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Bill Klaproth (Host): Over time many of us experience knee or hip pain, but for some, knee and hip pain becomes so problematic that total knee or hip replacement offers the only chance for pain relief. Here to talk with us about understanding hip and knee replacements is Dr. Erik Schnaser and Dr. Ghassan Boghosian. Both are board-certified orthopedic surgeons with Eisenhower Health. Dr. Schnaser and Dr. Boghosian, thanks for your time. Let’s start with the knee Dr. Boghosian. So, no one relishes the idea of any surgery including knee replacement. Can you give us a quick overview of the non-surgical alternatives you suggest first and when do you generally know a person has reached the point when knee replacement is necessary?

Dr. Boghosian, DO (Guest): Yeah absolutely. First of all, Bill, thanks for having us on. A knee replacement surgery is always the last case resort. When we get patients in the office who have knee pain, we always try to attempt non-surgical management options first. And that can include a variety of treatment options. Things like activity modifications, weightloss if applicable, physical therapy, strengthening the muscles around the joint to help stabilize the knee better and then we can also try a variety of medications some of which can be very safe and some of which can have some side effects, so we use them sparingly and cautiously. There are some topical alternatives that we can use as well that maybe will be a little bit safer. And then there is also bracing. Sometimes if the disease is isolated to one side of the joint; you can try an unloader brace that unloads the area where the bone on bone is that therefore helps decrease the pain. And if finally, there is a series of a variety of injections. We can do things like cortisone injections that decrease the inflammation in the knee caused by the bone on bone disease. We can do things like Viscosupplementation which is a gel-like injection that can be injected into the knee and there is a variety of other options to discuss as well.

But when those all eventually fail or do not provide enough relief for the patient; then we can move on to surgical options. And the surgical options become either a partial knee replacements or total knee replacements depending on the location and the severity of the disease. And the decision to pick one over the other or the decision to operate on an individual is predominantly based on the level of pain and the decrease in activity level. What I mean by that is if someone comes in and says you know I have had to give up a certain number of activities, it could be anything from golf to simply playing with the grandkids and we start talking about being a little bit more aggressive to allow them a return to a better quality of life.

Host: Right and Dr. Schnaser let’s bring you in. The era of being in the hospital for a week after knee replacement is long past. Patients are up on their new knee the day of surgery and I understand that knee replacements can be done on an outpatient basis now that a patient could actually be out of the hospital in less than 24 hours. Explain what has happened in knee replacements to make this possible.

Erik Schnaser, MD (Guest): Well thank you for having us on today. Yeah absolutely. The technique of knee replacements, believe it or not really hasn’t changed a whole lot. They have gotten a little less invasive in how we do things. But what’s really happened and what’s really changed is how we look at people in terms of how they recover. Thirty, forty years ago, when people were getting knee replacements; they stayed in the hospital for a month, they were in a cast for two weeks. We now know that all those things can be really dangerous for patients. And they just prolong recovery.

What’s really happened is the faster people get moving, the faster they recover. So, we really work hard in getting people out of bed the same day, getting them up and at least standing if not walking. We have changed how we treat pain. I use a variety of blocks around the hip and knee, but specifically with the knee; doing things like not using a tourniquet at the time of surgery, that can also be very beneficial. You don’t have this soft tissue damage. But really, it’s mobility. Mobility and pain management. And pain management doesn’t necessarily mean narcotics. It means multi-modal pain management where we are using a variety of things to help treat patients’ pain and that’s really made a big difference. But really, the mobility and getting people up and moving as soon as they can get up and physically move after the knee replacement which is often within a few hours. I did two knee replacements yesterday and both were out of the hospital and on their way home within four hours. And they just have better pain control, they have the ability to control their pain. They are forced to be more mobile and as a result, they recover faster. So, it’s the knee replacement – there are some technical things in surgery that we do a little bit better. It’s really how things are done postoperatively and how fast we push them that has made a huge difference. And the studies have shown that patients are actually much happier going home the same day of surgery. We have done almost 30 cases at Eisenhower where people have gone home within 24 hours and we’ve had no readmissions and the satisfaction scores have really been very high. We’ve had nothing but positive feedback.

Host: That is amazing Dr. Schnaser and Dr. Boghosian does this mean patients then are no longer under general anesthesia during surgery?

Dr. Boghosian: Yeah great question. So, more often than not, we try to do a spinal anesthesia. And a spinal anesthesia means the patient is numbed from the waist down. They don’t feel anything during the operation. And the anesthesiologist will give them some happy juice if you will through their IV, some sedation that will help them stay asleep. But they are not under general anesthesia in the sense that there is no tube in their throat breathing for them. They are breathing on their own with some supplemental oxygen being given through a mask or a nasal cannula. So, there are several benefits to using a spinal anesthesia when we can get away with it. And those are number one: It decreases the blood pressure ever so slightly, therefore less bleeding during surgery. And it decreases the risk of blood clot believe it or not during the operation or post operatively. So, decreasing their risk of what we call DVT or PE pulmonary embolism and deep venous thrombosis.

So, this combined with the fact that the spinal anesthesia is longer lasting as opposed to a general anesthesia which is only effective as an anesthetic during its administration. Spinal anesthesia will last longer and will wear off much slower so, there is not an immediate trigger of return to pain. Of course, a general anesthesia is always the back up option to a patient whose spinal doesn’t work or maybe the anesthesiologist can’t get a spinal in because of previous back surgery and so on. But to answer your question, that is definitely the preferred method for most of our patients and that combined with the perioperative blocks that we do that Dr. Schnaser alluded to, given preoperatively or postoperatively has really decreased the level of pain and improved function and motion.

Host: And Dr. Schnaser, this is just amazing. So, in general then, after the person goes home, you said they do get to go home earlier. What does recovery from knee replacement look like? How long is a person in physical therapy and when are they generally moving around pretty freely or doing activities they couldn’t do before surgery?

Dr. Schnaser: Yeah, that’s a great question. It really depends on the patient. If someone comes in and they’ve been in a walker for months or years; this is someone obviously that’s going to have a different recovery pathway than someone that’s coming in that has severe knee or hip arthritis, but they are still very active. A lot of how people do after surgery really is dictated on how they are preoperatively. Physical therapy is very tailored to the patient. I will tell you that really the only big thing that I care about with physical therapy after the knee replacement is to make sure patients get their range of motion back. Outside of that, physical therapy can have its pros and its cons. Sometimes people can be pushed too hard in physical therapy where they actually have a little bit of a setback.

But usually, typically speaking, we do physical therapy for a couple of weeks and when a patient comes in to see me for their first postoperative visit; if their range of motion is great and their swelling is not too bad; I generally encourage them to stop doing that. I have patients going back and starting to play golf in three weeks after the knee replacement and they are not out playing 18 holes, but they are doing things like chipping and putting. Usually other more rigorous activities such as tennis or pickle ball, they are just not quite ready then but usually within three months, they are doing pretty much everything that they want to do. The only thing that people tend to suffer from for a while after knee replacement is typically night pain. They feel pretty good during the day and then the night pain sort of creeps up on them and that usually last for a couple of months. But most people are very, very happy that they’ve had it and it gives them the quality of life back so it’s a trade off when you ask the people that have had it and have gone through it. It’s definitely been worthwhile.

Host: And for those golfers Dr. Schnaser, do you guarantee that you are going to take strokes off their game too?

Dr. Schnaser: Well, so the data, when you look at all the studies, what happens is that people’s driving distance goes down a little bit. But their handicap also goes downs so, in general, a lot of times people are playing better golf because they are not in pain. It is pretty amazing. So, they may lose a couple of yards off their drive; but you drive for show and you putt for dough, right?

Host: I asked that question in jest and here you have a data backed answer. I love it. Dr. Boghosian, we know that some patients have both knees replaced at the same time. Is that rare and are there occasions when you feel having bilateral knee replacement is important for the patient?

Dr. Boghosian: It’s certainly less often of a procedure performed. You have to take several things into consideration when a patient questions the need for bilateral or both knees replaced at the same time. The first of which is is the disease in both knees severe enough? In other words, is one at 100% and the other one at 60% and in which case should you just do one or should you do both. The other consideration is the patient’s pain tolerance. If I have a patient who has a fairly well pain tolerance, then I would consider it. And the third is is the patient’s activity level and motivation such that they can handle both knees being done at the same time? There are several medical factors to take into consideration, i.e., is the patient healthy enough, are there multiple comorbidities, is the patient at risk for various diseases or say deep venous thromboses or heart attacks and so on because the medical risks associated with having both knees are certainly higher. There are some data suggesting that satisfaction scores after both knees replaced at the same time might be just slightly lower, although that’s conflicting data that we don’t have a clear answer on at this point. I think more research is to be done. And lastly, I tell my patients look if you meet the criteria for me to agree to do both knees; then you have to understand that during your recovery period, you have to try to give 100% attention to both knees and not 50% to each knee. Because if you do; then the lack of physical therapy and the lack of exercise to each of the knees will leave you with a lesser range of motion leaving you with possibly a slightly higher level of pain or slightly higher level of dysfunction and we don’t want that. So, although I’m not a huge proponent of bilateral knee replacement surgery, I do do it and I do it probably about a half dozen times a year. So, not very often. But it takes a particular patient, someone who is extremely motivated and has a fairly high pain tolerance.

Dr. Schnaser: Yeah, I agree with Dr. Boghosian wholeheartedly. This really comes down to patient motivation. But I will also say that there are a lot of people that I see who have severe arthritis in one knee and they sort of have mild arthritis in the other knee and you replace the one knee that’s really bad and the other knee starts to feel better because they are not limping around and putting the stress on it. So, a lot of times people often can go for years without having the other knee replaced and no matter what we do, the knee that we give you is never going to be as good as the knee you are born with. So, I do them too and it’s just one of those things that I actually try and discourage people from doing unless there is very specific circumstances and the patients are very motivated. Because the complications have definitely been shown to be higher with bilateral knee replacements, too.

Host: Well that’s very good to know. And if somebody really wants that, at least it’s worth having a discussion with your surgeon. So, thank you for that. So, let’s move on to hip replacement. Dr. Schnaser, is it more difficult to diagnose a hip that requires replacement?

Dr. Schnaser: Not necessarily. We usually – so whenever we see someone that needs a hip replacement; we always get x-rays. X-rays and clinical symptoms are really the hallmark of diagnosing whether or not someone will require a hip replacement. If someone has severe arthritis in their hip and they have pain in a very vague location around the hip, that can be a little bit more challenging, but it’s almost always related to the hip replacement. When you have a bad hip, it can cause back issues and those back issues can in turn cause pain that radiates down the leg. The hip is more complicated, but there are very classic symptoms that people with hip arthritis have.

When we start with nonsurgical options for hip replacements; we always try and get people on anti-inflammatory medication. If the hip pain is very vague and it’s really hard to pin down where things are, often we will use injections into the hip joint. A lot of times, it’s not even the hip joint that’s bothering them, it’s bursitis. So, it really depends on the patient’s clinical symptoms that we do. But in general, the treatment for hip arthritis and knee arthritis, it’s very algorithmic. Anti-inflammatory medications, physical therapy and injections. And when those things don’t work; that’s when we start to talk about hip replacement.

Host: Got you. So, the nonsurgical alternatives for the knee and the hip are similar? Is that correct Dr. Schnaser?

Dr. Schnaser: You are exactly right. It’s basically a treatment of arthritis. There can be a couple of different types of arthritis. There’s inflammatory arthritis such as rheumatoid arthritis, but generally speaking, what we see is osteoarthritis which is when things wear down naturally or as a result of some injury that the patient had. But the treatment of arthritis is very similar regardless of the joint that you are looking at.

Host: Okay. Got you. And Dr. Boghosian, there has been a lot of talk over the last several years about having an anterior hip replacement. What is the anterior approach and why has it become a preferred approach to hip surgery?

Dr. Boghosian: That’s a great question. This is certainly a hot topic in orthopedics and especially in hip replacement surgery. The anterior hip replacement has – is actually an approach to doing a hip replacement which has been around for many, many, many years and has certainly become more popular in the last decade or so. And one of the main reasons is because it is a muscle sparing approach. Muscle sparing in the sense that you are not damaging muscle on the way in and therefore in not doing so, the recovery tends to be a bit quicker. There are four/five ways to really do a hip replacement. There is the anterior, the anterolateral, the lateral, the posterior and then also the mini-posterior. When you compare the variety of approaches to the hip, the anterior and the mini-posterior tend to be fairly similar with regards to recovery.

And I think the important point for patients to take home here is that don’t pick the approach, pick the surgeon. And if you pick a surgeon who has a good reputation and knows what they are doing; then you are going to pick a surgeon who is reliable and able to reproduce a good outcome with that particular surgery. What I encourage patients not to do is try to change a surgeon’s approach by seeing them and asking them to do something that they don’t believe is necessarily the best for the patient. I could tell you that Dr. Schnaser is an excellent anterior approach surgeon; that’s his preferred method. He does that regularly and his patients do really, really well. In my hands; I’m a mini-posterior surgeon. So, the mini-posterior approach, not the general old-fashioned posterior approach and my patients do equally as well. And sometimes patients come in and request a particular approach and I tell them look, if you were my father and I was operating on you tomorrow, this is how I do it and I could tell you that you’ll recover just as quick as an anterior patient and maybe Dr. Schnaser might have the same conversation with his patients regarding an anterior approach. We do what we are good at and that’s what we want to do for our patients.

Host: Yeah, that’s good advice. Pick the surgeon, not the procedure. And Dr. Schnaser, then question for you. Is it true that hip replacement surgery is easier to recover from than knee replacements and why is that?

Dr. Schnaser: That is true. Knee replacements are a lot – the knee is a much more superficial joint and believe it or not, the knee actually gets a lot more range of motion than the hip. The hip range of motion is not really much more than about 60 degrees before the pelvis starts kicking in and aiding in hip motion. Knees, they can get up to 145 degrees of an arch of motion. So, there’s a lot more stress that comes across the knees. Also, there’s a lot of nerves that are very superficial around the knee joint and people tend to feel things. The hip is a deep joint. It’s covered by a lot of muscles and it’s a very – it’s the type of joint – it’s a ball and socket joint so the movement on the hip is actually pretty simple. The knee is a completely different animal. The knee has got a screw hole mechanism. It just doesn’t flex and extend. It’s got multiple axis’s of motion throughout the range of motion. And traditionally, knee replacements have been kind of slow to recreate that. Ghassan and I, Dr. Boghosian and I both use knees that do a better job of recreating that normal motion and I do think it does help with recovery. But knees, you are almost having to teach them how to move again because they – when you have your knee replaced, it loses all the natural biomechanical motion that they have. So, they do take a little bit longer because the stresses across the knee and the range of motion that is expected out of the knee is just much greater.

Host: And Dr. Boghosian, let’s talk about medications. There’s a lot of discussion about pain medications after joint replacement surgeries. But I think many people don’t understand what happens during surgery. Most people say the first 24 hours are a breeze because of the pain medications that are used during the surgery which was mentioned earlier. Are nerve blocks then still commonly used?

Dr. Boghosian: Yeah, absolutely. So, we have a common tendency to use nerve blocks around the time of surgery and these have a big benefit in that they reduce the need for narcotic medications after surgery. You have to understand that the hardest time after knee replacement surgery is the first two weeks and after the first two weeks, pain substantially decreases and patients most of the time will cease the need for narcotic medications. So, our goal is to try to make the first two weeks as easy as possible. And one of the ways in which we do that is by administering a nerve block and that nerve block is essentially a pain pump that can be administered around the time of surgery which can help administer medications like ropivacaine which is kind of like lidocaine, around the nerve that goes to the knee, thereby minimizing pain from the knee. And although that only works for three to four days after surgery, that’s a bigger part of the hump. And so, for the remaining ten days of that two-week period; patients do need some narcotic medications and we try to discourage heavy use narcotics and rather use low dose narcotics combined with a variety of other medications. We call this a multi-modal approach. And that multi-modal approach is instead of using a lot of one drug; we use very little doses of multiple drugs, thereby affecting multiple receptors and decreasing pain across the board of various receptors. Blocking pain at the knee, blocking pain at the nerve that transmits that pain to the brain, blocking pain at the spinal cord, blocking pain at the level of the brain, so, by doing that, the multi-modal approach allows us to use a variety of medications, again, used in very small doses, thereby not allowing any of the side effects to present and allowing that patient to get through that first two-week period very comfortably.

Host: Well, that makes sense. The multi-modal approach and Dr. Schnaser, any additional thoughts about appropriately medicating for pain after surgery?

Dr. Schnaser: So, I generally believe that narcotics are our enemy and it’s not just the provider’s enemy, it’s the patient’s enemy. The hardest patients to control pain on after a hip or knee replacement are patients who are on narcotics before surgery. Because they are sensitized to the narcotic already. And they generally require higher doses of narcotic after surgery. What’s been amazing with everything going on in Washington and whatnot is there has been a lot of pressure on providers to just reduce the number of narcotic prescriptions that we provide people. And we have been forced to really change how we prescribe patients narcotics after surgery and all the publicity that it’s gotten. And believe it or not, what I am seeing as the fallout of this is that I feel the patients just don’t need the narcotics that they have traditionally used. The pharmacies and the California Board of Pharmacies really regulated how much we can give the patient and patients are just getting off things sooner. And they get off of these narcotics sooner, they feel better. In general, they get their energy back faster, their pain goes away faster. Now I think an important component which I use all the time in lieu of narcotics and this has been shown scientifically to work; when you take Tylenol in combination with a good anti-inflammatory, it is as effective as one tab of Oxycodone or Percocet for treating pain. So, like I said, one of the big benefits that we are seeing as a result of everything that is sort of the mandate on us as providers is people are just feeling better faster. And that’s actually been a really positive thing. We are not writing nearly the number of narcotic prescriptions after surgery that we were writing before and patients are feeling very good. I feel the patients are recovering faster.

Host: Yeah, that’s really an interesting thought on a topic like you said, is heavily debated right now, certainly the opioid discussion that we are having but I’m glad to hear you say that you are writing less narcotic prescriptions and people are feeling better faster. So, really good news there. Dr. Boghosian, let me ask you, are there any new emerging technologies when it comes to knee and hip replacement?

Dr. Boghosian: Absolutely. I think that the last decade has been – there has been a lot of emerging technologies which has helped us to become more accurate during the placement of these components which in turns allows these components to last a longer amount of time. Better placement of the hip and knee replacement will allow these components to have a longer lifespan so that revisions may become less often. One most important is that of robotic surgery. Obviously, another hot topic in orthopedics. We at Eisenhower have a MAKO robot. MAKO is a robot that allows us to use robotic assistance in placement of these components which helps us to place them more accurately, safely and allowing better recovery and longer longevity of the implant. Along with that, there’s other technologies like custom-made implants, custom-made jigs, navigation systems that Dr. Schnaser and I both use that allow for again, improved placement of these components which will allow longevity.

Host: Wow, that’s really good news. So, as we roll on into the future, good to know that these technologies will make knee and hip replacement surgeries even better for the patient with less recovery time. So, that’s really good news as well. And Dr. Schnaser, you get the final word. If you could wrap it up for us, the surgical program at Eisenhower Health really walks patients through the process with presurgical education. Why is that important for patients and is there anything else you want potential patients to know?

Dr. Schnaser: Well, at Eisenhower, we have a very good program. We are one of the busiest joint replacement programs in California. And all of our patients are tracked through the American Joint Replacement Registry so, we know how our outcomes are and we know how we compare to other institutions around the country and especially in California. We do very, very well in terms of compl – we have very low complication rates, very low infection rates. And a lot of that has to do with the program that we instill. It’s really no secret in the joint replacement world that preop education helps patients. The program that they go to before surgery, it really helps educate the patient. And what I tell patients is the what to expect when expecting for a joint replacement. They understand a little bit about the process. There’s a lot of anxiety about surgery and a lot of anxiety about hip or knee replacement surgery and a lot of what goes to helping calm that anxiety down is understanding what they are going to go through. And it really helps manage expectations. It lets them know that this is normal, this is not normal. It helps people stay out of the emergency department if they have a concern or they feel that they have nothing to do. The whole point is to educate them on how these things are supposed to go. So, they know what normal and what is not normal. And that’s been a very powerful thing. The joint replacement program, the class is taught by our nurse practitioners and we are soon going to roll out an online version of that within the next couple of weeks. Ans the classes have been shown to just increase patient satisfaction and reduce complications as well.

The biggest goal that Dr. Boghosian and I have after the joint replacement, after hip or knee replacement is the patients have a good experience. And when you end up going back to the emergency department for something that’s actually pretty normal or whatnot; patients are not very happy with that. And they may get admitted because of X, Y, Z concerns and a lot of these things can be dealt with over the phone or coming into office and these are the important things with the joint replacement program that we really emphasize. And then when patients do get admitted; again, we are doing a lot of these as an outpatient, but when patients do get admitted, the same nurse practitioners that – when they get admitted to the hospital, the same nurse practitioners that teach the class, they are there to walk them through. So, there’s a sense of familiarity. They know who they’re working with. And I do think that that just helps put everyone’s mind at ease. And that can be a very, very powerful thing. Stress can have a negative outcome on people. When people are stressed out about X, Y and Z; and surgery can be a big stressor; it can really have a negative impact. And I think these types of educational programs really help reduce the amount of stress that people have.

Host: I love that, so, the less stress you have, it sounds like better the outcome. Well this has been a great discussion and a lot of wonderful information today Dr. Schnaser and Dr. Boghosian. Thank you so much for your time. For more information about Eisenhower Desert Orthopedic Center and to watch short videos from Dr. Schnaser, Dr. Boghosian and other doctors in their medical group; please visit www.eisenhowerhealth.org/edoc, that’s www.eisenhowerhealth.org/edoc, or call 760-773-4545 to make an appointment. This is Living Well with Eisenhower Health. I’m Bill Klaproth. Thanks for listening.