Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-magine and better understand an extraordinary health and care experience.

Joey Wahler (Host): It's a procedure that can help restore a patient's previous quality of life. So we're discussing knee replacement. Our guest, Dr. David Alfieri. He's an Orthopedic Surgeon with Duly Health and Care. This is Duly Noted, a health and care podcast. Thanks for listening. I'm Joey Wahler. Hi, Dr. Alfieri. Thanks for joining us.

David Alfieri, MD: Hi there. Thank you so much for having me.

Host: Great to have you aboard. So first, what are the most common reasons that people consider knee replacement and when is it recommended by you and yours?

David Alfieri, MD: That's a great question. And as you mentioned in the intro, this is a very common concern for people or problems they have and a common solution for them. The first part I think people need to realize is what diagnosis or problem do they present with to help them that a knee replacement would help them with?

And kind of the short answer is arthritis. But there are several different reasons for that arthritis, you know, whether that is wear and tear, inflammatory conditions like rheumatoid arthritis, previous trauma, or the most common reason, the one that I say is just having a few extra birthdays.

The most important thing to realize is that knee replacement surgery, it's, it's an elective surgery. It's not like heart surgery where we have to rush them off. So coming into an orthopedic surgeon like myself, it often involves discussing other options than just surgery alone, whether that's activity modification, anti inflammatories, injections, physical therapy or bracing. We're there to help you through the whole process, but once those are no longer working, it can be still difficult to know when that right time is to say, hey, I think I'm ready for this surgery. So, a couple of things I use to help guide my patients are to kind of go through the following list and see what applies.

One, do you have more bad days than good days? Two, is it affecting your quality of life, limiting you from doing what you want to do? Three, is it affecting your sleep? And if, you're checking any of those boxes and you've tried some of those previous methods that we discussed, then it might be time to, to talk about the next option, like knee surgery.

Host: Gotcha. Well, you alluded a moment ago to alternative treatments before or instead of surgery. So maybe touch just a little bit more, please, on those. And from your experience, what would you say is the percentage of time that someone can go with one of those as opposed to having to go through with surgery.

David Alfieri, MD: Of course, and it, it can be very dependent on the patient and how their particular arthritis or problem is affecting their life. However, there, there are many different, options other than knee replacement to touch on first or to try first. Some of those are just simple activity modifications, meaning less impact activities, trying to lose weight, even potentially using a cane or assistive device, injections, kind of like steroid injections can be very helpful and can help people for quite some time while they're trying to delay or put off surgery. Anti inflammatories or non steroidal anti inflammatories, things like ibuprofen and Aleve, physical therapy is great. They're a great resource for us and a huge part of the healthcare team, and that can, to some people's surprise, help a lot before surgery, in addition to being vital after surgery. And then bracing. And all of them have their own unique purposes and benefits and some help others more or less than their counterparts. But, there are definitely options out there that are worth trying and worth attempting. And that is something that can be discussed with your surgeon and on a case by case basis.

Host: Okay. So if surgery is recommended, is there anyone that's not a candidate? Any age restrictions or is pretty much almost anyone, if not anyone eligible, if you will.

David Alfieri, MD: I mean, there's no hard and fast restriction on age per se if we're looking at that as a specific variable. The majority of these surgeries are certainly done between the ages of probably 50 to 80. But there are certainly instances where it is a viable solution outside those age ranges.

It would obviously, again, be dependent on the individual and discussed with the surgeon, but age alone should not prohibit someone from at least seeking the guidance of an orthopedic surgeon for what they have going on in their life and whether this would be a viable solution.

Host: Great. For the procedure Doctor, in a nutshell, what's the procedure? What's the hospital stay like for people? And then once recovery begins, what can they expect there?

David Alfieri, MD: Sure. So, the process of surgery, and not to belabor the point, but it is dependent on the patient themselves, because some people can be home the same day after surgery. The surgery hour, two hours, somewhere around there. You're up walking right away. You're doing stairs right away. Usually you use a walker for at least the first couple days and couple weeks as you build your stability. But then once you build that strength, you can, you can get around without any assistive device. I usually explain that the first six weeks are kind of the most intensive timeframe.

That's when you really have to push hard with those physical therapy counterparts that we touched on to get your range of motion and make sure you're as strong and stable as can be long term. And then the majority of people by, you know, around three months are doing well. But like any major surgery, it can take a full year to fully, fully recover from this.

 And the biggest way to help along that process is to kind of listen to your healthcare team and work with your physician, the nurses, the physical therapy to keep going along and keep improving.

Host: So, to optimize recovery, you're saying partaking in physical therapy and giving your all there and making that your chief focus, I suppose, at the time is really one of the main objectives here on the patient's part, right?

David Alfieri, MD: Yeah, the whole reason we do this surgery, or one of the main reasons, is to help with their mobility. They've been, most have been suffering with arthritis for quite some time and we're doing this to get them up and moving. And that's what, that's what we want them to do is get up and walking right away.

Gone are the days of sitting in the hospital for a week and then going to a rehab facility. We want to get you, get you home, get you moving and PT is vital to the success of that and of the knee replacement as a whole, that they you know, like I said, they're a great part of our healthcare team and working with them is the best way to ensure proper success after the surgery as well.

Host: Got it. What are the potential risks or complications associated with knee replacement and how do you and your colleagues manage those with a patient?

David Alfieri, MD: Sure. I mean, like anything in life, there's risks and that's certainly true with surgery as well. Some of the key risks that we focus in on and discuss with our patients are there's a risk of infection. It's typically, you know, around 1 to 2%, but there is a risk.

 We kind of modify that by 1, giving antibiotics around the time of surgery and 2, just optimizing the patient prior to the procedure. Meaning working with your primary care physician to make sure that you are as healthy as can be leading up to surgery, whether that is other medical conditions that need to be optimized, whether that is getting your weight to an appropriate level, whether that is holding off on smoking, things that can affect your outcome will then decrease the risk of infection. And those are all modifiable risk factors. Stiffness is another one we talk about. The theme is getting moving and working with physical therapy and working with physical therapy to prevent long-term stiffness is vital to the success. But in doing that, you need to help control your pain.

And, and we do that with ice, elevation and a multitude of medications that affect pain differently to better control your pain. And probably the, the other one that we talk about frequently is blood clots. After this surgery, you'll certainly be on some type of blood thinner.

Whether it be aspirin or something, something, stronger. But the best way to prevent blood clots is to get up and move. So walking is the best way to prevent those blood clots from occurring.

Host: I would imagine one big consideration by patients when deciding whether to have knee replacement is how long does one typically last and how often might they need to be redone?

David Alfieri, MD: That is definitely true, and it is, some people, you know, may have the misconception that it's one and done, and that is not necessarily true, that there is the possibility for a redo surgery or a revision surgery in the future, if it is needed. However, we used to say that 90 percent of these last 15 years, however, with the advancements in the, the newer plastic or polyethylene that is utilized within the knee, that number has kind of expanded, and it's probably closer to 20 to 30 years of expectancy. That may mean for many that, that that is the lifetime that they need that thing to be working.

But for some, if revision surgery is needed, that may be an option, but it's something that could be monitored throughout that timeframe to make sure everything's still going well.

Host: Well, you mentioned the difference in what the materials are made of and improvement there and improving as a result, how long these last. Other than that, doc, any particular technology or surgical technique advancement that you would say in recent years has really impacted knee replacement for the better?

David Alfieri, MD: Yeah, absolutely. I mean, like anything in medicine, things are constantly evolving to optimize the outcomes and to improve everything. And there have been advancements over the years in technique and technology, both, that have helped with that process along. Some of those things would include even just periarticular or injections given at the time of surgery, around the knee joint itself that helps with pain and so helps get people moving faster. Um, a medication used during surgery called transexemic acid or TXA that helps limit blood loss and so therefore limiting the need for transfusion. There is just the fact that, like I said, we don't keep people in the hospital for weeks and we don't send them to a rehab facility for the most part, because we've learned that getting them moving, getting them home and recovering there optimizes their outcomes.

 And then we touched on the, the improved implants that can help with the longevity of the knee replacement and stability at times of the knee replacement. And even some newer technology like robotics that may be, may give the surgeon additional tools to use so that they can optimize their craft for your benefit.

Host: Indeed, robotics seems to be touching just about every corner of the medical world, right? Let me ask you just a couple of other things. One being, what would you say is the biggest misconception or fear even that patients come to you with about having knee replacement? Maybe you can ease their mind.

David Alfieri, MD: So, this is great because like anything now with the internet, there's lots of information available for patients, which is great. There's good resources where patients can talk to other patients, but there's also a lot of conflicting evidence as well and conflicting info.

And patients can get confused, and I think it's important to reiterate that discussing with your surgeon is the best way, really, to clarify these questions and tailor it to your specific case. But some of the misconceptions that I see most commonly are one, thinking that they're going to need to spend, you know, months on bed rest or going to a rehab facility and we've kind of gone over that in detail, like getting up and moving is key, and although patient dependent, you might even be able to go home the same day from surgery, and start recovery even faster.

 Some people are worried or concerned that they should wait as long as possible and that surgery should only be for, you know, senior citizens or something to that effect. But surgeons evaluate each patient, and it's understandable that no one wants surgery, per se. But if your pain is such that it's limiting you and your mobility is decreasing and affecting your everyday life, then it may not be appropriate to delay the surgery, and delaying can even result in sometimes a more complicated surgery.

Host: And in summary, finally, we touched on this at the top, restoring your previous quality of life. What are the expected benefits and outcomes of knee replacement surgery? And what would you say are the realistic expectations one should have?

David Alfieri, MD: So, expectations. Everyone comes into surgery having different expectations for themselves, because everyone is trying to get back to whatever their lifestyle used to be. However, the realistic baseline expectation should be to be able to do everyday activities, to get around and do the simple things in life, which to some people becomes a miracle for them that they can just go and do their grocery shopping or walk and see their grandkids or whatever it may be to do and doing that without the pain that they were having before.

However, many studies have also looked in returning to sport and whether that is a possibility and certainly there's a general consensus that returning to low impact activities is certainly reasonable. Things like golf, cycling, swimming. Moderate impact activities are also sometimes an option, but that's a little bit more of a case by case.

But those things would be things like skiing or maybe doubles tennis. Higher impact activities are typically discouraged. I wouldn't recommend you become a marathon runner because as you can imagine, these are parts, these are pieces, and almost like adding a new set of tires to your car, the more use you do, the more, the more load and impact it goes, the more you increase the risk that could wear down in time.

Host: So no marathon running. It seems like a, a relatively small price to pay for a new knee.

David Alfieri, MD: Yes, I mean, that's, that is the outlook that vast majority of people take as well, because they are typically struggling through this condition for quite some time before they make the decision to change that and then don't have to look back on that with any kind of regret.

Host: I'm sure. Well folks, we trust you're now more familiar with knee replacement. Dr. David Alfieri, thanks so much again.

David Alfieri, MD: No, thank you, and thank you for helping me spread this information to our patients and others.

Host: Absolutely. And for more information, please do visit dulyhealthandcare. com. Again, that's dulyhealthandcare.com. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for listening to Duly Noted, a health and care podcast.