George Gates describes himself as "kind of hyper." He used to own Gates Oil Corp. and he lives in a Niskayuna, N.Y., townhouse with his wife. At 73, he golfs, gardens and rarely rests, but the pain in his arthritic knee became too intense this fall.

"If I went to Hannaford's or Home Depot, I could just make it back to the car," Gates said.

He realized it was time for a new knee.

Knee replacement patients have options today. Surgeons offer new surgical techniques that attempt to personalize the prosthetic knee to individuals big and small, bow-legged and pigeoned-toed, by using customized guides for cutting bones, gender-specific knee implants and computer guided surgery.

While some local surgeons have adopted the new methods, others are waiting to see results of long-term studies.

"This is a surgery that has a 90 to 95 percent success rate. You don't want to mess with that too much," said Dr. Richard D'Ascoli, an attending surgeon at Ellis Hospital in Schenectady, N.Y.

More than 500,000 knee replacements are performed in the United States each year, and the number is expected to skyrocket to 3.4 million by 2030, a 673 percent increase, according to the American Academy of Orthopaedic Surgeons. The demand is fueled by the increase in obesity and the aging population, namely baby boomers who want to stay active.

Knee-replacement patients have worn down the cartilage that cushions the bones at the joint. A total knee replacement essentially resurfaces the tips of the two leg bones that meet at the knee. During surgery, the end of the bones are cut and capped with a smooth metal or ceramic implants, and a piece of shaped plastic is inserted between them to act like cartilage. Most knee replacements retain the patient's own knee cap.

Better Alignment
The cartilage along the inside of Gates' left knee was gone, leaving him with bone on bone. He signed up for a total knee replacement with Dr. Joseph Marotta at Samaritan Hospital in Troy, N.Y,, who uses the OtisKnee, one of the new techniques that tries to customize alignment of the implant to the patient.

Alignment begins with the surgeon's first, and most critical, cut on thigh bone.

Like the cut on a Christmas tree that makes the tree sit wobbly, off-kilter or perfectly straight, the cuts on the bone are the foundation for the implants and, therefore, the alignment of the new knee.

"It's the point of no return," Marotta said. "It's very hard to go back and change."

Traditionally, surgeons go into the operating room with an X-ray of the knee, some measurements and a general sense of what size implant the patient needs. The surgeon attaches rods to the leg and ankle to judge the proper alignment and uses calculations to decide where to cut the bone.

All of these calculations are done while the patient is on the table with his or her knee sliced open.

"You do it by experience and by eye," Marotta said. "And it works very well."

3-D Knee Image
But Marotta believes there is a better way. A few months ago, he started using a technique offered by OtisMed, a California-based company. Marotta sends an MRI of the patient's knee to OtisMed, and the company creates a 3-D image of what the patient's healthy knee would look like. From that image, the company's software determines what size implant would work for the patient and then creates a plastic jig to guide the surgeon's cuts on the bone.

When Marotta opened up Gates' knee during his Nov. 12 surgery, the jig slipped onto Gate's femur like a cap on a bottle.

Marotta pinned the device to Gate's bone and slid his electric saw through the slots of the jig. The saw sounded like a distant chain saw, and bone chips sprayed as Marotta cut through the thigh bone. Within minutes, the tip of Gate's femur was transformed into four smooth-sided planes, a finely milled foundation for the implant.

"I think it's the biggest advancement in knee replacement surgery in 20 years," he said. "It's such an improvement to the fit."

Samaritan Hospital absorbs the extra $3,500 cost of the OtisKnee method, believing it will be recouped through shorter surgeries and hospital stays which traditionally last three or four days. The average knee replacement surgery costs $36,000 in hospital charges, according to the American Academy of Orthopaedic Surgeons.

Marotta has the OtisKnee on 10 patients and said they recover faster and have smaller incisions.

Gates walked to his room door the day after surgery and down the hallway on the second day. He transferred to a rehab hospital on the third day.

"I'm doing therapy two hours a day, and I tell you, it hurts," he said.

Dr. Lawrence Fein, of Orthopaedic Associates in Saratoga, N.Y., started using the OtisKnee method three months ago and has performed dozens of surgeries with it at Saratoga Hospital.

"It feels more like a natural knee," Fein said.

Dr. Marc Fuchs, a orthopedic surgeon and professor at Albany Medical College, isn't convinced that the OtisKnee is any better than the traditional way to align the knee.

"Not until I see good, long-term follow-ups -- not a three- to six-month follow-up -- will I be convinced," Fuchs said. "You really want something that has gone through peer review."

Anatomy and Gender
Another new development in knee-replacement surgery is the gender-specific knee.

"A woman's anatomy at the knee is different," said D'Ascoli of Ellis Hospital. "A woman has a wider pelvis for child-bearing reasons, and some of the angles around the knee are different."

D'Ascoli has been using the implants designed for women for a year and a half, and he said it's the best fit for about 65 percent of his female patients. The others fit into the traditional knee implants, which offer eight to 10 different sizes.

"I go into the operating room with the ability to do either one," he said.

Computer Guidance
Dr. David Abraham, chief of orthopedics at St. Peter's Hospital in Albany, N.Y., prefers computer-assisted knee surgery. Just like auto technicians use a computer to guide the alignment of an car's tires, he uses a computer to align the bone cuts in the operating room.

"It's like a localized GPS system that we can calculate the position of the hip and the ankle and the computer will guide us where to put the knee in terms of the cuts on the bone," he said.

The computer-assisted knee surgeries have been around for several years. The one-time expense of the computer guidance system is $200,000 to $300,000, Abraham said. The system is more cost-effective for hospitals than the OtisKnee, because surgeons in other specialities, like brain, ear, eyes and nose surgery, can also use it, he said.

As for Gates, the knee replacement patient, he plans to go to Florida for the winter and start golfing in early February.

Cathleen F. Crowley can be reached by e-mail at ccrowley@timesunion.com.

Source: Albany Times Union, N.Y. Distributed by McClatchy-Tribune Information Services. Powered by Yellowbrix.

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