Mark Shekhman, MD, FRCSC

Not quite two weeks after having partial knee replacement surgery at Hartford Hospital in February, Martin Ethier took a ride to New Hampshire, where he climbed into a John Deere loader.

"I made it back just in time for therapy," Ethier said.

The American Academy of Orthopaedic Surgeons suggests that people take nearly six weeks to recover fully from this type of surgery. But the fact that Ethier, 51, was up and about so quickly may well be a sign of things to come, as ever-improving robotics take hold in the operating room.

Dr. Mark Shekhman repaired Ethier's knee on Feb. 27 using a partial knee resurfacing technique developed by MAKO Surgical Corp. (MAKO Surgical was acquired by Stryker Inc. in 2013.) The operation requires the use of a robotic-arm system that enables surgeons to align and place implants with greater precision.

"It is a great progressive step in our constant efforts to improve our technology," said Shekhman, an orthopedic surgeon. "This is the evolution of constant improvement."

The robotic-arm system is also used in total hip replacement surgery.

Ethier long knew his knees would be a problem sooner or later. Ethier has a family history of osteoarthritis — the most common form of arthritis, in which the surface cartilage of joints breaks down, causing swelling in the joints, loss of motion and pain.

Ethier said he is one of nine siblings, "and four of us have had knee surgery."

But it wasn't just genetics that gave Ethier's knees problems. It was also what he does for a living. Ethier has owned and operated Ethier Excavating and Landscaping Inc. in South Glastonbury since 1995 and believes that climbing up on heavy equipment and jumping down hasn't done his knees a favor.

"I've walked over rough ground a good part of my life," Ethier said. In recent years, however, the pain in his knees got to be too much.

"Your knee is in pain every time you walk," Ethier said. "The pain came on in the evening. … Just walking and functioning was getting harder and harder."

Ethier said he first went to his primary care doctor, who ordered an X-ray, then referred him to an orthopedist, a doctor who treats disorders and injuries of the bones, joints and related muscles and ligaments.

That's when Ethier met Shekhman.

"As soon as he saw the X-ray he said, 'You are a prime candidate for a partial knee replacement,'" Ethier said.

Knee replacement surgery was first performed in the 1960s, according to the American Academy of Orthopedic Surgeons. Since then, improvements in materials used and surgical techniques have steadily improved patient outcomes. Computer-assisted surgery systems didn't see clinical use until the 1990s.

In December 2013, the AAOS reviewed studies of the only two robotic surgical assistance systems approved by the U.S. Food and Drug Administration for unicompartmental (partial) and total knee replacement and certain aspects of total hip replacement surgeries. The two systems were ROBODOC Surgical System made by Curexo Technology Corp. and MAKO Surgical's RIO or Robotic Arm Interactive Orthopedic system, which is used by orthopedic surgeons at Hartford Hospital.

According to the AAOS, as of September 2011, the MAKO robotic system had been used in more than 10,000 knee replacement surgeries.

The U.S. Centers for Disease Control and Prevention estimates that osteoarthritis affects roughly 14 percent of adults 25 and older, and 33.6 percent of those 65 and older.

Based on the reviews, the AAOS concluded that while the use of robotic systems in partial and total knee replacement surgeries improved component positioning, more time will be needed "to demonstrate whether the improved positioning will result in clinically significant improvements in patient outcomes."

Then there is the question of cost vs. the benefit to patients of robotic surgery, according to the AAOS. The "initial capital requirement can approach the $1 million mark for some systems."

"With every iteration it gets better and better," Shekhman said of the computer-assisted surgery system that the orthopedic surgeons at Hartford Hospital are trained to use. "One of its greatest strengths is to allow surgeons not as well versed [about a particular surgery] to perform almost at the level of an experienced surgeon."

The improvement in "computer-assisted navigation" allows the surgeon to more accurately position implants in a hip or knee to achieve real time accuracy."

Improved positioning should, in theory, increase the lifespan of the replacement parts used in the surgery because they will function closer to normal and be under less strain.

The robotic arm "prevents the surgeon from making inappropriate or inadvertent cuts" during surgery, Shekhman said. The system also allows the physician to get an idea ahead of time about what the outcome "will look like when finished."

"It has achieved a level of acceptance" among the orthopedic surgeons at the hospital "that makes it appropriate for prime time," Shekhman said.

It will take time and further study to determine whether this new technology will prove superior in terms of better outcomes when weighed against other surgical methods used to repair or replace osteoarthritis-damaged knees and hips, he said.

Ethier said he was "a little apprehensive" at first but he felt comfortable with Shekhman doing his surgery.

"He was being straight up with me," Ethier said, adding that Shekhman told him that the length of time repairs to his knee would last depended on how he takes care of himself.

"I should be able to get 10 years out of it," Ethier said, "if I don't jump or lift a lot of weight."

Ethier said he and his family, including his wife, Denise, and five sons, grow fruits and vegetables on the farm where they live in South Glastonbury.

"Hopefully, I'll be up and going and I'll be able to get back to a normal routine," Ethier said. "It's good to do what you want to and not feel the pain in your knee."