared to what is currently
reported in implant registries and comparative
studies.
Discussion
Since the beginning of partial knee replacement
in the 1950s and 1960s there have been several
factors that we now know influence PKA out-
comes. These include properly selected
patients, well designed implants correctly
sized, accurate alignment, and optimal balance
and tracking.
Most surgeons will not perform enough PKAs
to be proficient. The Mako robotic-arm assisted
partial knee replacement system can be highly
accurate and can allow the surgeon to achieve
good implant placement starting from the very
first case with proper training [2, 6, 8, 9, 11, 15,
24, 25].
1304
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