- [Dr. Adam Rosen] So I'm hoping today to give you guys some information.
It's actually really humbling to see that this many people
turn out just to hear what I have to say
so I'm hoping that when you leave here,
in addition to the packet that you can take
two, three, four tips,
go home and start a program that you can use
to treat your knee pain and,
for those of you that a little bit further along that path,
this might give you some more information
on where you may be headed.
My staff has probably heard this a whole bunch of times
and for those of you that I've seen that are my patients,
I have all my analogies.
Can you hear enough?
- No.
- Okay.
We'll adjust and if you can't hear,
let me know and I'll stay behind the podium...
just so everybody can hear.
Yeah, that's turned up all the way.
And then at the end we're gonna have time for questions.
So anybody that's got questions,
I'm hoping, I'm pretty good at getting through stuff.
Got it. (laughs)
Jeff's gonna follow me around and hold that up
but I'm pretty good I think at the end of,
let me just do this.
Is that any better?
No.
(audience chatters)
Okay, I'm usually pretty good at the end
where people say once they look at their sheet of paper
and they go through one, two, three, four, five,
and say oh, you answered them all.
So, hopefully, that's the case but if not,
we have plenty of time.
Let me just go through here.
So here we are and like Jeff was saying,
I went to college on the East Coast,
did two years at Muhlenberg which is a small private college
in Allentown and then finished up at SUNY New Paltz
and did a lot of biology there, and then back
to where I was born and raised in Philadelphia,
did my medical school, internship, residency at PCOM.
I was lucky enough to get into a fellowship here
and did an entire year here just of
hip and knee replacement surgery with the docs that were here
and I was really taken aback and felt very privileged
at the end when they offered me a spot.
So this was an easy no-brainer.
When I went home, my wife and I,
we were looking for places all over the country and I said,
"Do you like it here?
"Do you want to spend the rest of our life here?"
And she said, "Yeah, yeah."
"This is really nice."
So she loves it, my kids love it.
They get spoiled by all of the different things.
Every time we go away,
they think there should be a Sea World and a LegoLand
and a zoo and a Disneyland all within driving distance
but they get to live here.
So I've been here since 2006 predominantly doing
hip and knee replacement, and this is probably
one of the big questions that I get asked.
So what is a DO?
Where I grew up on the East Coast,
I heard there was a Philadelphia person there,
a lot of people, Philly, New Jersey, tons of DOs.
When I grew up, my doctor was a DO,
my orthopedic surgeon was a DO.
So we do our four years of college
and then a four-year medical school.
The main difference is more the philosophy,
looking at the body as a whole organ system,
not as individual parts.
So if you have a stomach problem,
it may also lead to back pain so we're trying to focus
on you as a person not just the one organ
that has a problem.
So they really focus on the musculoskeletal system,
which I think really leads itself to help you
become an orthopedic surgeon because for four years,
you've learned about all the intricacies
of the musculoskeletal system before being sub-specialized,
but what's interesting, and I found out
a lot of people don't even know this -
in California, a lot of MDs actually were DOs by training
but there's a whole issue.
Prop 22 in 1961 and I forget the exact,
it had something to do with the billing and insurance
and Medicare but they switched everybody over.
So if you were a DO,
you sent the state $65 and you became an MD
and that's what happened.
So UC Irvine actually was an osteopathic medical school
and for reasons to change over the degree,
they sold it and it became,
for $1, became an MD school overnight.
So this is the goal tonight -
I'm gonna talk about knee arthritis.
We're gonna talk about what it is,
how do you treat it and then beyond that,
if you need a knee replacement, what is it?
What happens?
And we're gonna go through some of the details.
So arthritis, I get asked all the time,
what is arthritis?
Do I have rheumatoid?
Do I have "osteo"?
So osteo-, bone, -itis, inflammation,
so osteoarthritis in its general terms
is an inflammation of a joint and it's typically due
to loss of cartilage.
Rheumatoid arthritis is different.
It's still pain of a joint but it's a systemic disease.
These people are born with a disease that affects
all of their joints.
It destroys the joints and it works on both joints,
symmetrically both right and left where osteoarthritis,
it's not uncommon to just have one bad joint
and the rest of the joints in your body are okay.
So basic anatomy,
because I'm sure everybody has been on the Internet,
everybody has a friend and everybody knows was a meniscus is
but there's a whole bunch of other stuff inside the knee.
So the kneecap, what we call the patella,
that is actually a bone within the tendon.
It serves as a pulley system so not only does it protect
the front of your knee,
but it makes your quad muscle stronger
so it can straighten out your leg and it acts as a fulcrum.
The thigh bone, or the femur, that's capped in cartilage.
So if you look up here, the cartilage,
that's what typically goes away with arthritis
and you also have a three millimeter cartilage cap
on the top of the shin bone here.
So three millimeters of what we call articular cartilage,
that's the cartilage that's smooth, that's shiny.
It almost looks like a hard-boiled egg when you look at it
but between those cartilages is the meniscus.
The meniscus is another type of cartilage that acts
both to cushion the knee and it stabilizes the knee
from going forward and backward, secondary to the ACL.
So that's the second most common thing I find
that most people know about in the knee.
The ACL,
they've all heard of sports players injuring their ACL
and the second one's the meniscus,
but they both serve a function to stabilize the knee.
When you get arthritis,
typically it can just be a wear and tear,
more commonly if someone injured their ACL
or someone injured their meniscus years ago,
they may or may not have had surgery,
but when you lose the structure that supports the knee,
the knee starts to microscopically slide around,
and when that does,
it starts to wear down the cartilage,
so what you start to see,
I don't know if that's coming up on the white as much,
but what you'll see is the cartilage starts to wear away,
so you lose that three millimeters of cartilage
and now you have exposed bone.
So when you stand it hurts,
when you bend and straighten your knee it hurts
and when you start to do things,
those are the things that cause the inflammation
and the swelling.
So I threw these in here.
I hope you like 'em.
My staff, I'm sure they've heard every one of my analogies,
but what I found is, over time, these make sense to people.
Most common question I get -
"Why does my knee make noise?"
When I stand up it cracks and crunches,
everybody in the room hears it.
So this was the best analogy that I've used,
which helps you understand that if you drove your car
down the street, it's asphalt or concrete,
the car doesn't make much noise.
The tires are running over the smooth surface
but now there's a rumble strip.
It's still asphalt or concrete, but it's irregular.
So as your car goes over it,
it wakes everybody up that was sleeping in the back seat
and that's what happens with your knee
because as you bend and straighten the knee,
the cartilage is irregular.
So when you get up from a squatted position
and you put more force on those little cracks and bumps,
it goes snap, crackle and pop.
So it's not a bad thing.
Sometimes, it smooths itself out, so it will go away
but that's what's gonna happen when you stand up
and that knee cracks and crunches.
Now, who gets arthritis?
This is the other common question
that I get from a lot of people.
"When am I gonna get it?
Who's gonna get it?"
Baby boomers,
our biggest generation right now as far as population.
So in that age group,
you just happen to be lucky enough to be in that peak
of when people get arthritis.
Older patients also get it, and we have lots of patients
that are living longer.
I have lots of patients that I operate on
that are in their 90s.
They're healthy, they're playing golf,
they're playing tennis and then their knee deteriorates
and they don't like their quality of life.
So these patients are starting to just get wear and tear
after being on this earth for 90 years.
Post-trauma, these are my youngest patients.
So the 40-, 50-year-olds,
these are people that had a fracture
or a bad injury at some point,
damaged the cartilage at an early age
and now they have a progression of arthritis.
So they have the arthritic knee of an 80-year-old
but they're 45.
We treat them the same. And obesity,
obesity epidemic is a huge reason that we're starting to see
lots of health conditions and health problems,
but it does affect arthritis.
So what do you feel?
Any of my patients that have been in,
they'll see I have half of my intake form
has a whole list of adjectives
because everybody describes it differently.
So I hate to say, "What kind of pain are you in?"
It's better to say, "What sort of symptoms do you have?"
because a lot of patients tell me, "I don't have pain.
I have instability, I have burning, I have giving way."
So there's all sorts of things that people will feel.
So none of them are wrong, and you may not have all of them,
and you may not have all of them at one time.
You might have one this month and another one next month.
So don't worry about it.
Don't try to figure it out.
It is what it is so you're not gonna fix it
by trying to predict the symptom, but it will come and go
and these are some of the things that you may
have already seen.
This, I think, explains a lot.
The reason I get all the time,
patients come in and "My knee gives way."
"Why did my knee give way?
"What's wrong with it?
"What unstable with it?"
When we as surgeons look at a knee,
there's an instability that we perceive based on your exam.
So if I pick your knee up and you fell
and you had torn your medial collateral ligament
I would describe that as unstable.
So the structure on the inside of your knee,
a strong ligament that's supposed to be sturdy,
when I bend your knee,
it bends in a way it's not supposed to.
That is what we would call instability
but a lot of people have a stable knee
and they describe their knee as being unstable
and what happens is that when you step on something,
the tack is my best example,
so if you were barefoot and you were over there
and I said, "Hey, come on over here.
"I wanna show you something," and you were barefoot,
walking slowly and stepped on the tack,
most people before their brain recognizes ouch,
that's a tack, that tack's sharp,
and if I put full weight on it, it's gonna hurt a lot,
before any of that happens, your brain says,
"Hey, that hurts.
"I'm gonna shut your leg off,"
and your quad muscle reflexively gets weak
and you fall to the floor.
So your knee's not unstable,
there's nothing wrong with the actual mechanism,
it's a pain generation thing that bypasses your thinking
and that's what happens in the knee.
So when your knee hurts, and you step or turn or twist wrong,
your brain says, "Hey, that hurts.
"I'm not gonna squeeze anymore 'cause if I do,
"it's gonna hurt."
So your knee gives out.
So that will happen.
I'm sorry, I can't predict when.
Yes, you might fall, so be careful if this is
one of the things that you notice,
but the more that you're aware that it is a possible thing
and the more that you notice that it can happen,
makes you a little bit more cautious in certain situations.
Now X-rays, this is a big thing,
so we will examine knees and a lot of times
without an X-ray,
I can tell if someone has arthritis or not
just by what their knee exam is,
but when we look at an X-ray,
what you're looking at here is on the right side,
you'll see a pretty normal looking knee.
That's the patient's left knee.
So when you come to the office,
we always set the X-ray up as if you were the doctor
looking at the patient.
So your right is the patient's left.
Pretty normal looking knee.
You see the end of the thigh bone and that space
which is equal between the thigh bone and the shin bone
is the cartilage space.
So three cartilages -
cartilage on the end of the thigh bone,
three millimeters thick, cartilage on top of the shin bone,
three millimeters thick,
and then a meniscal cartilage in between.
So on the left, the patient's right knee,
that's a severe arthritic knee.
So they've lost all the cartilage space,
both on the thigh bone and the shin bone and the meniscus,
at this point, is shredded.
So that's why everybody with arthritis has a meniscus tear
but these are the meniscus tears that we don't care about
because you're bone on bone.
The meniscus tear is obsolete at that point.
People will also get bone spurs.
So the bone spurs that you see on the side,
those are the bumps that people will feel
and when those bumps happen in the back of the knee,
that's why it hurts for people to bend.
They go to bend and the knee won't bend all the way.
So this is similar to a trailer.
So if you had a boat on a trailer, the wheels spin,
but when you get to where you're going,
you put some chock blocks in front and behind the tire
and that trailer doesn't move and that's what can happen
to an arthritic knee.
You go to bend it and it just doesn't bend
like the other knee.
It's because those bone spurs are in the back
and blocking it.
So do you need an MRI?
No.
You don't.
Don't ask your primary (care doctor) for one.
You don't need it.
It's a lot of times, a waste of your time to get it.
There's very, very few instances where we need it.
So an X-ray is the way that we diagnose arthritis.
Everybody with arthritis has a meniscus tear
and a lot of times we see the bruising of the bone.
You can see all the white on the left.
That's white fluid because there is no cartilage left,
it's gone.
So by the time that you wait three weeks to get it approved
by your insurance,
sit in the MRI scanner for 45 minutes,
wait for your primary (care doctor) to call you back
and then show up at the doctor's office,
we look at it and go, you have arthritis.
So a lot of times, the X-ray is a better option.
We do use it if someone falls and we suspect
they have a fracture.
So that's one indication and with arthritis
where we would use an MRI but an MRI
is not typically needed for arthritis.
There was a study, Wayne Goldstein that I know in Chicago,
and we did one here recently just a year ago.
We were curious, but patients that I saw in the office,
these were patients here that had knee replacement
that were referred to me for knee replacement -
42% of those patients showed up with no X-ray
but almost 35% of them had MRIs.
So we can actually do the less expensive,
better test for arthritis
before you kind of run through the mills.
So I just try to use that 'cause a lot of people think
the MRI's the better test,
and it is for a back if you're looking at a disc herniation
or a younger patient that you suspect has an ACL tear
but it's not something that we need for an arthritic knee
and the other important thing too is the X-ray
and how it's done because when you stand,
people notice if their knee's getting bow legged
or knock kneed.
When you lay down on a table and you get an X-ray,
you don't see that.
So when people go to the ER or their primary
and they get an X-ray,
you can be your best advocate and say,
"Hey, I think I should be standing."
'Cause we want you standing,
because the standing gives me the alignment.
This is an X-ray of a patient that had her X-ray
only two months before I saw her lying down.
So you see that one X-ray on the left.
It looks pretty good.
So the primary's trying to figure out why she's hurting,
I can't remember if she saw the primary or the ER,
and the radiologist reads it and says minimal arthritis
but the patient was in horrible pain
and she's wondering what's wrong with her knee.
So I had her stand up and do one X-ray and you can see
she's bone-on-bone, completely explains her pain.
So if you ever get an X-ray for arthritis on your knee,
just remind people and say,
"I think I should be standing for this."
It's gonna show better what your knee really looks like.
And everybody's talked about this, we talked about meniscus,
everybody knows about a meniscus.
Everybody knows about an ACL.
Everybody else knows about a Baker cyst,
probably the most common thing that people know about
in the knee second to the meniscus,
but it was first described
by William Morrant Baker in the 1800s.
He noted the swelling in the back of the knee
and what they found back then is even if you cut it,
lance it, operate and their surgeries and antibiotics
weren't anywhere near like ours today,
I think three or four of the patients in a series
had amputations because they got infections
but what he realized is that it's not a cyst
like in other parts of the body.
We have cysts that develop, but this is truly a swelling
of the back of the knee due to your arthritis.
So when your knee's swollen,
the path of least resistance in some people is out the back
and you'll have a fullness or a pain back there.
So we can't take it out.
It's not a separate structure.
It's just some people get swelling in the front,
nobody has a name for that, that's knee swelling.
Some people have swelling in the back.
That's called a Baker's cyst.
So you treat it just like you would treat swelling
anywhere in the knee -
compression, ice, elevation and it's important to know that
if you don't have any reason not to,
you can take an anti-inflammatory but this way,
if that happens to you, I hear it all the time,
people are in pain for weeks waiting to get in
to see the doctor or go in to the ER,
so start treating this right away.
You can wrap it, you can ice it,
you can use anti-inflammatories and some people find in 24,
48 hours, they're already feeling better.
This is not what we do here.
So there's lots of ways around the world
that people treat knee arthritis and we've come a long way.
So things that we can do.
There's an Academy,
our American Academy of Orthopedic Surgery,
comes out with guidelines for every indication,
every diagnosis, every surgery.
This is the brief view of their guidelines
for treating knee arthritis.
Top three, anybody BMI over 25, weight loss is a huge thing.
For every pound that we carry,
that is about four or five pounds of pressure
on your knee joint.
So if you lose five pounds,
you just took 25 pounds of pressure off your knee.
That's an entire backpack.
If you hurt a little and you have a little arthritis,
you might make all of your pain go away.
Some of my patients that have severe arthritis,
they'll lose five or ten pounds, they'll still hurt.
So there are still other treatment options.
Low impact exercise is key.
So here's too much exercise -
so I'm not asking people to do a triathlon.
Here's no exercise.
This is laying on the sofa.
Both of those are bad if you have knee arthritis
but there's a huge gray zone in between.
So you have to do something, and if you think about it,
most people, not everybody, but most people will tell me,
probably most of you after sitting here listening to me
for 45 minutes,
when you get up your knee's gonna hurt,
everyone's gonna stand there and be stiff.
So once you get moving, your knee feels better.
So all the patients that I see that exercise a lot,
they say, "Yeah, I get up in the morning, my knee hurts
"but once I get moving, I feel better.
"I have to keep moving."
So that's the key.
So if you exercise,
exercise everyday and if today's a good day,
exercise more but if today's a bad day,
just exercise a little.
Try to do something 'cause something is better than nothing.
And the other thing that I get asked a lot is
can't you scope it?
That was really common in the '80s.
So a scope is the surgery where we make two small incisions,
go into the knee with a camera and a few small devices
and trim that up.
It's great for a meniscus tear
that happens from a sports injury but what we thought
was a good idea in the '80s where we'd go in
and wash out the knee doesn't work really well.
Most people get worse because your knee
has 3 millimeters of cartilage.
Underneath that three millimeters is bone.
So if you have two millimeters left and I scrape it down,
guess what?
Now you're bone on bone 'cause it's not like
the old cutting board that was passed from generation
to generation in our family.
If I had a seven inch block of wood that was really beat up
I could take it to the garage and belt sand
a quarter of an inch off.
Now I get a six and a quarter inch of a block of wood.
It's brand new.
The knee doesn't work that way so we try
not to scope the knee unless there's
a very, very specific narrow indication.
This is important.
Old is not bad.
In America, for whatever reason,
everybody thinks old is bad.
You go to many other countries and the old,
they're revered.
They're special.
There's a lot of respect there.
So an old knee's not a bad thing.
An old knee's like your Model T Ford.
It takes a little bit longer in the morning
to turn the engine over,
makes a little bit of noise going down the street,
doesn't go as fast as the new car, but it still gets you
to where you're going.
So don't think that just because you have arthritis,
it's a bad thing.
It's just, it comes with the territory.
But treatment and this is one of those things
I want everybody to take away from this
if you haven't done enough for your knee arthritis.
So the top three - you all have control of those things.
These are all in your power.
So, one, exercise.
We'll go over a few, but exercise and strengthening are key.
They will lessen your pain.
Studies show that if you can strengthen your quad,
which is the muscle above your knee, this muscle here,
you can reduce pain by 40%.
The other thing is weight loss.
Weight loss is amazing for decreasing pain
and I harp on it all the time and patients hate it
'cause I've been this weight since high school,
I do exercise a lot, I eat healthy but when my patients
that have struggled with weight for years
hear it coming from me, a lot of 'em give me a hard time,
"Oh, it's easy for you."
It's hard to lose weight but if you do it,
I have enough patients that come back and say,
"I did it.
"I did it and I feel better."
That's the reason I keep pushing it
but it will lessen the pain that you have in your knee
and over-the-counter medication.
So, Tylenol and other anti-inflammatories like Motrin,
Advil, and Aleve if there's not a reason for you to take it.
So anybody that's concerned if you're on things like Plavix,
Coumadin, all the other anticoagulants for your heart
or for your brain,
you have to check with your primary first.
Things that are in my control?
We can do prescription medications.
We can give you injections and then braces.
I saw a couple people walking in with braces,
we'll get to that
and then the other stuff.
I had a few people stop me and ask me about others
so I'm gonna try to cover all the others,
probably won't get to all of 'em but most of 'em.
So my top three.
Walking is great, but a lot of people tell me,
"It hurts when I walk."
So walking is about 1 1/2 times your body weight every step.
So if you can't walk, get in a pool.
If you don't have access to a pool, get on an elliptical.
It's like walking, but you don't get the pounding,
and if you can't use an elliptical, try to get onto a bike,
a stationary bike is a great way.
Sit on, recumbent, doesn't matter,
whichever one's more comfortable,
you just wanna pedal and start with just five minutes a day.
The big thing that I ask with a lot of my patients
is just to try.
So if Monday, Wednesday, Friday they get on a bike
for five minutes,
they think that's silly, but in reality,
I ask them what they did last week and they said nothing.
I say well, five minutes is more than nothing
and it's not 30 minutes but maybe in two months
we can build up to 30 minutes so start somewhere.
Usually the first week or two hurts
but my patients that decide,
it's always January 1st, I'm gonna go to the gym,
New Year's resolution, I went to the gym,
worked out with a trainer.
I couldn't get off my sofa for two weeks.
So don't go overboard, but you wanna make a lifelong change.
The other one is strengthening.
So this exercise, and it should be in the packet,
it's super simple.
Everybody has a leg, everybody has a floor.
Lay on the floor,
the reason in the picture you bend the back knee
is to take some of the pressure off the back
and then what you'll do is you just lift the leg up
and lift it down.
Up, down, up, down 10 times, and I have my patients
do it actually in the office with me
'cause I'm in the office Monday, Wednesday, Friday
so I tell them that if they did 10 with me in the office,
they're done for the day.
That next day, Wednesday or Friday, they have to do
10 more for the week and then the week after, 20,
the week after, 30.
When you get up to 50, most people tell me,
the knee felt better.
But the big thing that's in a lot of people's control
is the weight loss.
If you don't know what your BMI is,
just calculate it and when you go home, on your phone,
you can Google BMI, Body Mass Index,
and figure out where you're at. It's scary,
but it is a huge reason for medical problems and conditions.
We're great at lots of things,
this is not a chart that we wanna be at the top.
So compared to all other countries,
we have one of the highest obesity epidemics in the world.
So you wanna try to get that down and people say,
"Well, does it matter?
"Does it really affect my arthritis?"
Yes.
So, a normal weight person,
the risk of arthritis in their lifetime, 16%.
An obese patient, double that.
Now if you get rid of the weight, unfortunately,
the arthritis is already there.
It's not gonna disappear but you're gonna hurt less.
So the earlier you start,
the less pain you're gonna have in the long run
and you can slow down the risk of progression of arthritis.
I'm not a dietician, I'm not a nutritionist,
so I've told people things over the years,
the big thing is diets, for me, listening to people,
they're crash diets.
I hear it all the time, I went on Weight Watchers,
I lost weight, I gained it back.
I did Atkins, I lost weight, I gained it back.
I did this one, I gained, so don't go on a crash diet.
Change the way that you eat forever and try to lose
a little bit of weight.
Don't set a goal weight.
So I always tell my patients, give me a pound a week.
Most people can lose a pound.
In a year, that's 52 pounds and that's a lot more reasonable
for people then trying to set a goal weight
and weighing yourself everyday 'cause it's gonna fluctuate
with your clothes and water weight.
So just weigh yourself once a week and figure out
where your issues are.
For some people, it's too much, it's snacking.
So figure out where your little thing is
but the two things that I wanna talk to people about,
the plateau,
'cause my patients,
when we're watching their weight decline before surgery,
everybody hits a plateau.
They all say, I hit this point.
I'm eating what I'm supposed to eat and I'm exercising
and I just stop losing weight.
Well, that's great.
You just became a more efficient machine.
Just everything that you do, going to the bathroom,
getting the mail, going to work, going shopping,
because you weigh less, you're burning less calories.
So now you have to do one of two things or both.
You increase your exercise or you lower the amount
of calories that you eat but the plateau is a normal
and a good thing because it shows that you actually
have become more efficient but don't be surprised.
I have patients that come in and they say guess what?
I lost 10 pounds.
My knee feels better and my back and my cardiologist
took me off one of my blood pressure medicines
and my other primary took me off
one of my diabetes medicines.
So all of those things are factors and you can actually
make yourself healthier by doing all those things
to address each of those problems.
Over the counter medications.
So Tylenol, ibuprofen, naproxen,
and we have a whole bunch of prescriptions that we can use.
The thing that I want people to remember though
is that when you use these medicines,
they take a little time to kick in.
So the analogy that I like to use,
in medical school everybody sees this
'cause this is the therapeutic range of most antibiotics
and most drugs.
They don't work right away.
So the mistake that I hear from a lot of people is,
"Oh, I took Tylenol once.
"It doesn't work for me,"
and "I took ibuprofen once and it doesn't work for me."
Well, if your primary gave you a prescription
of an antibiotic for 10 days and you took one pill
and you called them the next day
and complained that you were still sick
and that antibiotic didn't work,
you want another one,
they would laugh at you and they'd say,
"Whoa, whoa, whoa, stop.
"You gotta take it everyday."
And that's the thing that I have people do with Tylenol
or an anti-inflammatory, if you hurt
and I don't want you to take medicine
for a long period of time,
months and years, but if you hurt today or this week,
take it for a week. And if you take it for a week,
every time that you take it,
you're building up those blood levels of the drug
and then the pain and the inflammation go away
and then you might be in less pain
for two, three, four months but when you have a flare up,
you take it again for a few days.
So I like my patients to take this in little mini bursts
and then stop those drugs.
But the narcotics are bad and I've harped on this
for a decade and people always thought I was the mean guy
and I don't want people to be in pain,
so I don't say take nothing.
There's just other options and finally we're starting
to realize, and the rest of the world has realized,
that there's an issue.
99% of Vicodin in the world is used in our country.
80% of Percocet in the world is used in our country.
So if you have knee pain, you don't need a narcotic.
That's not the first line treatment.
So I always kind of tell my friends
that if you and I went duck hunting
and you were out in your waders and I showed up in a tank
you would kind of laugh at me.
It's a little bit overkill taking a duck out with a tank
and it's a little overkill to use a narcotic for knee pain.
So start with the other medicines and you may find
that after three, four, five days you feel better
because we know that patients that are on narcotics
before knee replacement surgery,
whether or not it was because of their neck pain
or their shoulder pain or their back pain,
but if they take narcotics regularly and then have surgery,
they have worse outcomes.
They don't do as well.
Their pain is not relieved as much.
They have more complications.
They have more revisions.
Someone's gonna ask why, I don't know.
We don't know yet why but we do know that it is a factor
so even my patients that are on high dose narcotics
before surgery for other reasons,
I try to wean them down before we do surgery.
But injections,
so cortisone's a great option after you fail pills.
So pills, exercise, strengthening,
all first line treatments.
If that fails, cortisone's a great option.
It reduces pain and inflammation.
A few people asked about the lubricants.
I only have a few of these.
Someone else showed me another one.
There's a lot of brands.
There's Coke, there's Pepsi, there's RC Cola.
I mean, you go to Baskin Robbins, you got lots of flavors.
They're all variations on a theme.
They're all what we call viscosupplements.
So these are lubricants that are meant to lubricate
the remaining cartilage in the knee.
They do not reverse arthritis.
They do not make your cartilage healthier.
They do not prevent arthritis.
There are a lot of misconceptions that people hear sometimes
but it may improve the pain in about 40% of people.
So that's the honest statistical truth
is that a lot of studies show it doesn't help everybody
and it usually helps people with early arthritis.
So even our academy doesn't recommend
using it on a regular basis so it's just another option
that we have to control pain.
As far as the ultrasound or the X-ray,
it's not necessary for the knee.
A lot of people ask about that also.
Do you need the X-ray or the ultrasound?
You do not need it for the knee.
In the small joints of the hand, the foot,
we can't see them.
People do use it in the knee, but it's not necessary.
Braces.
I saw a few people walking with braces.
If they help you, they're good.
If they don't help you, you don't need to wear 'em.
I have a lot of people walk in with a Nordstrom's bag
and they have the question,
they start pulling out brace one, the copper,
brace two, the magnets.
This one's got the straps, this one's got the hinges,
and they said they've tried 'em all, none of them help.
Do they need them?
The answer is no.
There's not a brace that will prevent arthritis.
There are some braces that people wear
that make them feel better and a lot of times,
it's the simple little slip-on knee sleeves,
the neoprene ones and it makes you more aware
of where your knee is in space.
So if you wear it,
you're more likely to be aware when I turn or pivot,
not to twist my knee bad or when I squat down,
not to bend it too much.
So if it makes you feel better,
wear it, but if you tried it and it doesn't help you,
don't feel that you're making your knee worse.
All the other stuff.
So I brought the cane for two reasons.
So if you can't hear me for a little bit,
I'll speak louder.
If my left knee hurts,
who thinks the cane should be in my left hand?
Raise your hand.
And if my left knee hurts,
who thinks the cane should be in my right hand?
And who didn't raise their hand? (laughs)
(audience laughs)
So it should be in the opposite and it doesn't make sense
to a lot of people because if their knee hurts,
everybody kind of leans on that side.
The center of gravity is right here.
So if this knee hurts
and I lean over that knee onto the cane,
I just put more weight on my bad knee.
So it's awkward for a lot of people,
but if you put it in the opposite hand that, as I walk
with my good leg, and then I walk with my bad leg,
I can lean away from the bad leg and take the weight
onto my hand, off my bad knee. And it's an awkward thing.
It's sort of like learning to do the waltz.
It takes a little bit of time, so practice at home,
but by people doing that, I have it in the office everyday.
I watch people get up and I say, "Give me the cane.
"Take two steps," and they go,
"Oh, it feels better already."
So just that one little trick.
The other one, whether or not you're using the cane,
that I get asked all the time are stairs.
So the thing that we always tell people,
up with the good.
So if you have to take 'em one at a time,
it's up with the good, down with the bad.
So this way you're always leading with the bad
and one of my favorite therapists here,
she has a great way to remember it.
Good ones go to heaven, bad ones go to hell.
So that way, you'll never forget it.
She teaches all of her patients and they always remember,
but that'll prevent if you need to use those stairs,
that's the best way to take it.
So creams, patches, Voltaren gel, Flector.
Those are anti-inflammatory patches or creams,
they do help some people.
All of the over-the-counter stuff,
if you use it and it makes your knee feel better,
that's great.
You're just, again, treating symptoms.
glucosamine, chondroitin,
there's not a whole lot of strong evidence
that it really does anything for arthritis.
That being said, if you do it and it makes you feel better,
that's okay.
We don't know of any harm.
So my feeling is, if it doesn't cost you a lot of money,
if it doesn't hurt you and you feel better,
then it's a good treatment for you.
A lot of herbal remedies.
People have used arnica, tumeric, there are options.
Acupuncture, I have some patients that use and swear by it.
It makes them feel better and diet,
people always ask about anti-inflammatory diets.
There's not a whole lot of proven stuff for me to say
you need to do this or try that or eat this,
but if you try it and you feel better,
then it's a good option for you.
This is my tip, so all of my patients, when they travel,
four things I tell them to bring -
a Ziploc freezer bag.
In the Ziploc freezer bag, put a bottle of Tylenol,
and if you can take an anti-inflammatory,
your anti-inflammatory of choice.
This way you don't have to spend $40 for a bottle of Tylenol
at the hotel with three pills in it, but you have it
and you have your anti-inflammatories
and most people in the hotel can find an ice machine
for their sore knee but they can't find a bag.
So now you have a Ziploc freezer bag,
and the other one is go to REI
or one of the local outdoor shops
and get a collapsible hiking pole and this way,
if you need it, it is in your luggage.
So I have patients that are always going all over the world
traveling to places that I'd like to travel to
when I retire and I say, "Bring the pole,"
and they'll say, "Yeah, I went to Machu Picchu
and I was able to take the cane and my knee hurt
but I made it through.
I'm glad that I had it."
So just throw it in your luggage and forget about it.
Now this is the other one people always ask,
"Is it gonna get better?"
I'm sorry.
Your arthritis is not gonna get better.
It always gets worse,
but it may not get worse quickly
and you may have good days and bad days.
So the stock market is sort of predictable
over a 30-year-period.
We know it starts there and it goes there.
But we know that today something good happened in the world
and it goes up, and today something bad happened
and it went down, but even the guys on Wall Street,
something happens and they have
no idea why it went up or down.
So your knee's the same way, just reversed.
So your knee's gonna get worse over time.
You're gonna have good days and bad.
Some days you're gonna do a lot,
you're gonna expect it to hurt and it doesn't
and other days you're gonna do nothing,
you'll wake up and it's killing you.
So don't try to figure it out.
Just if it hurts, treat it but just know that over time,
it will get worse and we deal with it down the road.
So can you scope it?
This is a question that we kind of broached on before
but I get asked all the time.
This is a pretty normal looking knee that if you look
at the picture on the left, the cartilage,
that little ball shaped thing up top,
that's the thigh bone,
the bottom is the shin bone,
pretty smooth looking cartilage.
And then you look at the second,
that's the other half of this person's knee,
that's a torn meniscus.
It's frayed and the third picture is after I've resected it.
The problem is, no matter how bad your meniscus tear is,
if you don't have the cartilage above and below
and I clean up the meniscus,
you're still bone on bone.
So you still hurt.
So that's the reason why when someone comes to us and says,
"But I have a meniscus tear,"
yes, but by fixing the meniscus tear,
it's not gonna fix the fact that you're bone on bone.
So that's the reason we don't typically scope
arthritic knees.
And then partials.
I get asked about this a lot.
Partials have been around for a long time.
They are a little less invasive
because the knee has three parts.
There's a kneecap part, there's an inside or medial part,
there's an outside or lateral part.
So the partials replace just that, just 1/3 of the knee,
and patients that have a knee replacement on one side
and a partial on the other,
they all tell me the same thing,
"My partial feels more like my normal knee,"
and you'd expect it to because it only replaced 1/3,
not 3/3.
It is a slightly shorter recovery.
It's a slightly shorter longevity meaning that
if you have a knee replacement on one knee and a partial,
a lot of times, the partials don't last as long
as a full knee replacement, but you can still get arthritis
in the other parts of your knee.
So for us, if you put a partial in a very young person
that only has arthritis in one spot,
you can predict that they're probably gonna get arthritis
in the other parts of the knee as they get older
but if you have arthritis in other parts
and we replace just 1/3,
those patients come back and say,
"But my knee still hurts.
"It's a little better."
So that's where we would err on a knee replacement.
So don't feel that a knee replacement's bad.
It's just different and if you do a partial,
surprisingly, you convert it to a total,
you'd think it would just be like any other total,
but the results are not as good.
So that's why we really have to pick and choose carefully
who are good candidates for a partial
because we don't wanna put you through two surgeries.
This is a partial.
So this is what we call a medial partial
where the outside half of this person's knee
and the kneecap joints were fine,
so there's just a metal part and a metal part,
sandwiched between is a plastic part
and that makes up for the arthritis
on the inside of the knee,
but we can also replace the kneecap joint.
So you can see the picture on the left
is a severely arthritic kneecap joint.
The kneecap is almost 50% out of the way,
what we called subluxed and almost dislocated
and then when you go in there
and shave off the bad cartilage and realign the knee,
you've replaced their kneecap joint,
but the thigh bone, shin bone areas were okay.
So those are partials.
But this is sort of the stuff that everybody
always wants to know.
Is there anybody that needs to stand?
Stretch a knee?
Everyone's okay?
So this is the knee replacement stuff.
So this is the stuff that I try to tell
all my patients about because the more information
that you have,
the more you understand what you're getting yourself into,
the better you're gonna do.
Most common question I get, "Do I need it?"
Luckily, no.
The cardiologists are different that if you showed up
in the ER with a heart attack
and a blockage in two arteries, guess what?
You need a stent or a bypass, you're gonna die otherwise.
Luckily no one died from arthritis but, it can lead
to other problems where people just don't like
their quality of life.
So it's an option if you're not happy with things,
and we're always gonna tell people,
you'll know when it's time.
And some of you may have heard that,
and it's hard to figure out what that means.
What do you mean I'll know?
You'll know when it's time.
I try to narrow it down though. So if you've done
an exercise program and if you've lost weight if you had to
and if you tried pills or shots,
that's first line treatment.
Everybody should do that first.
I have patients who say, "I don't wanna do that.
"I wanna have surgery.
"I don't like those pills they have lots of side effects."
Well, the risks of surgery are a lot greater
than the side effects of Tylenol, so I'm a very big fan
of try the simple things first.
Second thing is quality of life because if you can do
everything that you wanna do,
I have guys that come in with knee pain
that are surfing and playing golf five days a week
and tennis the other two days
and they're hiking up mountains,
I can't make that person better.
I can make their X-ray better, but I can't make them better.
So quality of life is within reason for a knee replacement.
It's not a normal knee.
The way that I describe it to a lot of people
is that if your normal knee's a 10 on a scale of zero to 10,
a great total knee's an eight.
So if you're a seven or an eight,
you're not gonna be happy with the outcome
of a knee replacement but if you're a three or a two
and we put you from a two to an eight, you're ecstatic.
You've got your life back.
The other thing and luckily rarely do I see this,
but you have to be medically stable.
It is a big operation, so we don't wanna put someone
under anesthesia and through the rigors of surgery
if you can't tolerate it, and you have to do the therapy.
It's the thing I tell people over and over again.
It's so important,
that this surgery works really well
if I do my job and you do yours.
If neither one of us do our job, the knee does not work well
and I stress that because I see a lot of second opinions.
I see a lot of people that come to me
with a knee replacement that was done somewhere else
and 99% of the time, the knee was done well.
It was aligned well.
It was positioned well.
It was sized well, but they didn't do the therapy
and they got stiff. And if you've talked to some people,
the worst stories that you'll hear are the people
that had a stiff knee after surgery and they tell you,
"My knee's worse now than it was before surgery."
They're miserable and there is no going back
and I tell them all the things
that I'm gonna tell you tonight
and the thing that I hear from everybody
which is the reason I stress it is,
they say, "Why didn't someone tell me this before surgery?
"Why didn't they tell me I had to work harder?
"I would've worked harder if I knew,"
and I don't know, I don't know, maybe they did tell 'em,
maybe they didn't hear it, maybe they didn't stress it,
but it's really important that you have to give 110%
And I tell people that if you're not willing
to do the therapy,
don't have the surgery.
If you're gonna have the surgery,
you have to be willing to do the therapy
and that's what's gonna make the knee work well.
Now, you're probably ready if you have trouble
getting off the toilet.
Count how many steps,
none of my patients that don't have knee pain count,
they'll come and tell me,
"I have 17 steps in my house separated by a landing."
So those are things that only people with knee arthritis,
sometimes hip arthritis deal with and even today, I mean,
everyone's gonna get up and, dinner -
you stand up and everybody starts walking
to the front of the restaurant
and you're stuck there holding onto the table
because you gotta loosen up your knee
and kind of get it moving.
So those are all things that people run through
if they have knee arthritis.
It's common.
Everybody gets it.
The medical things,
the things that I think about
that you don't necessarily have to think about,
but we'll talk about is, if you're a smoker, you gotta quit.
Luckily, Southern California, there's not a lot of smoking,
but it increases risks of infection, wound complications,
blood clots.
You gotta quit.
Diabetics,
there's a certain number that diabetics follow
for their sugars and anything over seven
increases their risk of complications.
So that's a modifiable problem.
We fix that first.
The weight is a big factor that people that are overweight,
over a BMI of 33, your complications increase.
The last thing you ever want to deal with is an infection
in a total joint.
It's a disaster, so anything we can modify, we do.
You have to have good teeth, and people wonder about that,
but the mouth is a source of infection.
So if you have a rotten tooth or a cavity,
that is a source of mouth bacteria
getting into your bloodstream,
and those bacteria love artificial things.
So they like heart valves and they like knee replacements.
So if you have a cavity,
we fix that first before you have a knee replacement
just so you don't develop an infection in the knee
from the mouth.
Good nutrition's really important too so we check this lab
called an albumin because people think about malnutrition
as people a lot of times over in Africa
when some of these epidemics,
people look really skinny, but you can be heavy
and you can be malnourished,
and if your protein stores are low,
you actually can't heal as well.
So they have more wound complications.
And we have to have good tissue.
So things like psoriasis,
some people have swelling problems where the skin
is not healthy,
that if you make an incision through that,
you increase the risk of a complication
so these are all the things that I think about
separate from the things that you think about.
So big operation,
600,000 are done every year in the United States.
So it's a really, really big and it's growing fast.
3.5 million knee replacements we anticipate will be done
every year in the United States by the year 2030.
So I got my work cut out for me.
(audience laughs)
But there's lots of people that are needing this
and the good news is they work well,
which is why people keep having them done.
So once you've decided, if you say, "Okay,
I've done the pills, I've done the exercise,
I've maybe had shots and I'm hurting.
I'm not happy,
my quality of life is not what I want it to be.
I'm ready for knee replacement."
Couple things that you need to do -
talk to your primary 'cause they would give you a once over
to make sure that you're healthy enough for anesthesia.
If you have teeth problems like we talked about,
you go to the dentist, take care of that first,
and if you have other issues,
a lot of my patients if they've had pacemakers or stents,
we get them into their specialist first
'cause they might wanna do special tests.
My office,
Veronica takes care of just about everything that I do
except operate.
So she's gonna call you,
she's gonna get your insurance authorization,
she's gonna set up your pre-op appointments,
the date of surgery.
She's gonna send you all the stuff that you need to read
and fill out, and then set up your appointments
for even after surgery.
And then you're gonna come in for your pre-op.
So usually two or three weeks prior to surgery,
you come and you meet with my nurse.
We do a wash that you do on your skin
and your body before surgery,
again another way of decreasing the risk of infection.
She'll give you instructions for both before and after.
We give you the after again after surgery.
We try to be very repetitious because people lose
and misplace things.
You'll meet one of our orthopedic fellows.
So they'll go over your exam again, talk to you again.
We do labs, EKG and a nasal swab,
so anything your primary didn't do
and we always tell people,
when you go to the hospital,
look for the cafeteria because you need to go
to the left of that.
So that's where that sign is.
So you'll look at the cafeteria,
the room you need to go is just to the left
and they'll do all those tests.
We do a nasal swab and the reason is that certain people
are carriers of MRSA.
So people have heard of staph infections
and there's a small group of people in the US,
about 4-5% that are carriers of MRSA
and if we don't know that,
we don't give those people the correct antibiotics.
So we do a swab on everybody, and if you come back
as a carrier, you're not sick, you're not ill.
It just means that you need a very special antibiotic
and we wouldn't know that otherwise.
So that's the reason we do the nasal swab.
And then you see the account rep upstairs
which checks your insurance
and goes over any other paperwork
that you need for the hospital.
Then you come in for surgery.
So this is the big day.
Everybody's nervous the night before.
Most people don't sleep well.
That's normal, but you'll get up early,
you'll come in.
Nothing to eat or drink except certain medications.
We will tell you take your medications
and that'll be given to you on your instructions
before surgery,
those you'll take. And then you'll come in
usually about two hours prior to your surgical time.
And then when you come in,
you're gonna come to this room downstairs by the cafeteria.
This is the waiting room.
You'll check in and then they'll take you back
but it's where your friends or family will wait.
There's an information board so they can follow you
through the whole process.
Nowadays they can watch and say,
okay, she's in the holding area.
Now they're in the OR
Okay, now they're in recovery room.
Now they're waiting for a bed.
So you'll know where they're at, and then I will come out
and talk to your friends or family after surgery
to let you know how everything went
and it's usually about an hour after that
before you would wake up.
So from there in the morning,
you'll go back to a pre-op holding area.
So here we keep you busy.
You'll see your pre-op nurse.
She'll put you in one of our lovely hospital gowns,
check your vital signs, check your paperwork, do labs,
and then pre-op meds.
So this is a little cocktail.
This is a cocktail of a pain pill.
This is a cocktail of an anti-inflammatory.
It's a cocktail of Tylenol.
It's an anti-nausea pill.
I'm not a genius, I didn't come up with it.
Everyone in the world's using some form or fashion,
but what we know is that if you can treat pain
before it starts, and a lot of these medicines
take two or three hours to kick in,
you will have less pain afterwards.
So we really try to start the process early.
While you're also there you'll see me again,
you'll see my fellow,
you'll see the nurse that works with me
in the actual operating room
and then you'll also see the anesthesiologist.
So the anesthesiologist will go over your history,
they'll talk to you about the anesthesia
and they do a nerve block.
So the nerve block will control about 60, 70% of the pain
in your leg. That reduces the pain that you feel
during surgery so you don't have to go as deep
and it also gives you pain relief for about 24 hours
after surgery.
So again if we block the pain before it starts,
the pain never gets as bad and this is not a new thing.
I got involved with a lot of the pain stuff
about 10 years ago and if you look at the very bottom,
The Lancet's a very famous medical journal.
This was published in 1913, over 100 years ago.
So if you study history,
a lot of times you can learn things that we forgot about.
So we now know that the preemptive analgesia,
giving you medicine to prevent pain before it starts,
your pain never gets as bad afterwards,
as compared to the old days where you'd have surgery,
wake up in horrible pain
and they just pump you full of morphine 'til you'd throw up.
That's not good.
It doesn't help with recovery,
so we do this all before surgery.
But this is the important thing that I like people
to think about because I am very big into making sure
that people's pain is controlled
but that doesn't mean pumping you full of narcotics.
So the top, the central sensitization,
so that is giving a little bit of narcotic,
but blocking it with the numbing agents
both in the knee and the nerve block.
Inflammation is controlled by anti-inflammatories,
and then the tissue injury we control with other stuff,
managing the soft tissue well. And the other big thing
is anxiety, and that's where I really spend a lot of time
teaching all of this because if you know what to expect,
then you're less likely to be anxious. And it's interesting,
they did a study in one of the nursing journals
where they had two groups of patients
having knee replacement,
exact same thing, but one group had this formal process
like we're doing now,
the other group was told
you're gonna have a knee replacement. And the group
that had more information,
they all perceived that their recovery was easier,
that they had less pain,
that they had a quicker recovery and when they looked
at how much narcotic the groups used, it was the same.
So people can feel better just by getting the information.
When you come back to the operating room,
this is one of the rooms you'll see.
We have three rooms.
I have a great staff that works with me.
So you have the trays on the back, we have all the implants,
everything's made sterile.
We use the space suits.
People hear about the space suits.
Some of that is for our protection,
it's also to protect you.
We don't want to get our bacteria anywhere in the room
and we also have these special rooms.
That back wall that you see,
there's actually air that circulates faster
than any other operating room.
So these are super-clean rooms to lower the bacterial load
in the room which lowers our infection rate.
But a knee replacement,
hopefully everybody had a chance to see in the back,
I like to call them a resurfacing
because when you see the implants you get an idea,
now, I think a lot of people think we chop your knee in half
and we drop a hinge in there and we have that
for complex cases but what we do is just shave off
the end of the thigh bone, top of the shin bone,
and put the metal and plastic so you've resurfaced
the bad cartilage with metal and plastic.
You preserve your ligaments.
So this is the thigh bone part once we prepare the bone.
Normally takes off about eight,
nine, 10 millimeters of bone,
so a small amount and then it gets capped
with that piece of metal.
The shin bone gets planed flat,
about two or four millimeters of cartilage gets removed
and then the metal part with plastic goes inside there.
And then the last part is the kneecap.
So on the back half of the kneecap,
we shave that flat and put a plastic button
so when you bend and straighten your knee,
it's the plastic that rubs on the metal.
Now one of the things that I like to do afterwards is,
I take a picture.
So when you're all done and the dressings are on,
I bend your knee up and I take a picture
and I give that to you and I let you know
that even though it hurts,
that you're not breaking anything.
You're not damaging the implant and that little piece,
I think for a lot of patients,
let's them push through some pain
because they're confident to know
that they're not gonna hurt the thing that was just put in.
And that one little picture, when I started doing that,
it was amazing how much easier people got motion
without changing anything that I did
in the actual operation.
So it's just that peace of mind that you can do it.
So after surgery you go to recovery
and that's what you're gonna see.
You're gonna stare at the ceiling and come to
and the nurses are gonna be on top of you
checking your vital signs but this is where you'll be.
(audience laughs)
They're gonna make sure that you're comfortable.
They're gonna make sure that you can take ice chips.
They're gonna make sure that you can have some crackers,
and you'll be there for about an hour,
and then we'll get you upstairs.
So the day of surgery, you are getting up.
You're gonna do therapy
and a lot of people, they look at me and they say, "No,"
and I say yes, you're gonna get up.
So the quicker that you get moving,
the faster you recover.
So we do start with bed exercises the day of the operation,
stand and if you're comfortable you can walk.
We put you on a pain regimen so it's not that you just
don't get narcotics,
it's that we put you on Tylenol around the clock.
I put you on anti-inflammatories around the clock.
We put you on a nerve pill around the clock
before you ask for it because if we can beat the pain
before it gets there,
the pain never gets as bad, and by doing that,
people use a lot less narcotic.
Everybody tells me, now compared to five years ago,
if I've had patients that had a knee replacement
before we did this, they all said, I felt better,
I was less constipated, I was less nauseous,
I was less foggy, and I recovered better
and I only used like 10 or 20 of the narcotic
where years ago,
people would just pump themselves full of narcotic
and they would feel terrible for a month
so we try to get away from that.
The day after, so post-op day one, I see you in the morning,
we change your dressing, we do more therapy,
once in the morning, once in the afternoon,
and 90% of people if you're comfortable,
you can walk the hallway, walk up and down the stairs,
you get to go home, sleep in your own bed,
eat your own food.
You don't have someone knocking on your door
at two in the morning to check your blood pressure
'cause my blood pressure would be high
if someone woke me up at two in the morning, so go home.
The motion machine.
This is the other question I get asked all the time.
No, we don't use it.
Old stuff.
It was actually introduced down the road at Sharp Hospital,
Dr. Coutts, 1982.
So do you want anesthesia or a knee replacement
or anything from 1982 if you can have something
that's more 2017?
It's an old way of treating the knee because before that,
in the '70s, if you had a knee replacement,
you probably spent two or three weeks in the hospital
but you woke up in a cast,
you didn't bend your knee for two weeks,
and then after two weeks,
you went back to an operating room, they took the cast off,
they bent your knee, they did what's called a manipulation,
and then you started doing your therapy.
So it's sort of a no-brainer.
Cast versus motion machine.
Who has better motion?
No-brainer, but nowadays since we get you moving early,
you using your muscles will make your knee recover better
than laying in bed and being on a machine.
So we don't use those anymore.
Motion, this is the other question I get.
I get a lot of people tell me,
I can bend my knee back all the way.
Most of the implants on the market now,
they all will get more motion than you will ever get.
They can usually get about 140 to 150 degrees of bend.
Most people never get that.
So if you have a very stiff knee before surgery,
you're not gonna get 130 but if you have a lot of motion
and arthritis,
you have a better chance of getting that motion.
So how much motion you have going in
is a really good predictor of where you're gonna be.
An average knee replacement
when you look all over the world,
all different implant designs about 115 to 120.
The exercises like we talked about before are key,
but what you describe as stiffness and what we measure
as stiffness are two different things.
I have a lot of people that, after surgery,
have 10 degrees more motion when I met them,
but they will say, "My knee is stiff."
So a lot of times it may feel stiff
but it will still move more
and a lot of the stiffness early on is inflammation
and that goes away over a number of months.
Two weeks at home, you're doing therapy,
you're responsible for this.
We tell you therapy's really important
but I always have my patients stop and think about it.
Yes, therapy's important but don't go bonkers
because your knee does two things -
your knee straightens and your knee bends.
That's it.
So you don't really need a therapist to tell you
what to do with your knee.
You just have to straighten and bend it.
Your therapist and me,
we're there to help you
because sometimes one of those exercises is hard
so we might show you a variation
on how to do the straightening
or a variation on how to do the bending.
The Tylenol and Celebrex, you'll take at home,
or some anti-inflammatory,
those medicines are around the clock for two hours.
That really controls the pain well
and then we use the narcotic
just for breakthrough pain only.
That is the option of last resort because that has
all of the side effects.
Icing, elevation, as simple as they sound,
they work a lot. And really a healthy, high fiber diet
because anesthesia, pain medicine,
dehydration all lead to constipation and you need to heal.
You're gonna burn through so many calories healing
so eat and eat well.
You'll see my nurse back at two weeks.
We take out the staples, we check your motion.
You should have 100 degrees at that point.
If you don't, I'll call you out on it,
she'll call you out on it.
We want you to work harder because the more work you do
in the beginning,
the easier your recovery is.
The next two weeks at home, more therapy,
more and more therapy.
You'll go from home therapy, you'll feel good,
you'll start to go to outpatient therapy.
You'll go from the walker to the cane to nothing
and everybody's off the narcotics at that point.
Usually most people decide at that point the Tylenol
works better for me or the anti-inflammatories
work better for me so most people pick on or the other.
I'll see you back again in a month.
We check X-rays, we check your motion
and then almost everybody, everybody walks in with a cane.
Everybody that I see and I ask them are you using it,
and they said, "No, I thought I was going to get in trouble,
"so I brought it anyway."
(audience laughs)
But you don't need it at that point so when you're okay
going off of it,
you can get rid of it.
We'll go over some things that are common at one month
because you're better but you're not fully recovered.
Most people can drive four to six weeks
so if it's your right knee, four to six weeks.
If it's your left knee,
by four weeks most people are driving the car already.
One to three months is just more therapy.
You're getting back to your normal life.
You're walking, you're exercising,
you're doing outpatient therapy
and everything's getting better, day by day.
Your motion's getting better, the swelling's getting better.
You're sleeping better.
Patients that are still working, you're going back to work.
I'm sorry but you do have to go back to work
if you're still working.
But those people are starting to get back into living
their normal life.
I see you back again at four months.
We check more X-rays, check your alignment.
We talk about going back to the dentist
'cause I do recommend that you take antibiotics
before you go to the dentist for the rest of the life
just because it lowers the risk of mouth bacteria
getting to your knee replacement.
It's extremely rare, but it does happen.
So we do recommend it.
Now, all the scary things.
These are all bad.
Luckily, they're all rare. So infection,
the risk in the US is between one and 2%.
Here our risk is less than 1%.
You can have a wound healing complication
which is again why we look at making sure you're
as healthy as possible going in.
Blood clots are a concern so we do get you up and moving,
put you on squeezers, put you on blood thinners.
We typically use aspirin unless you have other risk factors.
We put you on stronger medicine.
Blood loss is very rare nowadays.
Luckily, the risk of needing a transfusion is less than 1%
so you do not have to donate blood ahead of time.
All the other things are really rare.
Fracturing, injuring ligaments, dislocating the knee,
they're all extremely rare, but if there's a problem,
it can be revised.
So the other pictures that you saw,
the difference that you notice here is that post
that goes up and down the leg.
So if the first knee replacement fails for any reason,
we can put another knee replacement in
but we have to add to it.
So if you had a cavity, that's just like a little shaving,
like an orthoscopy of your knee.
If you had a crown,
that's like a knee replacement where we actually
cap your tooth with something artificial
but if that crown fails and now you have an implant,
the doctor put a post into your jaw
and then put an artificial tooth on top of the post
and that's what a revision is like.
Normally after surgery everybody has some pain
and stiffness at night.
That's normal.
It's typical.
It's more because your knee's not moving
the first two or three weeks at home.
Once you get up and move it goes away.
The knee will feel warm for a couple weeks
and a couple months in some people.
That's normal.
The knee will click a lot more in the beginning
just because it's swollen
and when that metal touches the plastic,
you'll get the (clicking sound).
You'll hear it or you'll feel it more than you'll hear it,
but most people are aware and it goes away over time.
And anytime that we make an incision over the front
of the knee for a fracture or a ligament rupture,
a knee replacement, the little skin nerves on the outside,
they always get cut.
You can't see them, they're microscopic.
So you'll have a little patch of numbness
and it goes away over time.
I follow you forever.
So, well, as long as you're here and I'm here,
we're gonna see each other.
So every year, every five years,
every five years after that we keep an eye on it
because if there's a problem with the implant,
a lot of times we pick it up on X-ray
before you feel symptoms, but luckily most of these implants
we think should last 20 or 30 years in most individuals
but we do keep an eye on it
and I want you to get back to a healthy lifestyle.
I mean, that's the whole reason for doing all this.
We keep an eye on this.
So if someone says, "Well, how good is it?",
we know and luckily we know because of Dr. Colwell.
When he started here in 1978, he started,
he saw this coming from a mile away.
He started capturing data on every one
of his hip and knee replacements, and we've continued that.
So we actually have over 20,000 joints in our registry here.
So when someone says how did that knee work
or how did that hip work or how long does this last,
we know it 'cause we have it all in the database.
We have over 600 publications.
The new thing that you may see in the news occasionally
is there's an American joint registry
that only started a few years ago so there's
a million patients.
Sounds impressive except there's a million joints
done in the U.S. every year.
A lot of other countries,
they started these registries in the '70s and '80s
so we're a little bit behind the eight ball,
but we're catching up.
So now we're gonna have outcomes.
So if you are here and then move halfway across the country
and there's a problem with the implant,
we will know about it and that's the important part
of collecting all the data on the knee and hip replacement.
So that's everything in a nutshell.
You guys got everything that I possibly can tell
every one of my patients in the office all at one sitting.
So hopefully you kind of walk out of here
with two or three things and learned a little bit
about knee replacement, but I'm sure there's some questions
so I'm happy to stay.
If people are tired and wanna stand or people have to run,
run.
Thank you for coming.
(audience applause)
Thank you.
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