Michael Anderson (Host): Hello, everyone, and welcome to this episode of The FortCast, the official vodcast of Fort HealthCare. I'm your host, Dr. Michael Anderson, ENT doc and President, and CEO of Fort HealthCare.

With me today is a very special guest. We have Dr. Izzy Zambrano. Dr. Zambrano, one of our esteemed orthopedic surgeons. Thank you for joining me today on The FortCast.

Isidoro Zambrano, MD: Thank you. My pleasure.

Host: And our topic today is going to be hip pain, a very common problem that plagues a lot of people and loved ones. Before we get started, Dr. Zambrano, how long have you been with Fort HealthCare now?

Isidoro Zambrano, MD: I am in my 18th year here at Fort HealthCare. I started September 1st, 2008.

Host: Eighteen years. Well, hey, we really appreciate it. You've been a stellar part of our medical staff for a very long time. And our patients and community really, really appreciate your expertise. So, diving in on hip pain. Dr. Zambrano, it seems to me that hip pain's pretty common, and I know people seek medical care for it. About how often are you seeing hip pain in the clinic? And what are the real symptoms that drive somebody to come see you?

Isidoro Zambrano, MD: I see quite a few patients with hip pain of all ages. Normally, they have trouble putting on their shoes, getting in and out of a car, walking for long periods of time, sitting for long periods of time. Essentially, it's just pain in the groin. Sometimes they'll go ahead and say that the pain's in their buttocks area. But normally, it's in the front of the groin.

And what I mean by having pain when they tie their shoes is when they're leaning in with their knee pushed in towards the middle, they lose that motion, then it gets stiff. So then, they try to bring the foot up and they realize that they can't. So, those are the main symptoms that I see patients for.

Host: So, it sounds like when somebody's experiencing this, it really affects their daily activities, their quality of life pretty quick. So when you see somebody and you're suspicious that it may be a pathologic issue with the hip, do you ask any more probing questions or kind of tell us a little bit about the workup.

Isidoro Zambrano, MD: I do. So, I answer questions that will rule out any other etiology for hip pain. So, do you have any numbness or tingling? Have you had any injuries in the past? Any other joint pain, any shooting or radiating pain? Is it going down the front of your thigh? Is it going down the side of your thigh? And that will rule out other etiologies.

Host: Gotcha. So as you're assessing that and you're trying to rule out other etiologies, is there anything on the physical exam? So when you physically see these people in your office, what do you look for on physical exam to help you assess the etiology of their pain?

Isidoro Zambrano, MD: First off, I see the way they walk. My office, fortunately, is right in front of the three rooms that I see patients in, and the first thing is having them get up from the chair to get onto the exam room table, seeing the way they maneuver themselves, that's part of the exam. Sometimes I do have to assist the elderly people, but the younger people, it's part of the exam when I see them get up.

So as they're sitting down, I examine the normal extremity And then, I compare it to the extremity that they're here for me to see. So, internal rotation is the first thing you lose with hip arthritis. And then, you press on the sides of their hips to rule out any greater trochanteric bursitis or ilioatibial band syndrome. Check their reflexes, check their strength, make sure that their nerves are functioning properly. And then, based on my physical exam, I will correlate that with the x-ray findings that we have.

Host: And I was wondering about the X-ray. So at some point, you've taken the history. It's always amazing what you can ascertain when somebody is just walking, and I imagine that's second nature to you. So when now you're looking at the diagnostic portion of it. So, take us through the X-ray process. What are you looking for and what do you typically obtain?

Isidoro Zambrano, MD: So, the X-ray process, I look at the joint space, I compare it to the opposite side. I look for any osteophytes, which are bony growths on the femoral head, any acetabular overgrowth that's on the cut part. I look at the quality of bone, whether it's a type A, type B or type C Larry Dorr classification proximal femur. I look for enthesopathic changes on the greater trocanter to see if anything else is contributing to the pain.

Host: Gotcha. So, there's clearly a lot of expertise that goes into when you're looking at an X-ray. So, what you just described to me—take me down a road a little bit of just good old-fashioned hip arthritis. What do you look specifically for in hip arthritis? All those things that you just mentioned.

Isidoro Zambrano, MD: I do, I do. Putting my hands on their hips, moving their hip joint. Assessing their gluteus medius attachment that would cause a trendelenberg type problem. And that would lead to a possibly co-diagnosis of hip arthritis, and those are pretty hard to fix.

Host: So in your practice, what are typically the most common reasons. After you've had the history and physical, after you've had the physical exam, and then done the diagnostics such as the x-ray, what typically are the couple most common diagnoses that you entertain?

Isidoro Zambrano, MD: Greater trochanteric bursitis is when they can't sleep on their side, and they have excellent range of motion with no groin pain that I see quite a bit. There are several muscle layers up by the bony prominence that we call the greater trocanter. So pressing on that, mainly on the backside of that bony prominence is where their bursa inflames. And that's treated with stretching cortisone shots. I tell them sometimes they're going to need two or three shots. So, I have them come back every six weeks to reassess them, see how therapy's going, and making sure that they're getting better. And the other one is just plain old hip arthritis.

Host: All right. Let's talk a little bit about hip arthritis, because I know that's also extremely common. So, now that you've had the x-ray done and you've been able to kind of decipher that you feel it's hip arthritis, what do you do at that point? How do you approach that patient?

Isidoro Zambrano, MD: At that point, I let them know what the diagnosis is, and I go over the surgical procedure. I go over possible cortisone injection if they're not ready for a hip replacement. Sometimes physical therapy will work depending on how bad the arthritis is. And if they do decide to undergo surgery, I let them know what approach I'm going to use.

So, there's several ways to do a hip replacement. You can come in posterior, you can come in from the side, you can come in from the front. About, I'd say, 60% to 80% of surgeons in the United States come in from the back. A small percentage still come in from the side. And the anterior hip is gaining popularity. And the reason why anterior hip is gaining popularity is because we, at first, did not have a Hana table, which is a specialized table to do hip replacements, and they're very expensive. So, doing these cases after learning posterior approaches, it's a high learning curve. But I tell them that I've been doing this since 2010.

The most common complication would be some numbness on the outside of your hip. So, laying down would sort of feel a little funny. I come in from the front because I don't take down any muscle. I find two muscle bellies. I go in between them, dig a little further, two more muscle bellies. And now, I'm at the hip joint. I'm at the hip capsule. So, this table that we have allows me to work in a hole as the femur where I'm working on is connected to a jig, and it allows me to drop the leg to the floor and bring it out. So, that allows me a straight and direct line into the femur.

As far as the anterior approach, the acetabulum is there. It's right there just staring at you in the face. And the problem used to be the femur, putting in the femoral component, which is now easier.

Host: So if I understand you correctly, traditional approaches have been from behind, from the posterior aspect. But it sounds like to me there's quite a few advantages coming from the front or anterior, but it requires some specialized equipment including the actual table that you're doing the surgery on, which is something you do have and do use at Fort HealthCare. Did I understand that correctly?

Isidoro Zambrano, MD: You did. And as a matter of fact, we have two Hana tables.

Host: All right. Well, I'll make sure to try to avoid them. I'll tell you that. I've seen some of those ortho tables. Boy, those are massive tables. It's incredible, the specialized treatment that you use in order to take care of our patients and community. So, I don't want to speak for you, but do you prefer the anterior approach? It sounds like you do.

Isidoro Zambrano, MD: I do. Ever since 2010, during surgery, I have an X-ray machine that allows me to see where exactly my implants are and to put them where I think would be the appropriate position. And as far as leg lengths are concerned, I do have access to obtain pictures of the non-operative leg and compare the length and the offset. So as far as lengthening the total hip, which used to be a problem back in the '80s and '90s, it is no longer a problem because I'm using x-ray to verify my length and my offset.

Host: So, that's right there in the surgery, right? At the time of surgery, you put in the implant to improve the hip through the front or anterior approach, and you're able to take an X-ray and compare it to the good side to make sure the length is correct.

Isidoro Zambrano, MD: Yes.

Host: So postoperatively, Dr. Zambrano, can you take us through a little bit of the recovery phase? Do these patients need to stay overnight? Do they get physical therapy? Can you take us through a little bit about what happens after the surgery?

Isidoro Zambrano, MD: Yeah, I do the procedure under a spinal anesthetic with a nerve block. So, Anesthesia does that. I perform the surgery. And pretty much, my surgical times are between an hour to an hour and a half, so it's a short-acting spinal block.

Once they get to the floor, I always get a postoperative X-ray and recovery. Once they get to the floor, once the spinal wears off and they're able to walk, physical therapy will work with these patients, show them how to navigate stairs, either utilize a cane or a walker, but they're up that day after surgery, a couple hours after that, and they end up going home.

The only reason why I would have you stay overnight is if you didn't have anybody to stay with you, or if you were elder or if you had any medical conditions that are at risk of being exacerbated from the surgery.

Host: I think that's an excellent point to highlight just how quick the hospital-based recovery is. I mean, sounds like a lot of patients go home the same-day. You're up and walking within hours of your surgery. It takes a whole team. I feel we have an amazing rehab physical therapy team here at Fort HealthCare, but it sounds like people get home in a timely manner.

Isidoro Zambrano, MD: Yeah. They do the ones that I start, let's say around three o'clock, which I try not to do, sometimes their spinals won't wear off in time, so yeah, we keep them overnight. They're always assessed by physical therapy. And you're exactly right, this is a team approach from the time they hit my office with my staff to the time they hit pre-op, they hit anesthesia, they go upstairs, hit the floor, they check with the therapists. So, it's a team process. This could not happen with just one person.

Host: Now once they go home, Dr. Zambrano, what's kind of the post-op recovery like for them there? Do they continue to work with physical therapy as an outpatient?

Isidoro Zambrano, MD: I always follow-up with my patients postop number one, whether it's myself or my assistant. Number one, I want to make sure that they're getting up and moving around. Number two, I show them the postoperative X-rays, let them know that everything went well, make sure that they're getting up and hopefully preventing any blood clots. And normally, they end up seeing physical therapy right after they visit with me.

They'll be in therapy, one to two times a week. And I tell them, in six weeks, you're just going to walk into my office with no walker. And normally, it's two weeks when they come into my office with no walker, but I do tell them that I'll let them go back on the golf course. I'll let them pick up heavy stuff between three to six months. Normally, it's around three months. I did have two younger male patients ride their motorcycle at two weeks for their postoperative check.

Host: I think the point there is it's actually a pretty fast recovery and anything that gets you on the golf course faster, I'm all for. Our summer season's so short here in Wisconsin, we gotta take full advantage of the golf course season. Once somebody walks in your office, say, they said sometimes they can walk as soon as two weeks in without a walker, how is their pain level compared to—I mean, I'm sure they have some post-op pain, but how soon before that arthritic type pain, the symptoms that they were experiencing, when can patients see an improvement in that?

Isidoro Zambrano, MD: That same night.

Host: That same night?

Isidoro Zambrano, MD: Yes. The arthritis is cut out. Metal is placed in there. Now, all they experience is a surgical site discomfort and pain. As far as narcotics are concerned, about a week's worth.

Host: That is remarkable how quickly patients feel better. I hear this sometimes in the media, Dr. Zambrano, what is the average lifespan of an of a hip implant? Can you comment on that?

Isidoro Zambrano, MD: I can. Fifteen, 20 years ago, if I was asked, "How long is my hip going to last?" I would say 15 to 20 years. Nowadays, studies have come out in a lab, but the studies have come out basically with all the joint companies, that they can last between 40 to 60 years.

Host: Forty to 60 years?

Isidoro Zambrano, MD: In a lab. Yes, we still don't data, but...

Host: that's pretty good length though.

Isidoro Zambrano, MD: it is. We just want one surgery. That's it. You don't want a revision surgery. Fifteen, 20 years ago, I say, I would tell them, "Well, you might be back when you're 80. You might be back when you're 85." But nowadays, the implants and the technology has improved so much. 1969 was the first total hip replacement in New York and the United States.

Host: Wow. So, about 55 years ago, and it's still going strong.

Isidoro Zambrano, MD: Still going strong and still learning.

Host: That's medicine. That's medicine right there. Well said, my friend. Well, I tell you what, Dr. Zambrano, thank you so much for being on this episode of The FortCast. As always, I learn a great deal from you whenever I talk to you. But this has just been very, very enlightening to learn about hip pain, and then of course the approaches to hip replacement. So, thank you very much for being on this episode.

Isidoro Zambrano, MD: You're welcome. Thank you for having me.

Host: Well, thank you for tuning into this episode of the FortCast. Please share us on your social media channels and please check out our website for our full library of FortCast episodes. For now, this is Dr. Michael Anderson saying thank you and goodbye. Take care.