Maret 01, 2017
- [brett] welcome here,it's a good turnout. thanks for coming. i know some of you, and othersi don't, but that's great. welcome to coordinated. and it's a kind of a cold, november night, and i'm glad you allcame out despite that. the presentation will be brief. the plan will be tobriefly talk about knees, a little about knees arthritis,and then there'll be time
i'm sure for a question and answer period. so we'll all, we'll be around, ok? so first off, knee replacement. the anatomy of the knee. the knee is largest joint in the body. it is a hinge joint, alittle bit about the anatomy. it is a hinge that allowsfor flexion and extension. is there a pointer here? and also allows for rotation,so it has a little bit of a-
it allows for the kneeto extend or straighten, flexion or bend, andthen translator glide. there's three major bonesthat make up the knee joint, the tibia bone, the femur and the patella. and it's estimated 70million patients in the u.s. have some form of arthritis. not necessarily the knee,but certainly that's probably a little less than aquarter of the population, and that's a very conservative estimate.
and there's many forms of arthritis. there's osteoarthritis, whichis the most common form, and that's basically a wear and tear, and it's something thatwe really don't know exactly why it happened. there's a deteriorating of the cartilage, and ultimately the boneunderneath the cartilage over a period of time. it's a degenerative condition,generally doesn't improve.
we can improve thesymptoms without surgery, but we can't change theprocess or deterioration of the cartilage. rheumatory arthritis isan autoimmune disease. it's a very complexprocess, and it's a much smaller portion of the population. it presents many times earlierin life than osteoarthritis, affects multiple joints,and again, is a much smaller portion of thetotal arthritic population.
and then there's also- osteoarthritis can besecondary to many reasons. post traumatic after a kneeinjury, such as an acl injury that has never been repaired, or after a major cartilage injury. so it also can occur after an infection, which is extremely rare,and there's other forms. so what's causing your knee pain? that's really what people comeand ask me on a daily basis.
really why does my knee hurt? and a healthy knee looks like this. it's the femur and tibiaare gliding on two cushions called the menisci, andthe cartilage on the knee is giving them that glide. and it's a very friction-lesssystem that has been developed over time for us. and basically thecoefficient of friction is one-tenth of the friction of ice on ice.
so a normal knee justhas a wonderful glide. and arthritis, there's abreakdown in the cartilage. breakdown in the cushion or the menisci, those two shock absorbersbetween the femur and tibia, and ultimately a breakdownof the cartilage on the bone. and there's that wear andtear and that deterioration that causes the knee toinflame, and those pain fibers to set off a chain of eventsthat is very uncomfortable. and mild arthritis iswell-tolerated by many people,
but it's when that processbecomes moderate to severe that i end up seeing a lot of you. so a lot of people wannaknow when is it time to see your doctor? when is it time to, you know,be assessed for knee pain? and really what it comesdown to is knowing, you know, what your activities are,and are they being affected dramatically by your knee pain. so does it reoccur forlong periods of time?
is it waking you up at night? that's a form of arthritiscalled osteonecrosis. often night pain causes that,and that needs to be assessed. is it painful to walk anddo your normal activities of daily living? like shopping or justwalking recreationally. are you taking over-the-counterpain medications that just aren't working? and if you're taking more of those,
are you starting to takemore ibuprofen or more aleve? is it affecting your daily living in terms of your activities? such as a sporting eventor just going to things. are you changing your lifestyle because of pain in your knee? that's when it's timeto have that looked at. it's time to seek amedical, or specifically an orthopedic opinionconcerning what's going on
with your knee. and have you gained a lot of weight with your lack of activity? that's another important consideration. so these are all considerationsof when it's time to see your doctor concerning your knee. and again, this is just aslide assessing your pain. this is like, you know,these are the activities that may be affected by knee pain
or by osteoarthritis ofthe knee, like bending, and stress on the hipsand knees, like walking and prolonged walking,is that causing you pain? are you changing theamount you're walking? do you have pain while driving? are your sports, likethe activities you enjoy, such as tennis or golf orskiing, are you not able to really, you know, have youchanged the things that you do because of your knee pain?
it's an important consideration. so that's a little bitabout the things we look for and what osteoarthritis is. osteoarthritis is not- the treatment for osteoarthritis is not just a surgical option. as orthopedists we treatour patients operatively, and also very much non-operatively. and as many of you knowwho visit an orthopedist,
a good orthopedist willtry conservative options in many respects unless theimplications for surgery are just too significant, too apparent. and what are some of thosenon-operative options? well we wanna try to decreasethe inflammation in the knee, and that can really changeor modify the symptoms, and make you feel more comfortable. one of those is using a steroid injection. it's still a very acceptableway to approach this.
it's not something thatyou'd do over and over, months and months and months. but the judicious use of anoccasional intra-articulate steroid injection cangive you some relief. it's not the use of it,it's the abuse of it by some physicians. so injections work. the other option is oral analgesics, such as tylenol, ibuprofenor one of the prescribed
anti-inflammatory medications. we very often do not usenarcotics for treating arthritis. we use narcotics fortreating pain after surgery, and that's really whatas most orthopedists use something such, you know, a narcotic, but we don't use thatto treat arthritis pain. the use of hyaluronic acid, such as- you may have heard about this medication. it's a-
just to summarize in abasic way, hyaluronic acid is a family of medicationscalled hyalurons, and they are basicallyan inert substance that we've developed syntheticallyto inject into the knee to give a little cushion toyour knee, a temporary cushion. it doesn't replace cartilage, but it gives a little cushion to thisarea, a little bit of a shock absorber effecton a temporary basis. it can last for months,it can be ineffective,
it can work for six months,it can work for a year. some patients have it,return to see me never again. it's not a panacea, but it'ssomething in our armamentarium. it's something we use totry to treat a patient non-operatively, if that's their desire. and it's really a decisionyou make with your orthopedic surgeon or rheumatologist. physical therapy? physical therapy is a very, very good way
of treating osteoarthritis. it's not, again, itdoesn't work for everyone, but regaining the motion in their knee and working on the strength can improve the biomechanics of your knee, and very much modify your symptoms. and that's what we're doing. it's not gonna improve or reverse the osteoarthritic process, butit certainly can help you
feel better and modify yoursymptoms so that you can go back to your normal activities, or at least improve on your activities. knee replacement is a surgical option for the osteoarthritic patient. many times knee replacement is an option, and in some circumstancesthere are some surgical options that preclude, or that we woulduse before knee replacement. such as an arthroscopic debridement,
and there's some controversy, but for the significantly arthritic knee, knee replacement clearly makes sense. and what does that do? knee replacement, you're notreally removing the knee, you're resurfacing the knee, much like you would crown a tooth. i use that analogy inmy office all the time. and it just, by resurfacingthe knee and changing
the alignment back to thenormal mechanical alignment that you were born with, or close to what you were born with, it relieves the pain,restores the mobility, gives you back that cushionthat you're missing. so you're not actuallycutting the knee out. you're really just resurfacingthe damaged cartilage. and there's very minimal,minimal bone loss on a knee replacement.
knee replacement surgeryis very beneficial if it's used in the right circumstances. it's for the patient thattruly has the arthritis that warrants that procedure. it's not indicated in my practice for the mildly arthritic patient. but 500,000 people receiveda knee replacement, you know, this past year in the united states, and that's a lot of people.
i think when i, you know,finished my residency, maybe 60,000 people had aknee replacement in 1989. but that's a significant change. so you know, why are more people needing knee replacements now if the population hasn't changed significantly? it's increased, but i thinkpeople are more active. there's a lot ofepidemiological reasons why there's been such a increasein knee replacement patients.
but given that fact,there still is a very high success rate from a knee replacement. it runs around 90 to 95percent, which is significant. that means that for the mostpart, the orthopedic surgeon is making that decisionappropriately for his patients in the united states, and they're not beingdone inappropriately. and the average age ofknee replacement surgery has gone down significantly, you know.
i think it, you know, it's dramatically. in as much as a decade,the average age is up at least ten years youngerthan it used to be, you know, 15, 20 years ago. this is what a kneereplacement looks like. it is again a surgicalprocedure to replace the diseased cartilage onthe femur and the tibia. so you're actually crowningthe femur and tibia. you're putting a stemmedcomponent, for the most part,
into the tibia, and thenyou're putting a little bit of- and the polyethylene liner,which is this little spacer, is giving you back thatspace that you've lost. it gets that diseasedcartilage, and that narrowing of that joint space is then corrected. and that's, there's manyknee replacements out there. this is a very good one, andreally i'm of the belief that it's not necessarily the kneereplacement that you have, but the surgeon who puts it in.
and how does it work? again, you're removing the diseased bone from the tibia and from the femur. you place this polyethyleneinsert in between, and then some patients havea patella replacement, too, depending on the amount ofarthritis of the patella. and that's a surgical decision. some physicians resurfacethe patella all the time, and some do it just whenthe arthritic process
is so aggressive that it warrants it. and that's really what a kneereplacement looks like today. this is a good shot. i like this picture becauseit shows a healthy knee on the left, and it shows that joint space that the arthritic patient is missing, ok? and if you have a bowed knee, like a varus knee or a bowed knee, you're gonna have thatnarrowing on the inside.
and for my patients who are knock-kneed, have that knock-kneed valgus knee, their narrowing isgonna be on the outside. but nevertheless, a kneereplacement restores this alignment and givesyou that space back where you're missing it. and i always show my patientstheir pre- and post-op x-rays so they can, it helps themi think in physical therapy, when they see the difference.
and i really don't wannaget into the nature of what knees you use. there are some kneesthat rotate a little bit, some knees that arefixed, meaning that this, the femur rotates on this, but this piece, this polyethylene doesnot rotate on the stem. but the research is- honestly the research out there is more, doesn't substantiate anyparticular knee, more or less.
it's really the technique of the surgeon that i think really matters. i am a big believer that physical therapy after a knee replacementis extremely important. if i think that a patientis unable to complete physical therapy after kneereplacement, i really do not- i dissuade them fromproceeding with that procedure. i really do. it's very, very important that you-
because i'm very proud ofmy results, and i really- if a patient can't do the pt afterwards, they're not gonna have a good result. again, this is a- if you break down the knee replacement, the femoral component,the polyethylene insert, the tibial component,basically three components plus the patella component. they're all customized.
every one of thesepieces or components has multiple sizes, multiple thicknesses, and some have constraintbuilt into them, some don't. it really is dependenton the patient's knees. so you really do get a customknee, when you add it all up. you know, ten different femurs, you know, 15 differentpolyethylene inserts, it really does become quite customized. i did wanna talk brieflyabout partial knee replacement
because it is still prevalent practice. i would say it's abouttwo percent of all the knee replacement i do,which is a very small part. but i use it for a patientwho's in their 40's, maybe early 50's, whohas just a little bit of- i mean only one side of theirknee, one third of their knee has intact, has diseasedor arthritic portion. the outside of theirknee has to be normal. patella, femoral space has to be normal.
their ligaments have to beintact, and they have to have pretty good range of motion of their knee. for that patient, we do apartial knee replacement. i consider it a much harderprocedure because basically you're leaving two-thirdsof the knee intact, and resurfacing one-third of the knee. so you're asking the bodyto really kinda, you know, it's tricky, because you're balancing, and it's just a little tricky.
but i consider that for just asmall portion of my patients. and this is what it looks like. this is a partial knee replacement. this is that little femoral component, this is the tibial component. this is what a total knee replacement, and you can see the difference. it's a very different procedure. this is what a partialknee looks like on x-ray,
and this is what a totalknee looks like on x-ray. and there again, very,very small indications for this procedure. i think, though, it isa very good tool to have for that 45-year-old, active, you know, recreational athlete that really doesn't, who has two-thirds ofthe knee quite normal. and you know, i'm surethat there are people right here in this audiencetoday that are just kinda
wondering are they readyfor a knee replacement. and you have to like assess, you know, your ability to function. and i think that as yourtreating orthopedist, i should be, you know,i can help guide you in terms of making that decision. and you have to ask, is yourpain and loss of function affecting your quality of life? i don't want my patientsto come in in a wheelchair
to have a knee replacement. that just makes no sense to me. you're so deconditionedthat you'll do poorly in physical therapy, andyou'll have a mediocre result. so when you have a kneereplacement, you want- a good orthopedic surgeonis going to be able to help you decide theappropriate time for that. and it's when the pain isjust not worth it anymore, you're not havin' funanymore, your quality of life
has decreased, and you know, you're taking too much ibuprofen, andyou're just uncomfortable. but you don't wanna be sowasted, so deconditioned that you're not going to,you know, rehab properly. and really, you know, thatdecision has to be made with your physician. you know and again, this isjust what i have alluded to, and that's that any, youknow, that these results- that joint replacementis extremely rewarding.
in most of my patients,they're very pleased with their knee afterthey've done their therapy and they've let it heal. there's risk to anysurgery, but i think that with proper rehabilitationand a well-placed knee, you can have an excellent result. and that decision for knee replacement has to be made, again, withyour orthopedic surgeon. so in summary, osteoarthritisis the leading cause
of knee pain and degenerativearthritis of the knee. osteoarthritis is degenerative. it doesn't get better, but youcan make it better at times and feel better, even thoughthe condition itself . may not improve in terms of the actual deterioration of the cartilage. early diagnosis andtreatment is very important because some patients don't need surgery for a fairly long period of time.
and knee replacement in thereally arthritic patient can be much harder in somepatients than in others, because we get some patientsthat really should have had their knee replacementa full ten years prior to when we see them. and those become muchharder procedures with much more surgery, muchmore types of more of a constrained prosthesis put in,and so much harder procedure. but if you weigh it all,at the end 95 percent
of our patients, 90 to 95percent is a good number, are quite satisfied with their knee. and i'll be aroundafterwards for any questions you may have, but dr. weissis gonna talk to you right now about total hip replacementand arthritis of the hip. thank you. - evening. gonna try to be a little bit brief and not replicate anythingthat's been said before.
my job is to talk abouthip replacement tonight. and in a way it's a littlebit easier to determine when your hip needs to bereplaced than it is your knee. 'cause you can substitutea lot with a stiff knee you really can't with a stiffhip, 'cause a lot of times there's difficulty sitting,there's difficulty climbing, there's difficulty sleeping. so what we're gonna talkabout initially is, you know, how a hip works, what the basics are,
and what to look out for if you think it's time for a replacement. the anatomy of the hip. the hip's a ball and socket,as compared to the knee. it's got a relatively deep socket, and a fairly good-sizedball that's got ligaments that hold it in position. there's a lot of reasonsfor a hip to wear. some is that the socket is shallow.
some is that the balldoesn't develop properly when you're a child, and someof it's just from trauma. all these variety of reasons will cause wear of that cartilageon the end of the ball. now we already talkedabout the osteoarthritis and the inflammatory types of arthritis, so i'm gonna skip over that. there's a high satisfactionrate for hip replacements, and i would say thebiggest difference between
hip replacements and knees is that they're much less rehab dependent. if you do a perfect knee replacement job, and you don't go to therapy,you're gonna get a bad result. if you do a good hip replacement, and you don't go to therapy,you'll get a good result, ok? it may not be an excellent result, but it's not anywherenear as therapy-dependent. we'll move on a little bit.
so healthy hip has nicesmooth gliding cartilage on the end of the bone onboth sides of the joint. the diseased hip loses that cartilage, just as it does in the knee,and you have a rough surface that catches, that grinds. now the one misconception iwanna leave everybody with, or get rid of tonight i shouldsay, is that when people say their hip joint, theyusually feel back here. your hip joint is in the groin.
when people schedule, youknow, and they come in for hip pain, nine timesoutta ten it's back. when they come in for groin pain, that's when it's hip arthritis. so if you have pain in the groin or buttock pain, that's hip. if you have pain back inhere, that's your back. alright, and hip manifestsitself different ways. difficulty tying your shoes,difficulty taking high steps,
you may have a significant limp. a lotta people when they walkwill try to unload that hip. when they walk, they'lltry to shift their weight over top of it so that theydon't put that bending force across the hip joint. one of the first things thatpeople tend to notice, though, are the difficulty tying their shoes, sitting on a low chair,sitting on a toilet, those type of things.
and again, non-operativetreatment consists of the anti-inflammatories. injections in the hip are difficult because it's not a subcutaneous joint. it has to be done under x-ray, and in certain circumstancescan be successful. discal supplementation thatdr. godbout talked about isn't approved for the hip,and therefore not an option. and then again, physicaltherapy in early stages
of osteoarthritis canimprove your range of motion and decrease some of thecompression across that joint and get you farther down the road before you need a replacement. so there are two differenttypes of hip replacements. one is a resurfacing, inwhich you keep the normal femoral head and you justput a metal cap on that and a big socket. and one is the traditionalhip replacement.
the resurfacings have comeunder fire as of recent because there's a fairlyhigh failure rate. about a nine percent initial failure rate because of the loss ofblood supply to that bone, and about a 15 percentdelayed failure rate. so the incidents of thosebeing done in the united states is decreasing, you know, as we speak. so what is a hip replacement consist of? well as opposed to the knee,which is just resurfacing,
in this case what you'retruly doing is that you're cutting off the diseasedhead and neck area and replacing that witha stem that goes down into the femoral canal,which has porous coating. and what happens is the bone then becomes adherent to that, and itbecomes a dynamic interface. it's an interface thatconstantly repairs itself. in situations where thebone is insufficient, and that's probably now lessthan five percent or less
in the united states,you have to use cement. but cement, like in cementanywhere, have fails eventually. so we've moved away fromthat, and i would say 95 percent or more of all hip replacements are done without cement. similarly the socket. what you're doing in thesocket is that you're reaming into the normalbone, getting rid of the diseased bone andputting a metal cup in there
that again, has a porous coating. and i encourage you tolook back at the table, and you'll see whatthe surface looks like. initially we'll use screwsoftentimes to hold that in position until the bone grows into it, but again, that's a dynamicsurface that constantly breaks down old boneand builds up new bone and constantly repairs itself. and then you have aninterface between the ball
and the liner of that socket. anybody who's read thepaper understands that the lawyers love that interfacebecause there has been one type of interface that'srecently been recalled. and that was a design, ithink, in which people thought bigger was better. initially the size of yourfemoral head is 50 millimeters, 55 millimeters, etc. the old hip replacements that we used,
used balls that were 28millimeters or 32 millimeters. well what you tradeoff there is stability. the larger the ball, thebetter the range of motion, the better the stability. so we went to the 36 millimeterballs, 40 millimeters balls. well to do that you needed a interface, a surface that didn't wear. so when we went to metal on metal, that allowed us to use a thinner interface
and therefore a bigger ball,and have all those advantages of stability and range that we didn't get with the smaller balls. well if people said, well ifthose balls are pretty good, why don't we go to even larger? well what happened is withthe even larger balls, you used a smaller socketand ended up getting some edge loading andgetting some metal wear, and you had about twice the failure rate
of normal hip components. well, that's- depew, which was the companythat had designed that, was very diligent in recalling those and making compensation to the people that had had that type of component,but unfortunately, it condemned a lot of theother metal on metal components which were working very well. and we can discuss thatin the question and answer
a little bit later. so this is a pre-op x-ray. you can see that thecartilage, the nice smooth cartilage interface iscompletely worn away. and when the body sees increased stress, it reacts by making more bone. that's what bone spurs are. this is the normalreaction of osteoarthritis. a hip replacement changesthat interface and gives you
a pain-free interfacewith metal on plastic, metal on metal, ceramic on plastic, and we'll discuss thatin just a little bit. well, let's just move on here. alright, so the bearings iswhat we're talking about. we're talking about thatinterface that fits into the cup and that the ball sits on. the options are metal on plastic, and that's been around for 25, 30 years.
and the problem with thatis that the plastic wears. metal obviously is a lotharder than the plastic, and so you get plastic debris, which early on causedinflammatory processes and caused erosions of the bone. we've improved that plasticright now to the point where it wears about one-tenth to one-hundredth, depending on how it's treated, what the old plastic used to wear.
so a lot of those oldissues have gone away. the metal on metal, theobvious advantages of that are that it allows youto use a bigger ball because you can use athinner interface here. and as we said before, the advantages are better range of motion, better stability. the ceramic on ceramic haspretty much been condemned because of what they found early on was about ten percentof those had a squeak.
just like a squeaky door. unable to predict whothat was, and you know, who it was gonna occur in. but obviously that's notsomething that you wanna have. so ceramic on ceramic hassort of fallen by the wayside. and a lot of people movedto the ceramic on plastic as another alternative. the ceramic head, notbeing as hard as the metal, and the plastic being improved,
we think that the wearfactors of that are gonna be intermediate between the metal on plastic and the metal on metal. so those are the interfacesthat are currently available. so you know, in summary,hip osteoarthritis is the leading cause of hip pain. it can be fixed by a hip replacement. there's other non-operativetreatments that we try first. and again, if it hurtsback here, it's your back.
go to the back surgeon. if it hurts in the groin, it's your hip, and we'll be certainlyhappy to take a look and counsel you in accord with that. yes. - [attendee] do you usethe anterior approach in any of your hip replacements? - there's basically a number of different approaches to the hip.
there's anterior,there's anterior lateral, there's posterior, posterior lateral, ok? and they all have advantagesand disadvantages. one of the biggestdisadvantage of the posterior hip approach, which most people use, is the potential for dislocation. and that occurred particularlywith the smaller balls and larger individuals. so the anterior approach doesn't disrupt
that posterior capsule,but it puts you at risk for anterior dislocations, alright? and it doesn't, from avisualization standpoint you need special tables,special instruments to be able to do that. so there are people in our practice who use anterior approach. when i trained in myresidency, that's what we used. for my practice i usethe posterior approach.
i think it works better,and the dislocation rate is certainly comparableor less than some of those who use the anterior approach. the anterior lateralapproach leaves people with greater trochanteric painbecause you're actually stripping the muscles off of that, so there's different approaches. many approaches came aboutwhere people tried to go smaller and smaller andoperate through keyholes,
single incision, two incision. the complication rateon those was fairly high because of lack of visualization. it was almost 10 to 14 percent,you know, malalignment, compared to when you cansee what you're doing. so that's the thing todiscuss with your surgeon as to what approach is used. i think there's advantagesand disadvantages to both. there is a learning curve to everyone.
you certainly don't wannabe the first person that that orthopedic surgeon doesan anterior approach on. if he's done posteriorapproach for 20 years, you're probably better offgoing posterior approach than you are anterior approach. if that answers your question. - [brett] yes. - [attendee] on a total knee replacement, the numbness and theheaviness in the knee,
how long does that last? - well you know, i think that everyone's a little different about that. you can have some numbnessfrom the skin incision. that numbness is, those arethe whole sensory nerves in the skin, and that'sgenerally what patients either complain aboutor notice after surgery. and that can diminish rapidly, and to a point where it's very tolerable,
and then they may have a little numbness. some patients never complain of numbness, and some complain ofnumbness that can last up to a year or two. but generally that goes away. it doesn't seem to affectany of their activities of daily living, so likethe things that you do on a daily basis aren't affected by that. it's not dramatic, heavy numbness.
and the way to address these is if, when i show my patients whatthe knee replacement looks like, they feel like, wow, this is heavy. but your body neverreally, your body generally adjusts to that, likethe weight in the knee. it's not something that youfeel like you're lugging around. - [carl] six to eight ounces ithink, is the average weight. - yes. - [attendee] on a total hipreplacement, you leave here,
and you're doing thetherapy and everything, you have the follow-ups,but how long would you say, on average, before you're notworried about fallin' down, you can walk, you canget into the car again. what are you talking about in downtime? - most people aredriving somewhere between two to six weeks. and a lot of that dependson what car they have. you know, if it's a car wherethey go straight across,
that's a differentstory than if it's a car where they sit down into itand have to get themself up. - [attendee] (mumbling) - yeah, i mean it's notgetting down because the gravity certainly helps you down. it's being able to push yourself up. with both knee and, youknow, hip that's an issue. you're pretty independent when you leave. you've done stairs, you know,
you're able to put full weight on it. you know, you're sore from the incision, but not really debilitating. - yeah. - it's amazing, there'sa lot of variations. some patients are drivingin, you know, 7 to 10 days, and some are driving in, youknow, 6 to 8 weeks, you know. it just depends on thatstrength of the patient, their kinda desire to movealong to certain things,
whether they have a rideor not, that type of thing. it's really, it's a lotof it is individualized. - and we've done hipsin people as young as 40 and as old as mid-90's. so a lot of it depends on their, you know, state of debilitationbefore their surgery, too. it's hard to generalize. - [attendee] you can try to do it if you can do it, basically?
- correct, correct. and in most patients yourweight-bearing status is as you tolerate it, soif you walk out of here with a walker or crutches, and you come into the office with a cane, that's quite alright. and most people do usesome assisted walking for two to four weeks, atleast up to four weeks. they need at least to carry acane, or something like that.
and many walk quite nicely at four weeks without any assistance. - [attendee] would you tellus what the differences are in the types of anesthesia you use for a knee replacementor a hip replacement? - oh, that's a very good question. let me talk a little bitabout knee replacement. and then in knee replacement we definitely believe in regional anesthesia.
what does that mean? like not completely knocking you out, not putting a tube inyour mouth and trying- rather keeping yousedated and comfortable, not knowing that the surgery is going on, and keeping you so that you're, you know, just not aware of your surroundings, but not intubated with a full, you know, full general anesthetic.
we use regional anesthesia. what i mean by that iswe use specific blocks, and every, we generallyhave a consensus on what blocks those are,but those blocks are to make your entire lower bodynumb for a very short per- completely numb for about four hours, and then but when that numbness wears off, you still have at leasta good sensory block so you don't have any significant pain
during those first day or two. and we think that's critical in terms of your rehabilitation. so by breaking that initial cycle of pain and giving you a sense of comfort, it just helps that first two or three days of your initial rehab so that you are confident with your knee,comfortable that you have, you're going to have a pain-free knee
and a relatively, you know, reproducable rehabilitation process. and so we use regional anesthesia. we can use regional anesthesia- do you wanna talk a littleabout hip replacement? - the other thing is that you do have a catheter in the grointhat stays in there for the first several days, which you can give yourselfyour own medication.
so that's certainly an agitant. it gets rid of a lot ofthat anterior pain, yeah. and for hips, the same concept. you're much safer breathing on your own than you are having somethingelse breathing for you. much less chance of being sick. so by doing the spinal or the epidural, and i get a lot of that is back-dependent. if somebody's had six back surgeries,
they have metal rods upand down their spine, that's not gonna be an option. most people you're ableto do the regional blocks and sciatic nerve blockand the epidural or spinal, and that's what we do for hips as well. - and i think regionalanesthesia for both hip and knee is very helpful to rob, whodoes the physical therapy post-op day one, becausethat patient's more awake, more comfortable, moreaware of his surroundings.
and for the nursing staff toassess their pain and so forth. - less narcotics, lesschance of being sick, less chance of gettin'goofy seein' things, better chance you can get up and eat and you know, get back tonormal activities quicker. - [attendee] dr. weiss,what are pre-op conditions before you could actuallyoperate on a person to replace the hip? what are the requirementsfrom their internal physician,
and how many time wouldyou have to see that person before you were able tooperate on that person? - we want people to beas healthy as possible. i mean, no surprise. so typically, what we do,we get medical clearance and/or cardiac clearance. if someone hasn't had a stress test within the last year, two years,we typically get, you know, cardiac clearance and get a stress test.
most of the time it's anon-exercise stress test, a valued stress test because obviously, if they have a hip or kneethat warrants surgery, they're not gonna beable to go on a treadmill and do an exercise stress test. the family doctors, wework intimately with them. they review all the blood work. you know, nobody knows the patient better than their own familydoctor, and we make sure that
their clearance is there, andthat everything is tuned up. that there's no urinary tract infections, that the person's inthe best shape possible. so those are the clearances that we get. if there's any question, we get an anesthesic clearance as well. if there's any issues,i.e., previous back problems or a history of nauseaor somebody being sick or having difficultywith a prior anesthesia,
we'll get an anesthesia consult as well. - [attendee] i've hearda lot of controversy about double knee replacements. but if you have a patient,you're havin' a bad day, you don't know which knee (mumbling). - that's a very good question. i mean in this i've gottaget well quickly society, there's a lot of patients that come to me and ask me about havingboth their knees done.
and generally i steer themto doing one at a time. because their is- for a number of reasons. one is it's a lot of surgery. and even if it's one houror per di, it's still- those patients are goingthrough a much different rehab than the patients who haveone knee done at a time. and i've done 'em as close asthree months apart, actually. it is two rehabs, it is tworehabs, it's two recoveries.
i think the other thing thatis there's a slight increase with a bilateral knee replacementwith pulmonary embolism, which is something we really wanna avoid. and so with that in mind, i am only doing knee replacements bilaterallyon patients who are so dramatically deformedthat they need both done at the time or theycouldn't rehab properly. and you'll get different opinions. there's a guy out in indiana that,
if you come in with two knees, he'll do two knee replacements right away. and i just feel like there has to be some careful considerationabout that procedure. so unless there's some really, really, dramatic reason for me todo both at the same time, i will stage them. - i would say that it increasesyour complication rate for about one to two percentto about ten percent.
and the rationale for that is you have twice as much blood loss. so most people, if youhave one knee replacement, rarely do you need a transfusion. if you have both, even though the blood is filtered, washed and given back, you get about 60 percent of it back, and oftentimes you needa unit, and there's about a 10 percent complicationrate with any transfusion.
you have twice as much pain, so you have twice asmuch narcotics on board. that in and of itself can cause confusion, you know, decrease your breathing, your risk of pneumonia increases,your risk of blood clots increases 'cause you don'tmobilize quite as quickly. there's a lot of thingsthat people think about, or don't think about i guess i should say, that goes along withbilateral knee replacements,
that you don't encounter ifyou just do one at a time. so it's certainly safer. i tell people that i'm not a big gambler, that you know, you haveyou know 98 percent, 98, 99 percent success rateif you do one at a time. you have about a 90 percent success rate if you do both at the same time. your decision. saying that, 90 percentof the people who have
bilateral knee replacements do well. but it's a ten percentincrease in complication rate. - i will say that whenyou have two knees done, it's not twice as hard. it's like 50 times as hard, initially. but then the initialrehab is a lot tougher, and then it gets easier as it goes along, and then obviously, you don'thave to have a second surgery. - i think and totally as agroup we've done very well
with our bilaterals, the oneswe've done at the same time. but they definitely are moreanemic post-operatively, and the potential for complicationrate is certainly higher. - [attendee] does it depend on your weight if you're gonna do it or not? - well that's a good question. there are some doctors thatwill tell you to lose weight, and this is an interestingspecific that people after knee replacement don'tnecessarily lose weight, ok?
so, or hip replacement, for that matter. but in an ideal situation,you'd like to lose some weight. it definitely takes stress off your knee, and may really make you feel better. and some people who've had weight loss don't need knee replacementafter a significant weight loss. there's no question about that. but i've had- i really have had a hard time like
getting weight off mypatients pre-operatively. it's just not the easiest thing, and i'm a realist about that, so i- and there's been somevery good data to support that you don't- that people who are a little overweight do do pretty well after knee replacement. i think the complicationrate, the risk of infection goes up a little bit, andthat's something to be
aware about that idiscuss with my patients, but i don't like tellthem that they can't have a knee replacement 'causethey're overweight. - [attendee] ok. - [attendee] is there a good, better, best in all products? - i tell everybody it's alittle bit like, you know, toyota, ford chevy. everybody feels reallystrong about what they use,
and with good reason. and there's some advantages and some disadvantages with both. i think if they're put inright, all of 'em work well. as i said, i think there's- everybody uses thecomponents that they use for specific reasons, but they all work. - there's a lot ofmarketing going on, frankly. i just want, i say buyerbeware a little bit.
i'd be much more- i'd really- if there's anything you can take out if you're considering ahip or knee replacement, be comfortable with your surgeon. be comfortable with him. it's more important than like exactly what knee or hip he's putting in, 'cause he's gonna makethat decision for you,
he really will. - [attendee] thank you. - [attendee] i'm 48 yearsold, and i'm an avid hiker. i hike 1,000, 2,000 miles a year. and i was diagnosed witha defect in my lateral, which is like three centimetersby one and half centimeters. and i was also diagnosedwith my femoral condyle being two by one and ahalf, and the tibial plateau being one by one.
now i was a candidate forthe denovo nt juvenile cartilage implantation, whichi'm eight weeks post-op. during that surgery, theysuggested that i have a osteotomy done to correct the alignment. now my question that i have is, one, what's your general opinion on it? and two, if you were todo it, what complications would result in time that i'mgonna need a knee replacement? would you be able to put the devices in?
does it limit what you can use? like you have the modern way we did it, or you used to use the rods. what does that do to your chances if you decide to go to do that? - that's a great question. it's a very complicated- let me just summarize briefly. like you had a cartilagereplacement procedure,
so you're in the small groupof patients who is having- but because of the, you know- and we can put cartilageback in knees, but just it's the actual alignment issue that makes the cartilage be removed again. so you need, i think thatthe osteotomy makes sense if someone went through a denovoprocedure as you described. 'cause you're changingthe alignment back to some being more anatomicthan that bowed knee
you might have right now, ok? so an osteotomy makes sensewith a denovo procedure, but you know, there's sofew of these done today that you wanna have that procedure done- there's really no data thatsupports that your knee's gonna be any better nowwith this double procedure than it was before youhad any of this done, ok? so it's a very, very experimental - [attendee] like when ineed a knee replacement-
- let's go back to that,then i'm gonna take a- and there has been data- talk about it. - it takes you from havinga primary knee replacement to a revision replacement,basically, alright? it's much more difficult,there's a lot more scarring, there's a lot more bony deformity. typically you have to use a stem instead of a surface replacement.
it's technically moredifficult, and as i say, the best thing i can tellyou is that it takes you from doing a primary total kneeto a revision total knee. - [attendee] but it doesn'tremove the option again. - [brett] no, not at all. in fact, there used tobe may osteotomies done in the 70's and early 80's, ok? many more than we do todaybecause we're using these half a knee replacements, and we're doing
other types of cartilage,but there has been data that said that those patientsdid not do quite as well as those patients whonever had an osteotomy and went on to just a primarytotal knee replacement. there is some data tosupport that that group doesn't do quite as well. but i've had many osteotomypatients, a good number of osteotomy patients,as dr. weiss has, too, that have done very wellwith knee replacement.
- say if you haven't had an osteotomy, in a primary kneereplacement you should get on a pain scale and functionscale of like 93, 94, out of a hundred. if you've had an osteotomy,you're down probably 87, 86, 87, something like that. so it changes things. - [attendee] is there a risk benefit? is there a risk benefit?
i mean like does it giveyou ten years, three years? i mean is there any studies- - depends how much wearthere is to start with. it depends where your mechanical axis- sometimes you can't shiftthe mechanical axis enough without you lookin' likeyou're walkin' like a duck. you know what i mean? you can't make somebody so knock-kneed to shift that mechanical axis over.
so it really depends onyour intrinsic anatomy. you need to get long legfilms to see what your mechanical axis is and where it- - [attendee] yeah, ithink i'm three percent. - where it lies right now. - [attendee] and i don'tknow if that's great or not. - two or three degrees is not that much. - [attendees] thank you, thank you. (applause)
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