Updated Treatments for Knee Pain & Arthritis

[Music] welcome to Washington Hospital today the program dedicated to sharing timely information about the community hospital that's been taking care of Washington Township health care district residents since it opened in 1958 Washington Hospital today is provided for the sole purpose of informing residents about health care topics and issues that have been covered during community forums free health and wellness classes or as part of educational sessions held during the district's open board meetings this program is one more way that Washington Hospital helps empower you the residents of the district by providing information needed to make informed decisions about your health [Music] you today's presenter is Alexander saw dr. SAW is a native of Fremont and was born at Washington Hospital dr. saw completed his bachelor's degree at Haverford College in Pennsylvania he completed his internship at Massachusetts General Hospital and his residency at Harvard combined orthopedic residency in Boston dr. Shaw completed his fellowship in minimally invasive and revision hip and knee replacement at Rush University Medical Center in Chicago we're gonna cover everything I can in terms of updated treatments for knee pain new york--the Rytas and both the non operative and surgical management of that so just a little bit of background as you heard I was indeed born and raised here in Fremont my parents raised me here and my father was a head and neck surgeon here for 40 plus years my parents if you know them they still volunteer at the hospital so they have a deep commitment to this hospital in this community and that's why it's a great privilege for me to come back and do the same I went as you heard you already heard all about this habit for college and then where I train in Philly and then Boston and Chicago but then I've been here since 2008 this is actually a picture of my dad if you don't know him and this is a picture a long time ago when I was just a youngster and then something happened in between now we've changed in terms of who's taller but but he's actually here in this room it's it's obviously great to be in the community to work with the colleagues that he worked with see patients as he's seen it's just been a real privilege and honor to again work at this hospital and then in this community and I appreciate the recognition I do not do my job or work for awards but this means the world to me because the community has recognized me hopefully for doing a good job like my dad did again it's it's always fun when I see a patient they say I remember your dad or he took care of my kids or he took care of me again nothing nothing warms my heart more than that so I'm trying to trying to provide that care in the same personal way as he did so what do i do I do total knee replacement I do total knee revision I do partial knee replacement and I'll introduce you to that today if you're not aware of what that is and I do total hip and revision surgery with the amount of surgery that I do here I'm very fortunate that allows me to be Co medical director of the Institute for joint restoration I'm director of the outpatient joint replacement program and I'll talk about that more later as well but all of these other committees as well so what's nice is that I'm able to be involved not only at this hospital but on a state level and with national organizations so I continue to travel to lecture to other surgeons give talks at other meetings so that I can talk with my colleagues and bring all the most up-to-date information and surgical techniques back to our community here so I find that that's very important to do and this is just one example of an honor that I received last year where our national American Association of orthopedic surgeons selected ten orthopedist in the country and I was fortunate to be one of those to be involved in their leadership program last year so we traveled around the country and again they were basically grooming us to be the next leaders in the field so I I appreciated that so I'm going to cover a lot of information as I said some of these handouts you have have this website on it definitely take a look at it write it down because if I go too fast or you want to refer to it later a lot of information that I'm going to present here will be available on that website there's also a phone number there if you need to make a call or on the website you can call us for more information or to make appointment so again this website will have a lot of this so this is what we're going to attempt to do it's a daunting task it's a lot of information but I'm gonna try to keep it interesting for you if I can so we're gonna cover knee arthritis basics just introduce you to the anatomy and the function of the knee we'll talk about non-operative treatments will talk about knee replacement traditional versus less invasive surgery partial knee replacement we'll talk about our unique to our replacement program here rapid recovery surgery and then even outpatient joint replacement something new and on the cutting edge so first let's talk about knee arthritis so here's a diagram of your knee and what you can see here is your thigh bone is on top and your shin bone is on bottom and that white covering is just like the white covering on the end of a chicken bone that's what cartilage is you can see the ligaments around the knee you can see the meniscus inside the knee that's extra cartilage between the two bones so this diagram depicts all the anatomy around your knee does anyone know what this is right in the middle of the knee ACL very good so that's your anterior cruciate ligament so ACL that's what you read about every day and then sports paper some athlete ruptured their ACL all right this is the ligament that they're describing so it's called and to your cruciate ligament because cruciate it crosses it crosses the posterior cruciate ligament behind so there are two ligaments there one's anterior in front one's posterior and back they're called the crews shits because they cross so they're in the middle of the knee their major stabilizers of the knee but all of you have probably heard of the ACL again that's the most commonly injured ligament you hear in in athletes so this is the side view of that same knee and again the white is the cartilage being represented here's the kneecap in front that bone there and this depicts the patellar tendon and these white things on the side would be the ligaments so if you look this gives you an idea of what happens every time you walk or you go up a stair that knee bends and you can see anywhere there's contact of one bone against another there's cartilage there because that cartilage lets the bone move freely and without pain so college is your friend that's what you want on the end of the bone you do want to know that the knee does feel three to five times body weight and even more with jogging more like seven times so for every 1 pound loss that's potentially 3 to 5 pounds of force off a painful name so just something to keep in the back of your mind when we talk about arthritis we're talking about simply the loss of cartilage at the end of the bone so instead of having that white covering it starts to get degraded like the picture on the left so that the exposed bone underneath is now there and when bone starts to rub on bone that's more painful on the bottom left you can see how the white is smooth right like that chicken bone that's good cartilage intact cartlidge when it becomes pitted and eroded that's what we term as arthritis usually due to wear and tear sometimes can be due to trauma sometimes can be due to inflammatory arthritis like rheumatoid arthritis or lupus or other things but most often it's simply wear and tear so the question is is why does the joint wear out well let's make the analogy that your joint is like a car tire why do some car tires wear faster well maybe it was bad quality rubber to start with maybe was set up to wear like this tire maybe it had to do with the driving habits of that person that car he went very fast they made a lot of turns or maybe like a freeway the low frequency lower weight left lane tends to not break down as much as the right leg which is used more often higher frequency and higher weight trucks so just in how much it's used you can imagine one may wear out more than the other and some of it may be genetics or but the bottom line is our thright as' means breakdown of that cartilage like here the bones exposed underneath and so now it becomes a painful joint even though we're talking about knees I do want to take a moment to notice that some people have knee pain or pain in their knee area but it's actually not generated by the name meaning some people will have hip arthritis or hip pain and it will refer to their knee and they'll feel it in their knee but there's actually nothing physiologically wrong with their knee so it's always important for physicians and doctors to evaluate the entire patient entire person because it can be misleading as an example I had a patient a year ago who came in who had two knee replacements somewhere else and he was came in on a walker and for two years he was undergoing every test trying to figure out what was wrong with his knees for two years on a walker I came in he came in he saw me we reviewed his examination and what I discovered was both of his hips were extremely arthritic like this so at all for those two years doctors were looking at the wrong body part I fixed his hips and his knee pain went away so just bringing up that not all knee pain means it's coming from the knee now knee arthritis what does it look like knee arthroscopy is when you use a small camera and just like the picture on the top left and you can go into the knee and look with high-definition and another small instrument to clean up a small amount of cartilage that's knee arthroscopy using a camera and small instrument to clean up the knee well these are pictures of what a knee looks like on that camera so on the bottom left this is very magnified of course but the probe is in the knee and you can see the rounded portion on top that's the end of the thigh bone on top that's why it's rounded because it rolls on that bottom flat part portion which is depicted here in the lower part of the picture the part in between is the meniscus so most people who have an arthroscopy have it for a torn meniscus you're looking at a meniscus right there but the reason I brought this up was to show you what our itis looks like on the pictures on the right so this here the white remembers the cartilage so this is a big defect of cartilage missing a big pothole if you will and here you can see part alleges tearing pinkish that's the bone exposed below all of these are pictures of cartilage breaking down that's what it looks like on the camera this is what it looks like in the operating room so these are the ends of two bones these are the ends of the knee the end of the thighbone remember that cartilage should be white should be smooth these are areas where Carla's have been broken down it's shiny like a cue ball because that white protective layer has simply worn away that's what it looks like in the operating room this is what it looks like on x-ray so an x-ray only dents things show up so only bone shows up on x-ray so as you're all learning this is the thigh bone on top and shin bone on bottom remember the white cartilage covers the ends of the bone but cartilage is invisible on x-ray so the way we know there's cartilage is as those bones are separated so this space here is because there's cartilage on the ends of both bones so what does it mean when the bones get this close together it means that that Carla just can't be there it must have been worn away so it's the absence of space that lets us know that that cartilage is wearing out but we see some other things in this x-ray so we ask again anyone have any idea what's going on there's a staple and a screw what's happening in this knee anyone want to throw out a guess this is actually related to that ligament we were talking about before remember the anterior cruciate ligament well when that tears orthopaedist try to reconstruct it how do we reconstruct it we take a cadaver graft we take hamstring we take patellar tendon we take some sort of tissue and put it back in that knee in the same orientation so see these tunnels if you will you can imagine that that's where that tissue is going so what happens is because the ACL is deficient we take tissue drill a hole through the shin bone in the orientation of how that ligament goes put the ligament across the joint put it through the thigh bone on top and then fix it with a staple or a screw or something but then what's happening is that cadaver or host tissue is mimicking the function of the ACL so what this means is by just looking at this x-ray I know that this patient ruptured their anterior cruciate ligament at some point had some sort of injury they had a reconstruction of some type of their ACL and now they're bone-on-bone and now you can tell that - in 30 seconds you can tell a lot of this patients history just by that x-ray but the bottom line of arthritis is we don't have a cure yet once that College breaks down we don't have a way of growing back normal cartilage or filling that space which has been ground down so it's sort of like that car tire analogy again once that car tire ruptures it's time to replace it so that's the knee arthritis basics and then we're going to talk about how do you treat that so if you have knee whether it's from knee arthritis or from some other injury the first thing that you can do for it of course is rest the pneumonic rice rested ice compression and elevation just for any body part that often helps the occasional ache in pain but for paying that persist motrin advil ibuprofen many of you probably have this in your bathroom or kitchen cabinet this is a non-steroidal anti-inflammatory drug everyone here is familiar with steroids right that's a very powerful anti-inflammatory these are drugs that have an anti-inflammatory effect but are not a steroid they don't have any of the side effects so advil motrin ibuprofen celebrex aspirin these are all examples of NSAIDs or non-steroidal anti-inflammatory drugs they help with pain they help reduce inflammation the only caution you have to have is that that they can upset the stomach so if you have reflux or heartburn sometimes it can aggravate or if you get ulcers and that also can thin your blood a little bit because it affects your platelets so if you're on coumadin Xarelto plavix you have to be a little careful taking this in addition to it but it's a great over-the-counter medicine for pain and inflammation I give it to my children it's very safe aspirin is another anti-inflammatory many of you may be taking that now not so much for its anti-inflammatory effect but for its protection of the heart but it is an anti-inflammatory acetaminophen tylenol is different it's not an anti-inflammatory has no anti-inflammatory properties but it is a mild pain reliever and it helps reduce fever as you all know for someone who has arthritis someone who has pain for many reason Tylenol is another over-the-counter medicine which is very safe to take it does not affect platelets so if you are on plavix coumadin xarelto what have you you can take tylenol safely the caution you want to help with Tylenol is that if you have liver impairment if you have a diseased liver or any problems with your liver that's when you have to be cautious with Tylenol but if you don't have any other contraindication you can take Advil and Tylenol in the same day and stagger them they're safe because they have different mechanisms they work in different ways now if those don't work some people will go to analgesics things like tylenol with codeine or tramadol or vicodin but of course we don't want people to be on pain pills if your pain is bad enough where you require narcotics or pain pills you need to have it evaluated because there's an opioid epidemic in this country and there are downsides of being on pain pills long term how many of you are taking glucosamine chondroitin sulfate good number and it's very popular because what it is is that it's a natural compound and healthy cartilage it's not approved by the FDA it's not a drug it's really classified as a dietary supplement the reason is is there's no clear evidence to show that it actually does anything there's no data to show that it regrows cartilage or anything else and because there's no regulation when you buy a bottle on the counter of the pharmacy or the GNC you don't really know what's in bottle one or bottle two just so you know now one of my mentors in Boston gave me a great analogy which I will never forget because glucosamine is a is a building block of cartilage he said that the analogy of this working is sort of like a bald man who eats hair so just because you eat what you want doesn't mean your body's gonna process it and put it back where you want to so I will never forget that but again if it works for you there's nothing wrong with it it's not a bad thing you just might be losing some money but there's nothing really no harm can come from it just no data that's really supported either same with these supplements there are a lot of these it's a multi-billion dollar industry so there's a lot of money in it people United States buy a lot of this joint juice art though gold all these things they sound great unfortunately no data to show any of them actually do anything clinically but again if it works for you it's okay to take physical therapy can help because they can work on strengthening and range of motion those things can help an arthritic knee in terms of function but of course it doesn't reverse the arthritis process so it may make someone feel better function better but it's probably gonna be short-lived because eventually that arthritis will worsen but the most important thing to take away from this slide is the last line the benefits are lost within six months of stopping that exercise so if you do do the therapy if you do exercise remember it's something you have to continue don't stop it or else you lose the benefit now let's say all of that doesn't work now what do you do well that's when you come see a physician and now you move to something a little bit more invasive only knee injections but still invasive the most common injections probably cortisone as we talked about earlier steroids are anti-inflammatories very potent anti-inflammatories so it can reduce swelling it can reduce pain we typically mix it with a lidocaine which is like novocaine at the dentist so it's so a numbing medication put it in in the office it helps with pain it's an anti-inflammatory but it doesn't cure arthritis and it doesn't last forever for some people it might last a couple months some people a few weeks some people if you days so it's highly variable but for some people it can help particularly if they're gonna go on a trip or they're just not quite ready for surgery yet but it's not something you can do regularly forever you can do one every four months for the rest of your life so it's a temporary fix there are some downsides by the way with cortisone that if you do too many that cortisone can start to affect the good parts of the knee as well and that's why there are limitations on how many you can take but if that doesn't work the next you can try is viscosupplementation or this gel see all on the picture on the left that material is very thick its gelatinous the idea of this is a lubrication and that it can be injected into the knee and potentially act as a shock absorber if you will you'll reduce some pain reduce some inflammation however it's important to know that our orthopedic Academy does not recommend this not because it causes harm but again there is no data to show it actually does anything it does not cure arthritis it doesn't grow back cartilage and some studies suggest it's about as good as injecting saline or water into the knee but again some people get it they say they feel better can't argue with that but just so you know there's not good data to say it actually has any clinical benefit the third option and a newer option are biologics PRP or stem cells you've probably heard about it it's a very hot topic in the news it's interesting areas of research but we're not quite there yet we don't have the ability of taking your own stem cells growing cartilage and putting it back we're just not there but PRP is what again sports athletes are doing you hear about Kobe Bryant or these other people going to Europe to do these injections we I can do them for you here it's taking your own blood spinning it down to filtering it and taking growth factors and other things naturally in your blood and then injecting it into the painful joint to hopefully stimulate some repair and reduce inflammation again not a lot of data about how well it works it's new it's being investigated it's also not covered by insurance because it's so new but some people have done it and I've said they've had good results so it's just another option to be aware about lastly are these devices and gadgets you've probably seen these you've heard about them that middle one in the bottom I think is called the willow curve and a lot of people have seen it because I think it has a celebrity promoting it on TV but all these things again no data to say necessary does anything I like the one on the top left the arthritis killer that one sounds very very interesting and effective but again we don't know it probably just works does it provide some heat or other things but you can try the gadgets if they work great again you might just be throwing some money away unfortunately so once all those things don't work now that's when we talk about surgical intervention knee replacement it's a little bit of a misnomer it's not cutting out the entire knee and replacing the whole knee it's really a resurfacing of the knee but we call it total or full knee replacement because it's resurfacing the entire end of the bone so if you remember those pictures before if this is your thigh bone you can see how this metal cap caps the end of the bone it's really just a few millimeters thick so here's an example of a component it's a few millimeters thick and the idea is that when this goes on to someone's knee it recreates the same size the same shape the same depth of what that knee looked like when it had cartilage so these comes in all different shapes and sizes so it can be mixed and matched to that individual but you can see it's pretty narrow it's pretty thin and it caps the end of the bone and then what happens is a platform goes on the bottom the picture on the right so metal again and then plastic in between so what happens now is you have metal rolling on plastic so instead of bone on bone so this gives the opportunity to get rid of any bone on bone articulation and also this to correct any malalignment of that leg someone asked what metal is that and the bottom piece as you pass it around you'll notice is pretty light that's titanium that's what the plastic fixes to the top parts actually surprisingly heavy that's cobalt chrome and the reason is that cobalt is less likely to scratch and because the metal is what's rubbing against the plastic you obviously want that to be very smooth because if that metal gets roughened it will act like sandpaper on the plastic below so that's why there's a difference in the two weights one cytanium and one's cobalt chrome so in this picture this part here cobalt chrome this bottom part is light it's titanium so what's it look like on x-ray here's a knee replacement going in and surgery in the middle the implant on the right and then on x-ray there's our arthritic knee we saw before bone on bone this is what it looks like in the front so from the front view metal on top blasting in between metal and bottom this cloudy white stuff is this cement and when you look at the side of the knee it's again metal on plastic on metal with the kneecap in front so that's what it looks like on x-ray so how does knee replacement work well people do well it's typically something like a 12-week recovery people are walking biking swimming typically pain free we expect fewer than 1% to fail meaning that 20 years over 8090 percent should still be working well how many knee replacements are done in the US over 700,000 every year and is expected to exponentially increase because of the baby boomer so this is a very common procedure this is traditional knee replacement traditional knee replacement is a pretty big incision exposing the knee putting in those components you're passing around staples using this this is called a CPM machine it's a machine you put your leg in it moves the knee for you and then walk into a walker so traditional knee replacement nothing wrong with it you can do a great knee surgery through it it just may not leave to the fastest recovery right you can imagine trying to heal this kind of incision could take a little while so people have traditional knee replacement often are in the hospital three or four days many go to a skilled nursing or rehab facility and many are on a walker cane for a number of weeks traditional New York placement is fine it works fine but are there some advantages of less invasive surgery minimally invasive surgery is doing that same procedure but doing it through much less soft tissue trauma less muscle injury less bleeding less pain hopefully for a faster recovery and so that's what I've been doing here since 2008 that's what I was trained to do so on the left is that traditional knee exposure and the incision and on the right is what a less invasive surgery is you can see it's just much less invasive so doing that since 2008 I was constantly trying to modify how I was doing things in terms of improving pain a multi-modal pain management so trying I try to focus on using many different medications to improve pain without using just a narcotic for example I try to avoid narcotics try to avoid any high dose of any one particular medication to give a better overall result and I talk to a lot of surgeons and around the country about how to do that I'll talk about that later but I was working on better blood preservation minimize bleeding minimize pain after surgery and then enhancing those rehab protocols so what that led to was in 2014 I started a new program here where all my patients were walking the day of their knee surgery and as a result of that I was able to get my patients home the very next day it had not been done here before so I've had 40 year olds and 90 year olds go home the day after knee replacement the bottom is my study on that presenting it on the national level and showing people how people can do very well with these protocols this I just have to show is a 95 year old man on his first post-operative visit to we after knee replacement 95 years old pretty impressive now what can knee replacement do certainly can fix the very simple but he can fix the very complex look at this gentleman he's one of these who walk in and you know what's going on before you even take an x-ray I mean you can see through his pant leg what's happening his knee not only is bone on bone but you can see how in the picture on the left the x-ray it's shifting out of place and he's actually eroding bone but with this technology and a knee replacement you can make that leg straight again you can put it back to how it's supposed to be and take away bone on both even in those patients who've had knee replacement before this is a picture of someone who is referred to me their knee replacement I was in there for 20 years and it started to fail and it was collapse and you see how crooked her leg was but with revision surgery we can rebuild it and make that leg straight again so that's the kind of things that we can do with total knee replacement and a revision knee surgery now I'm gonna introduce partial knee replacement so partial knee replacement is very similar to what we talked about but it's refined to only one part of the knee so remember total and full knee replacement is called that because every surface is the inside-outside in front of the knee all three compartments what I'm talking about now is a procedure that only resurfaced as one of those three compartments so here as opposed to the very far right where arthritis is diffuse and spread throughout the knee now we're talking about a knee where there's only arthritis in one part so the question is is do you need to replace the whole knee in that situation maybe less is more so that's what partial knee replacement is so it's still metal on plastic on metal but you can see it's isolated to only one portion the potential benefits of partial knee replacement are many it's less invasive its bone conserving its ligament preserving there's less blood loss the knee has a better range of motion it's a faster recovery and because the knee keeps all of its ligaments it can feel more normal than a knee replacement it can be durable for up to 15 years and in that rare case that it fails it can easily be converted to a total knee replacement I learned in Chicago how to do partial knee replacements and that's what I've been doing here since 2008 in the appropriate patient because as well as knee replacements can do studies have suggested that partial knee replacements can actually have even better results so in the comparison of partial to total knees these studies have shown that it can be superior with better motion prefer it with improved results compared to total knee but only in those patients where it's appropriate and that know if you're appropriate is you have to be evaluated by someone who does them so there are a lot of patients who go to surgeons and ask if they can have a partial or total knee replacement but if that surgeon only does total knee replacement they're probably not going to offer you a partial knee replacement so if you think that you may be a candidate you want to see someone who does them and is experienced in them to see if you truly are a candidate there this x-ray on the bottom right hopefully everyone can see that the total knee replacement you're becoming familiar with is on the far right of that bottom right picture right the metal plastic and metal you can see how on the left side it's metal plastic metal again but notice the middle of the knee is preserved and for the third time bringing up that ACL you're all becoming experts you all know what lives there right the ACL and PCL so with a total knee because it goes all the way across those knees are typically sacrificed you don't have it anymore total knees can accommodate for it they can work very well but this is one of the major benefits of a partial knee those ligaments are untouched so the partial need every native ligament of the knee remains typically partial knee replacements the inside of the knee like this model here so you can see again it's metal on plastic on metal analogous to what you're passing around with the total knee but it's just on one portion of the knee that's one part of one type of partial knee a partial knee can also be on the outside of the knee that's the second compartment the third compartment is the kneecap area which I'm showing here so some people particularly women can get arthritis of just the kneecap so the kneecap glides in that groove every time the knee bends but with bone-on-bone arthritis like in these pictures here this can be resurfaced separately instead of replacing the whole knee but again you have to be a candidate for partial knee replacement so you have to be seen in evaluate because if your arthritis is more diffuse a partial knee replacement may only fix part of your pain but you want to be seen to see if that's a possibility cuz there are many benefits I do a lot of partial knee replacement I'm actually the United States lead investigator for the Zimmer companies new partial knee that was just released this week in terms of the partial in the implants I actually with this particular component the company has told me that in last year I did the most in California and actually top 13 in the United States with that component and for the knee cap only replacement I did the top 5 volume in the United States these are two pictures one of my patients partial knee double partial knees and this is him surfing in South America and then this is a patient of mine who sent me this picture of her scuba diving in Hawaii looks like they're living pretty good lives I'm envious I'm now gonna talk about our Institute for joint restoration so the unique program we have prior to surgery we emphasize a lot of education so that people can be educated by our therapists our nurses our patients attend the class even before they've had surgery so that they know everything they need to about surgery it really helps the recovery there's no surprises this is supplemented by an educational binder which has all the information about what to do before during and after surgery so we really do stress education our personnel we've done fellowship training our anesthesiologists RoR techs our nurses therapists this is all we do is joint replacement so really everyone in every facet is an expert at their particular field this is our facility if you haven't seen it the top floor is our office and the office there it's just on the top of that Center for joint replacement building so it's on the top floor and then on the middle floor is where our joint replacement recovery Suites are so here's the nursing station there are 30 private rooms so every patient has their own individual room the only patients in that entire building are healthy elective joint replacement patients all the sick and ill people are in the main hospital so we quarantine the healthy people away but that also means that the therapists and nurses are also only dealing with healthy patients so everyone in that building the goal is to be as healthy as possible to prevent infection to prevent complications and that's why we've been rated very highly which I'll talk about later in terms of safety and infection reduction with the number of surgeries that I do I'm able to present the data that I do here at national level meetings the AOS is our national orthopaedic Academy meeting publish these things in our orthopedic journals as well so I am very involved with the research and presenting the data here on a national level and these are just some examples of talking about joint replacement of different sizes and different knees or the results of cemented hip replacement or using gender type components which was a female type knee design so all these things get presented and these were just some other talks that I gave last year at our national hip and knee meeting so I enjoyed doing that I think it benefits my patients here Fremont is here obviously you all know that we are a local Community Hospital we actually do draw patients from a large geographical area so I've had patients coming from Hawaii in Washington State New York and Texas and these people are coming here because of our program because of the building the therapist the team and the and everything from top to bottom in what we do here so again while we're a tri city hospital that's represented here in this blue the majority of my patients are coming from other places and that's a great privilege that they're willing to drive past many other hospitals to come here so we take that responsibility very seriously we've been recognized in terms of our orthopaedic this is a survey by patients they've consistently rated us one of the top actually in the country in terms of satisfaction and Becker's has reviewed a Washington Hospital and their joint replacement program again one of the top and with health grades you can look online five stars as their highest rating for hip replacement highest ratings knee replacement highest rating we were their top two our replacement center just a couple years ago in California so we get a lot of recognition the people people often ask about this in terms of safety consumer report maybe a year year and a half ago did this to look at the safety of hospitals in California and what you can see there on the top left is Washington Hospital got the highest report for safety and knee surgery higher than Stanford and UCSF and we were one of only maybe eight given their highest rating and then for hip surgery we're one of five Consumer Reports highest rating so in terms of safety infection reduction and other things were one of maybe two or three in the state to get Consumer Reports highest rating next we'll talk about rapid recovery surgery so every what no one wants to have surgery but if they do they want to get back to doing what they want to as quickly as possible and as safely as possible typically as surgeons we've we've historically only been focused on the surgery because that's what we love to do well with more and more time surgeons are realizing with education and meetings and other things that you have to look at the whole picture if you really want people to have a good experience you have to look at everything from selecting the patient patient education pain nausea bleeding to rehab to support system to follow-up you have to look at all these things to have rapid recovery and you have to have something in place to maximize that so that's what my emphasis is I actually give lectures and talk international means about how to optimize this for other surgeons and other practices so the goal is not only to be sufficient in all of them but hopefully to excel it's a because if you can excel at some of these aspects maybe some of these patients can even go home the same day now that's not everybody you don't want to send everyone home the same day but if you have the things in place to allow that clearly that will benefit those other patients who do have to stay longer and I always tell other surgeons when I lecture them that all of these things have to be functional if even only one thing is not working well the patient will not go home same day or next day so you can have all the aspects of care very well controlled but if their pain is not well managed right they are not going to be able to recover quickly and that applies for every other aspect of this all of them have to be running on all cylinders to be successful so what do I do that's a little bit different for pain management again it's an emphasis and focus of mine I employ multimodal pain management so using many different medicines at low doses to give a better overall effect and that's been shown to reduce the amount of narcotics needed to reduce the amount of side-effects from narcotics and that's something that's very very important in addition is reducing blood loss by using a special medication special devices special techniques there's less swelling and less pain for these patients after surgery but avoiding narcotics is key as I alluded to earlier there is an opioid epidemic going on in this country where there's more addiction more abuse than ever before as physicians we have a responsibility to try to help stop that because if you look at this database study in 2012 over 1.6 million patients who are in the hospital and treated with pain medicines three out of four we're getting narcotics only that's actually a staggering number because there are so many other medications we can use that don't involve narcotics that we as clinicians need to do a better job at reducing the amount of narcotics we dispense but the reason multimodal analgesia can work is because pain is actually a very complex pathway there are multiple ways to intercept that pain so traditionally like you like I showed you most people just get morphine or narcotics and you just keep getting more and more but here you can see you can intercept pain at the site of injury so example where the surgery is you can intercept it at the nerve that goes through the legs or with a block or anesthesiologist can do regional anesthetics they can have spinals or epidurals and see zoologists again can help numb pain before it reaches the brain we can use various types of medicines tylenols anti-inflammatories we talked about before there are many different medicines we can use to reduce pain before we even try in our Kotik and this is just an example of a multi-modal protocol that i wrote up in terms of how to best manage people's pain around joint replacement and how to avoid those narcotics and these are some examples of some webinars and some lectures I've given about how to try to do that because then it's very important both for the safety of the patient but also to maximize their recovery so this is my typical multimodal protocol something as simple as Tylenol you would think would not help a lot during a major surgery like joint replacement but it actually does in combination with other medications actually reduces overall pain and our Kotik usage there's also an intravenous form of acetaminophen which can be used so Tylenol and acetaminophen the same thing the intravenous form may be even more effective at reducing pain so I can use that or these anti-inflammatories which come in pill an injection form or even nerve type pain medications like lyrica all these things in combination can give a better overall pain relieving effect I also depend on my anesthesiologist I work closely with them to give blocks of nerves or spinal or epidural anesthesia so that there's less pain people don't have to have general anesthesia when they have surgery here I try to avoid that because it's less medication right less side effects of medication people being intubated means you're paralyzed and a machine's breathing for you with these regional anesthetic techniques you can some people will watch 10 to 15 percent of my patients will watch their own surgery believe it or not but even for those who don't what it means is they're breathing they're on their own and they're getting less medication which will hopefully be less knowledge and other things this is an example of a novel medication I brought to the program here that brought to the hospital about three four years ago it's like novocaine which you have at the dentist but it's made in such a way that it actually is released over time so what I do is I inject it around the knee or hip at this time of surgery and then the medications in these bubbles as you see in the top right and what happens is it bursts over time and this graph shows how the pain medication is in the system over three days so it's nice as I can inject that medicine around the surgical site help numb that area for hopefully two or three days and that's not without even giving any medication yet that's the nice thing so local management of pain first and these are some clinical trials which I've run here with my patients and actually studying these things objectively to make sure there is true data to show that these things work and so far it has shown that he does we've seen it clinically but it's always nice to have the data to prove it this is just a quick example of a medication that I use around surgery which helps reduce bleeding with less bleeding there's less pain and quicker recovery or various techniques I have in the operating room again to reduce bleeding I even use something simple like this which is a special type of suture who would think that suture could make a difference but this suture is nicked or barbed like you see in the top right and what happens is this engages the tissue so the knot no knots are required what that means is that there's less foreign material in the wounds and that these incisions are closed watertight so what speeds recovery and helps reduce infection so I brought that here a few years ago and it works very very well so this is what a typical knee incision would look at a few weeks the picture on the left six weeks or the middle and twelve weeks on the right so no staples nothing to remove everything dissolves under the skin and then on top of that is this dressing so there's dressing I brought here maybe five years ago it's different than the typical tape and gauze that you put on the problem with that is with tape and gauze you change it every day it rips the skin it causes the blisters are not very sterile this is a sterile dressing that goes on in the operating room at the time of surgery and stays on for a week so patients can shower right away no one's touching the incision it's stayin sterile we hope for multiple days so all these conveniences add up so if people are able to shower they don't have to worry about drainage from their incision they're able to move and do their therapy right away without worrying all these things add up to success which lead to something like rapid recovery joint replacement or even outpatient replacement outpatient joint replacement going home same day of surgery is here and it's happening it's hard to believe because when I was in training again just a decade ago joint replacement patients were routinely in the hospital four or five days on a walker for weeks and going to rehab but now we're talking about people going home hours after surgery these are some lectures that I've given at our national meeting in terms of my results with same day surgery or on presenting my data on the rapid recovery results so here is a small video of partial knee replacement it's resurfacing the inner outer or front part of the knee only so an isolated portion you don't want to watch just look away but you're not gonna see any blood because there's a tourniquet and the knee looks that yellowish color because there's a antibiotic film that we use to prevent infection you're just seeing the knee because the rest of the body is covered with sterile sheets they regional anesthesia and so they're numb ways down they may even be watching or even talking to me during their own surgery we're dressed in these gowns to stay sterile but as I mentioned before orthopaedics is simply carpentry of the bone so I'm using all my gadgets I'm using my tools I saw my hammer my drill to just take away a little bit of bone to put in those implants that you're passing around so this procedure this partial knee replacement takes me about 50 minutes five oh so I can do it quickly and then these patients will get up and walk and go home the same day so this person on the Left had the kneecap replacement you can see here and he had the inner knee replacement this is them walking this is a few years ago this is when I started my same-day partial knee replacement protocol this is them walk in a few hours after surgery they're gonna walk and go home so that was a few years ago and I've been routinely doing that since 2014 so they get come in the morning have their partial knee replacement and then go home so people can do very well with all those benefits we talked about now total knee replacements the same thing it's just a little bit more invasive right because you're resurfacing all the surfaces of the knee so here you can see here's that drill so you can imagine that that might sting a little bit so you have the drill we have various guides we use these things to help align the implants where we want to put them but you can see it's a pretty small approach again I want to make sure I put in the best long-lasting knee I wanted to have a good long-term result but if I can do it with a less invasive technique beneficial to that patient potentially but you can see I'm using my saw I'm just trimming a few millimeters of bone to make space for that implant that you've passed around this surgery takes me about 60 minutes one hour and same thing like I told you since 2014 they've been walking day of surgery and then this is what they would look like the next morning so they are going home 24 hours after surgery so I'm using a cane so I'm using nothing as all as you'll see here but in that in that video on the top left you can see various jigs and guides and other things in order to perform that knee replacement just so that there are precise bone resections to make space for those implants that you're passing around but this is people walking now under 24 hours after knee replacement so when I first started this I must admit my my therapist and nurses told me that it was crazy he said that there's no way that people could do it and that it would be hurt too much and there they would not it would not help them would hurt them so when they said that I actually came back at night at surgery and walked all my patients myself and showed them that the patients can do it and what happened is that very quickly this has become the norm this has become the standard of care because we find that paradoxically patients have less pain are more mobile and have better range of motion because they're using their knees faster these are some articles explaining some of my patients experience with this partial knee replacement or she was actually my first patient to go home next day after surgery so with all of those protocols has allowed me to advance to outpatient or replacement and in 2015 I became director of our outpatient or replacement program started a whole new program we've never had before there are two sites us in California and another one in New Jersey where we are educating other sites across America on how to achieve this I've been very fortunate to be able to participate in that I'm the only surgeon doing outpatient partial and total joint replacements at our surgery center so Washington Hospital has a Washington outpatient surgery center right across the hospital on Mallory and I'm doing partial and total knee replacements they're sending them home the same day so this video here is a woman who had total knee replacement three hours before this video so she's walking with our therapist getting ready to go home so she actually went home a few hours after total knee replacement and this is her at her two-week visit after total knee replacement home same day so again not everyone can go home the same day I'm very particular I want to make sure the patient's safe and has the right medical history for it but the point is that the protocols the pain management the blood management are all in place that people can actually go home very quickly after surgery so I'm gonna close with just a few videos again a lot of this information is on this website so feel free to visit it this is my patient but his wife sent it to me to tattletale on him he was playing golf two weeks after surgery I didn't recommend it but that was him playing golf two weeks after this is a lovely patient of mine her passion was dog agility so she sent me in this video of her going back to what she loves doing dog agility on her partial knee and this gentleman I don't know why his passions to be dragged by a boat on a lake but this is him six weeks after surgery going back to wakeboarding and I'm gonna end with this we didn't talk about hip replacement but this gentleman of mine has a very interesting hobby where he does this motorized paragliding and so what it is easy to get this device and that big fan blows and the parachute goes behind and he can fly wherever he wants this is him six weeks after hip replacement so number one I want to thank you all for your time and attention and number two please I'll open up the floor to any questions that you have just wondering about the physical therapy protocol following the surgery how long is that and if you've already been told you need double knee replacements can you have them done at one time or is it better to wait if so how long in between all good questions so double replacement double knee replacement I do do a lot of surgeons don't do it but in the right situation I do do it it of course is two major surgeries in one sitting even though I'm showing you patients who are going home same day next day even though I'm telling you it's a one-hour procedure and it's a very quick procedure I never like to belittle the fact that's that it's still major surgery and so even one knee surgery is still major surgery but in some patients who have equally bad knees and they're candidates they're healthy enough to have double knee surgery than I do perform double knee surgery so just this Tuesday I had a female had horrible knees and I replaced both knees it took me an hour to do one an hour to go so she had both knees done in two hours which often is how much time it takes community surgeons to do one single knee but she went home two days later so even with double knees can have a relatively quick recovery so but it depends on again the patient's medical status because double knee surgery can be more stress on the heart or lungs so if people have medical problems maybe it's not the best in which case I would stagger them if one knee is worse typically I would do the worst knee and then as soon as six weeks later I can do the other knee but that's how it helps separate out the risk of having two surgeries at once but double knees are an option and doing them as closely as six weeks together is the second option in terms of physical therapy with knee replacement we teach the therapy before surgery during surgery after surgery it's in the binder that we provide our our therapists teach people how to do it before they go home when people go home we typically will send a therapy to that patients home to help guide them on their exercises and then when they're driving at a week or two weeks then they will go begin outpatient physical therapy and do that for maybe four to six weeks but most patients after total knee replacement are going back to golf like activities at six weeks as a rough estimate partial knee replacement even faster than that in a couple of weeks some having cool leaf nerve oblation procedure for temporary pain relief do you think that's a good idea okay so for people who don't know in this room cool leaf is a technology of a blading and nerve so what is doing is it's called Cooley because it uses a certain temperature to basically temporarily temporarily gnaw manner so I was actually just in Atlanta as a adviser to that company they flew me out and a handful of my colleagues from across the country to advise them on how to use that in orthopedics so it's very fitting you asked that question at that meeting we're talking about its benefits cool leaf you can ablate nerves just like you can in your back or any of your about other body part so that nerve is responsible for the pain it can make you feel better does it do anything to cure the underlying problem does it do anything to address what's causing the pain no but does it block what's transmitting that pain yes but it is temporary so we were talking to that meeting and what we were discussing was would that technology perhaps be beneficial before surgery maybe if you numb that nerve and then it was less painful after surgery made without help or maybe for people who have continued pain after surgery may would help or maybe for people who can't have knee surgery maybe that would be a useful option so those are all the things we are discussing in terms of temporarily relieving pain possibly but it doesn't treat the underlying problem so it's eventually going to come back it is important that you all realize that arthritis the natural history of arthritis is typically it's absent flows so day in day out in may vary and whether it's feeling good or feeling bad so some days are good some days are bad but overall is decreasing at some rate the good days aren't as good as they used to be and the bad days are a little bit worse it's when that crosses the threshold that someone says it's time for something like surgery you don't ever have to do surgery of course the surgeries I've discussed here are mostly elective but it's when it impairs your activity level enough when you're giving up more than you want to that you decide that it's time yes I actually have two questions one is where is the medical profession in terms of stem-cell procedures and to losing weight how how effective is that to avoid knee surgery good questions so I'm gonna start with the body weight first remember body weight multiplier of forces across your joints so losing weight is helpful I've seen patients who've lost weight and their symptoms got better however losing weight does nothing to treat the underlying process right so unfortunately it may make the symptoms better it may make it last a little bit longer but ultimately that bad knee or bad joint it's probably gonna show itself again but in the meantime it certainly does help and at the worst case scenario if someone loses weight leading up to surgery that's less weight they're gonna have after surgery so the recovery will be easier so they can only win in terms of stem cells I touched about it briefly before stem cells is by far the hot topic and you're gonna read a lot about it in the paper because stem cells sound great if you can harvest stem cells from bone marrow or fat right that's a progenitor cell which can basically go into any kind of other cell so the thought is can we make these stem cells become cartilage cells or something else the bottom line is we don't have that technology we don't we have a way of harvesting stem cells but we don't have the way yet of telling that cell become this cell that we want and even if we could grow perfect cartilage cells imagine this dilemma if you have that let's say in a paste and let's say I paste it on the end of that knee and is there how do I prevent that pace from just getting rubbed away the minute that person steps on it so so the there's there's some real challenges and not only getting the cells to be what we want them to be but to get them to stay where we want them to stay so it's a hot topic there's a lot of research a lot of money going into it but as of right now it's all pretty much experimental terms of cement cement is the gold standard of how to put a knee replacement hip replacements different some hip replacements are cemented and most are not cemented but these are different the gold standard is to use cement the benefit of cement is it fixes these components immediately so before that patient leaves the operating room it is rock solid so patients can walk right away whether it's cemented or cement less so to answer your question it gives you no benefit to be able to bear weight sooner the one downside of a cement 'less device is you do have to wait for the bone to grow into that implant to make it secure so in very rare circumstances the bone may not grow and just like a fracture may not heal bone may not grow into a spineless device but with cement you know it's rock solid right away when you're doing the total replacements on the knee do you do you replace do you try to save the patella yes so in them if you can't save it does anything go in its place Oh another good question so I did not mention that the patella is saved in all cases what happens on the back of the kneecap is like that model that we passed around the partial kneecap replacement the kneecap is preserved the back side is cut flushed so a few millimeters removed in a plastic button glued to the back of it that way it's plastic on metal when it glides because if we don't resurface it it's going to be cartilage on metal and you know what's gonna wear out then the kneecap is gonna wear out so we resurface the back of it but in all cases that kneecap is mostly preserved the sizing since everybody's a different size how do you I mean are these off-the-shelf and you cut them to size or or do you get them measured for each patient ahead of time and just order them so people love to ask about sizing yes every knee in here is completely different and even your right knee might be a different size and your left knee so how do we deal with that we've looked more and more in ways to optimize the personalization of these implants there's only one company that actually will make an implant a metal implant custom to the individuals knee but it's not as as great as it sounds it hasn't proven to be really clinical bit clinically beneficial it costs more it takes longer to make unfortunate hasn't taken off just because it hasn't proven to do what we thought maybe it would but it's probably because the implant companies have made so many different sizes that you can basically personalize it on the fly so what happens is when I have a surgical candidate I have their x-rays I'm able to put them on the light board and use templates to measure what size they'll be so before that patients even in an operating room I have an idea of what size they need on the femoral side for example there's about 24 different sizes that I can pick and choose from different sizes Heights and widths there's about 12 different sizes on the bottom so I can mix and match those so when I'm in the operating room I know what I templated what I think it's going to be based on x-ray but then I have various sizes so I can size the knee you the surgery to the exact and figure out which will fit them best and then after that I have metal trials as what they're called they're the implants that I put into the knee and test the knee before I cement in the real ones so I have various checks and balances to basically individualize it for the patient I've seen a lot of literature lately that it said most cases if you're gonna get a partial shoe probably go for the full because like you said the partial only apparently lasts 15 and a lot of cases 10 and for last 20 and the second question is there was a new mercury-news about six months ago there's an article where the surgeon used robotic assistance and cutting just your opinion good questions this is a good group you guys are all asking very good questions keeping me on my toes partial knee replacement again has many advantages over total knee replacement and when I trained in Chicago that's where I did fellowship actually learn from one of the nation's experts and he's actually the one who did President Bush's two partial knee replacements that's why we learned the technique and how to do it they also happen to actually have the longest published data the longest research on partial knee replacements and what that data shows is in the correctly selected patient done the right way by the right surgeon they've followed patients out decades and at 20 years over 90% of partial knees are still functioning very well in their hands so partial knee is done well can still last decades and with all those benefits there's a that that is a huge advantage like I said let's say in that minority of cases the partial knee replacement fails usually the knee replacement the partial knee replacement doesn't fail but arthritis progresses elsewhere over 20 years that could happen but what's good to know is that a partial knee replacement done by a surgeon who specialized in it and the knee replacement surgery if needed that follows if done by that same specialist the results show that that's the same as getting your first total knee replacement then so what that means is if you're 50 and you have a partial knee replacement and you're 75 now and you need a total knee replacement that's like getting your first total knee replacement age 75 it burns no bridges as opposed to your first total knee replacement at 55 and then your second revision one in your 70s so there are benefit of the partial meet and again it can be very durable equal to total knee replacement ways the computer this is sort of like the gadgets and the lasers and the stem cells and all these things you hear in the news and it's in the mercury because people are interested in robotics I didn't bring up these slides it's in a different talk but technology we live in Silicon Valley we everyone just saw the Big Apple release right and everyone's by pre-order their phone already we live in the center of technology and we're basically groomed to believe that the next best things got to be better that's not true in medicine so in medicine if you know something works you want to make sure it has 20-year results because that's the standard of care someone could come out with the shiniest new component or the best fastest computer but until the results of that show it lasts 20 years by definition you can't be any better than standard I'll give you an example metal-on-metal hip replacements right you've all heard of it a few years ago everyone thought that that was a new thing it's less wear better stability better for patients but what happened a couple years ago Johnson Johnson other companies had a recall a hundred thousand of them because it failed and these were done in young people who only had them for a few years so even though somebody looks better in the lab or something looks better on paper until you do it in a person because medicine is different you'd really don't know how the durability will be so robotics is interesting it's fun it's a toy I mean surgeons like it just like they use robotics and prostate surgery or other things but what happens in a lot of these situations is these expensive robots end up sitting in the hallway collecting dust because it takes longer there's sometimes downside so there are some some things on the computer and the internet if you look what if you're in the middle of a computer surgery and the computer suddenly malfunctions or doesn't work are you gonna be able to finish the surgery maybe not but when the results are very good with joint replacement again if the results are this good and the margin of improvement is relatively small the question is does the computer actually make it better or does it just add new chances for error and with navigation computers custom joint replacement all these things time often shows that it's not as good as it's been promoted that's a great question well you guys pass it around and you felt the weight of it some people ask me is this gonna add weight to me and I usually respond and tell them if you want to blame those holiday pounds on me at the end of the year you can go ahead and do that but though you won't feel it because it's in your body so you won't really notice one legs heavier than the other for example and in terms of feeling it remember with the partial knee because you keep every ligament that knees gonna feel more quote-unquote normal to you than a total knee but totally you still work wonderfully well but potentially you might feel a little clicking at times you might feel a little bit less stability than your normal knee it's not a 16 year old knee it works very well functions very well but you may feel some differences but it's typically not noticeable I didn't really understand what you said about compromising the ligaments in total as opposed to partial I know I need a total do you do you sever the ligaments do they I didn't understand the difference the total knee replacement you passed around remember it goes all the way across right it's going from as to go from all the way to the inside the knee to all the way the outside and what lives in the middle that anterior and posterior cruciate ligament so the only way those devices can fit is if they're sacrifice so in almost all knees 99.9% the ACL is sacrificed in variable amounts the majority the posterior cruciate ligament is also sacrificed now the total knee makes up it has a mechanism to recreate the function of the total of the part of the posterior cruciate ligament but it's a mechanical right artificial mechanism and the anterior cruciate ligament is not greatly recreated which y-you can feel a little bit looser now that being said total knee replacements were great and they're still stable and people can still but that's why they're not playing soccer or cutting sports or things like that but with a partial knee those ligaments aren't even touched that's the difference first of all scheduling seems like we are very busy let's say after initial consultation evaluation of tests x-rays how long are we looking at it to be on your calendar hopefully we're able to be very responsive the other thing I'm trying to work with our staff is we're trying to be as responsive to our patients as possible and get them as soon possible see them and then a lot of the scheduling depends on the patient's medical history so some of my patients have heart problems lung problems medical issues diabetes you obviously want to optimize that before any elective surgery because it's not an immersion surgery don't have to do it right away you want to be as healthy as possible before surgery so those patients it might take a few weeks or even months to get them optimized if someone comes in and they're very very healthy and have no medical issues they're gonna get scheduled much faster of course so I typically do about 7 to 8 or more placements in a day so yes Tuesday I did seven or eight and Thursday I did seven or eight and then they all went home the next day so I can go I can get to a lot of patients quickly but they're still your right is a lag it's probably somewhere around the six-week timeframe because I'm also doing some of these at the outpatient joint replacement or the outpatient center so I have places where I can shift people and try to help them sooner thank you again everybody [Applause] [Music] you

Channel: InHealth: A Washington Hospital Channel

Views: 157,793

Keywords: Washington Hospital, WHHS, Healthcare, Health, Care, Fremont, Newark, Union City, Knee Pain, Knee Surgery, Total, Knee, Replacement, Partial, Joint, IJRR, Arthritis, Orthopedic, cartilage, ligament, ruptured, injury, therapy, sprains, strains

Id: 4rlPxS0bgrI

Length: 60min 44sec (3644 seconds)

Published: Thu Dec 21 2017