Michael R. Anderson, MD: Hello, everyone, and welcome to this episode of The FortCast, the official podcast of Fort Healthcare. I'm your host, Dr. Michael Anderson, President and CEO of Fort Healthcare. And I'm very excited today because I have a very special guest with us today. We have Dr. Paul Schuppner, and we are going to be discussing total joint surgery, in particular for the knee. So Dr. Schuppner, thank you very much for being on this episode of the FortCast.

Paul Schuppner, DO (Guest): Well, thank you, Dr. Anderson. I'm glad to be here.

Host: So I've been with Fort HealthCare now for a little over 20 years. It's hard for me to say that because it feels like yesterday, but how long have you been with Fort HealthCare now?

Paul Schuppner, DO (Guest): I started practice 10 years ago, so I'm just now in my 10th year.

Host: Boy, it's amazing how fast time goes and, and I remember when you visited us for the first time and, and here we are 10 years later doing a podcast together on total knee joint surgery. That's just, I can't thank you enough for your great, great care to our patients and our community. Thank you.

Paul Schuppner, DO (Guest): Well, I appreciate the kind words. Fort's a great place to work and I'm glad to be a part of the team.

Host: All right. So Dr. Schuppner, we had a wonderful podcast earlier with Jonathan Beck in regards to pain management with total knee joint surgery. And what I'd like to discuss with you today is the actual surgery itself. But before we get into that, if you could just let our listeners know, what are the main reasons and what are the main symptoms that go along with a patient on their journey to potentially getting total knee joint surgery.

Paul Schuppner, DO (Guest): Sure. So, you know, I guess the question is why would someone need a total knee replacement? You know, the simple answer is osteoarthritis. From a medical standpoint, that is by far the most common diagnosis that will be associated with knee pain. There are other diagnoses, but not to bore the audience.

 Rheumatoid arthritis would be one or post traumatic arthritis, but by and large, for most patients that present to the office with knee pain, osteoarthritis is what we talk about, usually in quite some detail. In layman's terms, it's a degenerative process and we just call it kind of a wear and tear type process or a wear and tear type pain.

You asked about symptoms for the patient. In general with knee pain, most patients are going to come to the office and report pain in or around the joint. They'll describe stiffness of the knee and a lot of times, swelling can be an important factor that goes along.

Host: So, Dr. Schuppner, is there a typical age demographic that it affects it being more of a, a wear and tear type situation? I know certain humans are harder on their joints than others, but is there a typical age group where you see this most commonly?

Paul Schuppner, DO (Guest): Typically it's in the older population, anywhere between 50 to 80 years old is, if you were to read about this in textbooks, would be the age bracket, but you mentioned, I've been here for a decade now, which is, uh, kind of funny to think about, but as time goes on, younger and younger patients are coming to the office with complaints of knee pain.

So it doesn't mean just because you're 38 years old or 45 years old that you couldn't also have early onset arthritis causing you pain and dysfunction. But typically it is the older population.

Host: I see. So, when you're suspicious that somebody may be going down this route, how do you diagnose it? Do you do x-rays, or can you take us a little bit through that process?

Paul Schuppner, DO (Guest): Yeah. For knee osteoarthritis, there's two ways that we diagnose this. One is with a physical exam, which we do typically when you're at your first office visit. And the second would be with diagnostic imaging, and that's just a fancy term for x-ray. For a physical exam, it's really pretty straightforward and simple.

You know, a lot of times we'll assess your knee joint for swelling. We'll look for signs of redness or warmth. Those are kind of indicators of knee arthritis. You know, a lot of times we'll palpate, which means we touch around the knee to see where it's tender and where it hurts. You know, most patients have a spot where they point to, so it's a pretty easy way to figure that out.

We always assess for range of motion, both active and passively. So active motion means we ask you to move your knee and see how it moves. Passive range of motion means that you're relaxed as the patient and your surgeon or your doctor does the moving for you, just to get a, an assessment of how your knee moves.

You know, other things that we look at, we look at stability of the knee joint to make sure that the ligaments and the tendons are working appropriately. Crepitus term that we use in the office. Crepitus relates to grinding. So if you've ever felt some creaks or grinding in your knee, you know, when you get up from your seat at the office, a lot of times that is your kneecap, which is real commonly affected, so we'll assess for crepitus or grinding. You know, sometimes we'll have patients get up and walk down the hallway so we can just see how their gait or how their ambulation is. You know, that's our orthopedic physical exam of the knee.

I tell people all the time that a picture is worth a thousand words and for what I do for work that really is the rule and holds true. You know, a set of simple knee x-rays gives me as your surgeon a wealth of information about what most likely you're going to describe to me as your pain or your problem.

You know, we go over these x-rays in the office with the patient. You can see it because seeing is believing, as I like to tell people. And, you know, radiographs, we look at, and that's a way for us to assess the severity or the degree of arthritis, because, there's not just one picture that shows arthritis.

You know, you can have early onset arthritis or mild arthritic change, all the way down the spectrum to severe knee arthritis, you know, which a lot of friends and family will refer to as, you know, Doc says I've got bone on bone arthritis. And that's just kind of a descriptive term that describes severe knee arthritis.

 Based upon what we see on the x-ray and what we talk about in the clinic and what your exam shows, that just kind of sets us up for a discussion as to, hey Doc, what are my options here? Because it really is a discussion with the patient. There's never a one size fits all solution you know, ultimately the patient decides and, tells me what they prefer in terms of how we move forward.

Host: I would love to touch base on that, because I imagine having the x-rays in hand and reviewing that with your patients has got to be very powerful. It allows the patient insight into the arthritic process. So when it comes down to options, what do you typically discuss with them?

Paul Schuppner, DO (Guest): So my options for knee pain, you know, there are several. A lot of times we'll look at the radiograph or the x-ray together. And let's say, for example, it's an older patient and clearly they have severe knee arthritis. You know, I like to just to explain things in a clear and concise way, because as you mentioned, you know, patient insight, you know, being prepared and understanding what your physician is talking about, I think is key.

 For that example that I referenced, severe knee arthritis, oftentimes the definitive management, that's just the term that I use to describe how do we typically fix this problem. You know, definitive management oftentimes can be a total knee replacement. You know, when I meet a person for the first time, the last thing I want them to do is to think that, wow, this surgeon is, is pushing surgery.

This is my only option. I, I knew this when my family doc said, Hey, go see the orthopedic surgeon. But I think being on, on the same page is important. So, you know, a knee replacement oftentimes is the best option, but is it your only option? No, of course not. It isn't. In other situations, if the patient is not ready for surgery, because they're perhaps not medically safe for a surgical procedure, you know, we talk about benign neglect and that's just fancy speak for, you know, I know what my problem is and this is arthritis that I'm dealing with.

This isn't. cancer per se, I don't have to treat it. At least now I know and I can modify my lifestyle and I can live with it as is. And that's a choice that we can make together too. And that's just fine. And then I'll always describe kind of the in between steps. So the treatment options between benign neglect, which is kind of living with it as is and having a major surgical procedure and knee replacement.

And those in between options, there are several, you know, they include a different medication therapy. They include injection therapy, which is shots. They include physical therapy or forms of different therapy. And a lot of times they can also include, knee bracing. You know, there's different specialized types of knee braces that we can utilize, to help, you know, different varieties or forms of arthritis.

 And oftentimes we'll incorporate several of those non surgical options. You know, we'll offer a cortisone injection and we perform that, we initiate physical therapy, we can order that custom knee brace and we see how the next 6 to 12 weeks play out for you and if your pain goes away or if it's improved, it's just fine to live with knee arthritis. It doesn't always have to be treated surgically.

Host: Well, I think that's a very valuable thing for people to remember and take away that there are multiple options of treatment, it's not just a surgery, but Dr. Schuppner, let's say that patient fails those more conservative measures and they don't want to live with it and now they start to ask about surgical options and total knee joint replacement.

So when you get to that point with a patient, how do you approach them with the joint replacement surgery? What is their process?

Paul Schuppner, DO (Guest): When I speak to a patient about total knee replacement, and it's not just me; this is a conversation in the United States that's had by many orthopedic surgeons every single day of the week. Over the last few years, there's roughly 800,000 total knee replacements that are performed annually.

That number is expected to triple by the year 2030. So just over the next five to six years, the number of joint replacements specifically for knees are expected to triple, which is really astounding when you think about it. You know, the first thing that I'll discuss with patients is being prepared.

The more prepared you are, the more you know about your knee replacement procedure that's upcoming, the better off you're going to do. And without question, I feel strongly about that. There are patients that frankly probably shouldn't have a knee replacement if they're not prepared, and by being prepared, you know, there's different aspects of that.

 You know, of course, a physical aspect is part of it, but there's also a psychological aspect and a social aspect. So when we discuss a total knee replacement in the office, it can be a lengthy conversation. You know, we talk about optimizing yourself for surgery. That's kind of a catchphrase that many different physicians throw around or discuss with patients.

But you want to be optimized for your surgery and for knee replacement surgery, part of that is, a strong, healthy leg or as best as you can accomplish. Sometimes we'll incorporate physical therapy leading up to a procedure to help increase your strength and mobility.

 Part of our conversation is just about the fact that, you know, psychologically a knee replacement is a major procedure. The first two or three weeks after a knee replacement, they can be challenging. You know, your knee is going to be sore. It's going to be swollen.

Some days, frankly, it's just going to hurt. And you're not going to want to necessarily do the exercises that we all want you to do. And so there's a team approach, to kind of progressing you as the patient those first few weeks after therapy, or excuse me, after your surgery. And, therapy and your physical therapist is a key component of that.

We also discuss, prior to your surgery, kind of the social aspects. So we talk about your life, where do you live? Who lives at home with you? Who is your loved one that's going to be around? Or who is your good friend or family member? Or at least, you know, living in this area, people have great neighbors in Fort Atkinson and the surrounding communities.

So who's your neighbor that's going to help out? You know, let's say we're going to replace your right knee, well, that's your driving knee. So that means that for a period of time, you're not going to be safe, nor are you going to want to drive a vehicle. So for, you know, a month or sometimes longer, you need to be thinking about who is my loved one that can take me to my checkups, who can take me to physical therapy.

So these are the things that we incorporate with that preoperative discussion to get you thinking so that you're prepared. And being prepared is just a key to success. Just to answer your question in a little more detail, you know, we talk about length of stay after your knee replacement.

You know, not too long ago, patients would spend a night or several nights in the hospital. But, you know, over the last few years, for different reasons and factors, total knee replacement has become primarily an outpatient procedure, and that means that many patients have surgery early in the morning, and go home at the end of the day.

You know, we talk about your anesthesia, you know, what type of anesthesia and how is that going to impact you? We always talk about the recovery length. We talk about postoperative pain control. So it is kind of a lengthy discussion to get you prepared for surgery. I don't think I specifically answered your question about describe the knee replacement.

So, if I may, I'll try to do that here briefly. A knee replacement, the surgery, we always get asked from patients, Hey, doc, how long will this take?

In general, the answer is typically between one to two hours. From a surgeon's standpoint, you know, there's four basic steps to performing a knee replacement. Step number one is that we, we prepare the bone. So, you know, what does that mean? You know, in essence, we use carpenter jigs, by using these carpenter jigs, we can take and make a series of geometric cuts, to remove the damaged joint, the arthritis, which is the damaged cartilage and bone.

You know, after we prepare the bone by making those geometric cuts, by taking really small slivers of bone with the overlying affected cartilage, the affected arthritis, if you will, we move on to step two. You know, the second step is positioning the knee implants or the metal implants, if you will. After using those geometric cuts, we replace that area of arthritis and we replace it with metal components. The metal components that attach to your thigh bone, which is your femur, and the metal component that attaches to your shin bone, which is your tibia; most of the time in the United States are fixed to the bone with a bone cement.

The third step for most surgeons in the U.S. is that we'll resurface your patella. Your patella is your kneecap. So we actually make a surgical cut through the bone along the undersurface of your patella. And that small sliver of bone with the overlying arthritic cartilage is replaced with a plastic button that's usually held in place with bone cement.

 The final step, the fourth step for a knee replacement is we insert a plastic spacer. This is a medical grade plastic spacer. It's placed between the metal components and this creates kind of a smooth gliding surface to recreate your knee joint. You know, those four steps from a technical standpoint is what I do, is what your orthopedic surgeon will do, while you're under anesthesia and while we perform your knee replacement procedure.

Host: Well, that was a wonderful review of the process. So in summary, it sounds like you talk to your patients about, about a host of things prior to surgery. Most notably your support network, as you will need that support network. When you list the steps of the surgical process, it's pretty amazing you can do that in one to two hours. In my eyes, that's a pretty fast surgery and for our patients to go home within a day is pretty remarkable, in this day and age after going through something like that. So it really is a pretty darn smooth process. Now, Dr. Schuppner, when our patients are immediately post op phase, do they work with physical therapy at all before they even leave the hospital?

Paul Schuppner, DO (Guest): Yes, absolutely. So, your surgery typically occurs, you know, the patient, you would go to, your room at the hospital, and physical therapy is started, pretty quickly after you're awake from anesthesia. There's been plenty of research throughout the orthopedic field that's been done that shows the quicker that you get moving, that you get up on your feet with walking and with range of motion exercises for your knee, the better off your recovery will go and the faster you'll progress.

So your physical therapist works with you at the hospital. Going home after a knee replacement can be a little bit of a daunting thought. Your orthopedic surgeon has an important role with your outcome because we perform your surgery, but, we do that with you asleep essentially under anesthesia. A physical therapist can be your best friend. They can be your, not just your physical therapist, but your mental health specialist, because they've been there and done that. So the reassurance and the tips and tricks that they'll teach you, it's really invaluable. But your physical therapist works with you on day zero, right after surgery.

We always make sure that you, quote unquote, pass physical therapy, or that you graduate right after your surgery. And if you're an older patient, or if you're a patient that just is struggling for whatever reason; we don't kick you out of the hospital. We don't make you go home that same day.

We take good care of you and you spend the night. But, in general, I would say for the patients in our community at Fort HealthCare that are undergoing joint replacement, I would say approximately 90 percent are going home very safely and very comfortably. And that physical therapy component right after surgery is a key ingredient for you

to accomplish that goal of getting home and sleeping in your own bed at the end of the night.

Host: Well, I tell you that physical therapists, they're definitely an extremely valuable member of the healthcare team. And it's wonderful the work they do post operatively for a total joint, particular knee patients. So Dr. Schuppner, what is the total length of full recovery? Is it, eight weeks, 12 weeks? What do you typically tell your patients and what's their activity level like once they're fully healed?

Paul Schuppner, DO (Guest): The answer might vary depending on which orthopedic surgeon you talk to. But in general, the length of recovery that we tell everyone is that you got to give this a full year. A one year full recovery you'll hear from, I think, probably most orthopedic surgeons across the United States.

Now, that doesn't mean that it takes one year before you're back living your life and doing what you want to do. But, you know, you'll always hear that from your orthopedic surgeon. A recovery in general, the first two or three weeks, your activities are probably less than what you're used to.

Your focus is on your physical therapy, your home exercises, icing, getting good rest. Usually after week two or three, most patients kind of turn the corner as I tell them, that you kind of get back to more normal sedentary adult life. And then over the course of the next two to three weeks, so that takes us to, let's say six weeks after your surgery, most patients have recovered.

Their incision is well healed. They're nearing completing their physical therapy process and treatment, and they've gotten back to normal life. So it's not uncommon that most patients six weeks after surgery are back to work. And that's an important thing that we talk about prior to surgery. You know, everyone has different jobs and different demands at, at their work. But six weeks after surgery back most work, you know, activities such as walking, sometimes low impact exercise, sports such as golf. That's the general timeframe that we discuss.

Host: Well, I'd say all in all six weeks, it sounds like they make some really good progress within that six week timeframe, which is pretty darn fast. Dr. Schuppner, I can't thank you enough for coming on this episode of the FortCast. I've learned a lot during this podcast. I hope our listeners have too. Thank you for joining us.

Paul Schuppner, DO (Guest): Dr. Anderson, it's been my pleasure. Thank you.

Host: If you enjoyed this episode of the FortCast, thank you for listening. And if you'd like, please check our full podcast library on our website for other podcasts. This is Dr. Michael Anderson. Thank you for listening to this episode of the FortCast. Have a great day.