Scott Webb (Host): Many of us suffer from knee pain, and my guest today is here to discuss surgical and non-surgical options, including a revolutionary muscle-sparing approach to knee replacements. I'm joined again today by Dr. Nikhil Pandhi. He's a board-certified orthopedic surgeon with Franciscan Health.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctors, nice to have you back on the podcast today. And today, we're going to talk about knee pain. Last time, we talked about hip pain. Today, we're talking knee pain. So, let's just start there. Like, what are some of the symptoms of knee pain, besides the fact that, "Ow, my knee hurts," right? Sure, that's a symptom, but what are the specifics when it comes to the symptoms of knee pain?

Dr. Nikhil Pandhi: You know, there can be many symptoms that exist. There's the idea of just walking. You can't walk as far as you used to be able to due to the pain. They maybe used to go on two-mile walks, but now you can only go about a mile because until you start walking, you realize it's not the endurance, but it's actually the pain that kicks in a little bit faster. Or you can't go up the stairs as easily due to knee pain. Perhaps you see that your knee swells and it's associated with pain, sitting to standing. So, there's a myriad of symptoms that can occur, which are, you know, there's some general symptoms like we just spoke about, and there's also specific ones where it just hurts in one spot of your knee or when you kneel on your knee. It wasn't hurting before. But now, you're noticing the past few months it's starting to be a little sore that when you put that consistent pressure on it.

Host: Yeah, I see what you mean, right?. Like, so obviously if your knee hurts, then you have knee pain, but there's some specific symptoms we can be on the lookout for. Maybe give us a sense of like what are some of the general causes of knee pain? Like, I know mine is osteoarthritis and just being old. But in general, like what are the causes of knee pain?

Dr. Nikhil Pandhi: Sure. Like you mentioned osteoarthritis, you know, people ask me, you know, what is osteoarthritis? Think of it as the smooth cartilage on any of your joints, but we're speaking about the knee here specifically, but the smooth cartilage eventually kind of wears away. You lose a little bit of that buoyancy or that cushioning effect in your knee joint, so you lose joint space between your thigh bone, your shin bone, otherwise known as your femur and your tibia. Losing that space increases as we get osteoarthritis, and osteoarthritis leads to that. So, it's kind of a back and forth scenario. And it's also an inflammatory condition where, you know, it creates pain. Now, some people have osteoarthritis and don't have pain. So, that's one way to look at it.

It could be, you know, related to aging. It could be related to just wear and tear injury. If you're an athlete and you're 21, you're a high jumper, and you had an injury. But you kind of got by, you know, for a while. Eventually, it can catch up to you where the cartilage that wears away eventually does kind of lead to kind of a post-traumatic osteoarthritis of the joint.

And so, these are all things that can lead to knee pain. And increased weight, increased forces on your knee joints. Anytime we gain weight, there are some studies talk about every five pounds, you get an increased pressure on your knee. These are real things that you can actually treat and do on your own as well. And that also includes loss of muscle mass in your core and your hip. And obviously, your quadriceps and your hamstrings. You know, that affects the quality of your knee, the knee pain, what you can actually endure and get by with. So, these are all factors.

Host: Yeah. Everything seems to be connected and our youthful transgressions, if you will, that bill seems to come due at some point, maybe in the form of osteoarthritis. And as you're saying there, there's some things we can do to help ourselves, maybe lose some weight, get more exercise, all that. But I want to have you, like since you're someone we would come to, go to see to help us, when we think about non-surgical relief, surgical relief, give us some of the options or solutions we have for knee pain.

Dr. Nikhil Pandhi: There's a lot of things that you hear about now with what you can do for knees that aren't necessarily surgical. The number one thing is, you know, what's the actual cause of the knee pain? First, you see the patient, like I'll see a patient, evaluate them, examine their knee, look at X-rays, and see how much joint space they have and what do they feel, where's their pain, you know, do they have a ligament issue or is it mostly just an arthritic issue?

And that being the case, you know, there's different treatments for different issues, and there's a whole host of issues. Let's just say arthritis. People are very familiar with things such as physical therapy to strengthen the muscles. That's always a good first start. Maybe an anti-inflammatory of some sort, medication, if it's not contraindicated, there's no reason you can't take it.

There are activity modifications. Then, there's things such as, you know, cortisone injections are very popular. While I don't recommend too many cortisone injections, doing one, maybe two, not a bad way to decrease an initial knee pain and the inflammatory effects of the knee, because you're basically putting the medicine right to the knee joint. And that helps it directly, as opposed to like an anti-inflammatory you take by mouth. There are injections such as something called platelet-rich plasma, which studies do show some efficacy with different forms of knee pain, like osteoarthritis. I tend to do a series of these injections one every four weeks, because the first injection, then the second injection potentiates and helps the first injection. The third one helps the second and the first. So, these have been things in my practice I've seen help quite a bit.

People see advertisements now, which is interesting to me because, you know, these injections have been around a long time, but they're gel injections, otherwise known as viscosupplementation injections. You're basically creating a more viscous layer of fluid in your knee, so to speak, to create a cushioning. So, people look for this. Not everybody's a good candidate for this, and that's where we have to evaluate the patient, because just indiscriminately giving these injections may be not worth the patient's time if they're bone-on-bone arthritis or they're not really able to function. As you lose joint space, you lose your mechanical ability of your knee to move, and sometimes the gel injections can actually induce more pain if given in the wrong patient.

So, you know, these are all things that we can do out there. Those are the kind of the basic treatments we do in the office. There's a lot of different things you can do now that's on the market as well.

Host: Yeah, lots of options. As you say, it's a case-by-case basis. I love hearing, as a potential patient, of course, that we have lots of options. Wondering, Doctor, like, does nutrition contribute to knee pain? And if so, are there things we can add or subtract from our diet to help?

Dr. Nikhil Pandhi: The things you can do, keeping bone strength, keeping weight within a reasonable body mass index, so your joints such as your hips and knees, which are load-bearing joints, as opposed to your shoulder, which the forces aren't as great on the shoulder as you're walking on your knees and hips all day, you know, you want to keep your weight down.

Vitamin D supplements, which I always, preach to patients. You know, people talk about the value of vitamin D. But really, the vitamin D on its own, you really need to have it with vitamin K2 as well as the magnesium. All these things help with the absorption. That helps your bone density, which helps you with, hopefully, with knee pain. Keeping your core strong, so your abs, your hip abductors, your quadriceps, your hamstring. Even if it's just doing body squats at home, you know, 10 body squats every few hours, just things like that. You don't need to have a fancy gym, but that keeps your knee strong, and that helps keep the health of the joint intact. Because even if one day you need a knee replacement, you still need that lever of the quadriceps and your extensors and your extensor mechanism of your leg to do well when you have a knee replacement too. So, keeping the attrition away. So, those are things.

High protein diets. Obviously, you want to be mindful and talk to your primary care doctor about this as well. But, you know, especially if you have long-standing kidney issues or other issues where you can't have high quality protein, but whole food sources of protein where, people talk about now getting 0.8 to 1 gram of protein per body weight, what your ideal body weight is to really keep up and decrease the loss of muscle mass, otherwise known as sarcopenia, where you lose the kind of the volume and the mass of the muscle, which also can lead to more knee pain and dysfunction of the knee joint.

Host: Right. Yeah. And you gave us a sense there earlier about sort of the non-surgical options, the greatest hits before we get to surgery. So, let's talk surgery. Let's talk minimally invasive knee replacement, which does not cut the muscle tendon. You're doing it there. It's obviously proving to be effective. Has it been well-received by patients?

Dr. Nikhil Pandhi: I've been doing this for a while now. I mean, this is my 15th year of practice, and I've done knee replacements all sorts of different ways. I'm the only guy really in Northwest Indiana that I know about doing this, where you're not cutting the muscle and tendon. So, patients are moving faster. They're getting better range of motion on their first post-operative visits when I see them. Patients are coming in with minimal assisted device, you know, with maybe just using a cane or barely using anything. But really, in the first few weeks, I'm seeing a much better increase in range of motion, where they're getting more degrees of flexion and extension sooner, because their muscle's not being traumatized. Because anytime you cut through the muscle or tendon and you repair it, that's going to be part of the recovery process. So, if you're not disturbing that, it makes sense to say, "Okay, well, hopefully, my muscle's not shutting down, where it's actually working in a faster, more efficient manner." And that's what I'm seeing.

Some people would say it's kind of a gimmick. There's no gimmick. I mean, you look at patients that have had knee replacements on one knee one way. And I'll tell you, when they do it the way where you spare the muscle and tendon, I see it. They even tell you, like, "Yeah, I'm still a little sore from surgery. My pain's less, my movement's better. I'm getting better range of motion. I feel like recovery is quicker. I'm going back to driving sooner. I'm going back to golfing sooner." And that's my population of patients of people that want to go golf, they want to go hang out with their grandkids. They want to go travel. And those are people that are looking for this kind of quicker turnaround. So, some people call it what's called a subvastus technique, where you're not cutting the muscle. But the one I do, there's a website you can actually take a look at if you're interested. There's about, I think, about 90 surgeons on there right now in the country. It's a program. It's called jiffyknee.com, J-I-F-F-Y-K-N-E-E.com, and I've been a part of for a while now. And so, people can find a surgeon in their area, and I'm the only guy in Northwest Indiana from here to South Bend doing that. So, you can find me on there, and you can click, and you can get an appointment through there and find me pretty quickly and see me at Franciscan.

So yeah, it's been great. I love adding it to things like robotic-assisted knee replacements, navigation, sort of using all these little tools to see how can you get people better in a more quick, efficient manner and take kind of the scared nature of getting a knee replacement. You know, patients are scared to get these things, and I get it. You know, it makes sense to me, but they're kind of left with no choice at some point.

Host: Yeah. Are there some folks that are just better candidates for this particular procedure?

Dr. Nikhil Pandhi: I would say 99% of my patients are good candidates for the approach I do with this muscle-sparing approach. You know, I think the only ones that sometimes if they have some previous issue with their quadriceps tendon or their patella tendon. But really, it's more kind of also based on patient size, but I really have not had an issue with that, with patient selection.

I think, for the most part, everybody's been a great candidate. And, you know, I will evaluate case-by-case basis to see if they're a good surgical candidate to begin with. But I've really been happy with it, and I think the patients have been happy with, and it's really good to see little more word getting out there about this, that patients have other options.

It's a more technically difficult approach to the knee, but I've been doing it for a while, and it's really not difficult in a sense that patients getting knee replacements probably the implants and everything are usually in within 30 to 45 minutes. And we have a team that knows how to approach this process, and they've worked with me for a while. So, they're very well-versed in surgery, understand what I need as a surgeon, and it helps the patients. So, it's team continuity, people being on the same page, but I've been very happy with it.

Host: Yeah, and you touched on recovery time. Maybe you could just be a little more specific, like, you know, how much faster is the recovery time with the way you're doing things here? As you said, folks want to get back to whatever it is, golf, pickleball, hanging out with the grandkids. So, give us a sense on the recovery time.

Dr. Nikhil Pandhi: So, the way I look at it, every patient brings their unique set of physiology to the table before surgery. So, every patient's different. I tell patients, "Don't compare yourself to patient A, to patient B. You're your own person. Don't worry if this person got better faster, you're going to have your own timeframe." And that's important for patients to have some perspective on that if they've been debilitated for a while. But I mean, I've had patients go back to driving in two to three weeks. I've had patients off the cane, you know, within two to three weeks. And for knees, I say that's a really big achievement.

I've noticed at least on average, the first post-op visit, I usually see patients back at the two-week mark after surgery, and usually most of these surgeries are outpatient surgeries. They go home the same day. Patients come in the office and they already have like maybe like 15, maybe almost 20 degrees more flexion in their knee than they did with the previous. So, they're already getting better range of motion, full extension, and those are the things you really want in the first few weeks, because that's extremely important to avoid things like a stiff knee. Now, some people still get stiff knees and they're more prone to it, but there's less pain, less need for pain medicine, opioids and narcotics post-surgery, which is huge.

And I've noticed that across the board. And patients are getting back to where, you know, they'll tell me, "Yeah, I was in the garden," you know, already the two, three weeks. And I'm like, "Okay," you know. Like, "Yeah, I know I wasn't supposed to doing it, but I felt good. Little soreness, but I'm doing good." And that's kind of the stuff that patients don't even realize that they're doing sometimes that lets me know that they're doing better with this technique. And I've been very happy with it. You know, I get more and more people asking about it all the time.

Host: I'm sure.

Dr. Nikhil Pandhi: And it's been great.

Scott Webb: Are there any risks or drawbacks, any downsides to this procedure?

Dr. Nikhil Pandhi: There is always a risk for things like infection, very minor risks of things like infection, blood clots, things like that. It's a little bit more, I say it's a little more technically, challenging approach to the knee. But again, it's like anything else, you know. They said this about anterior hip replacements without cutting the muscle or any technique. You have to just do enough of these to be comfortable with it. And, you know, I just happen to be lucky to work with people that I used to do something similar to this in my fellowship. This is just a little bit of a different take on it.

So for me, it wasn't really a difficult venture. It was kind of like riding a bike. So yeah, I mean, I think those are the basic things. Like any knee replacement, you still have to pay attention to detail, you still have to pay attention to the balancing of the knee when you do the surgery and follow your patients closely.

But as a whole, I mean, I can tell you I've been seeing a lot of patients finding us from out of state, places like Iowa, you know, the west side of Michigan, coming to Indiana for treatment, from Illinois, further south. It's been interesting. People find you or they have a friend that you had surgery, had this technique, and they are seeking it out.

Host: Or maybe they heard a podcast and—

Dr. Nikhil Pandhi: Oh, I hope so. Yeah. I mean, honestly, podcasts have become now the really the new way for people to learn and innovative techniques. And this is great. You could be in your car and you could listen to this, right?

Host: Right. I'm sure folks are, right? Absolutely. Well, it's always great to have you on and hear about the new, cool, innovative things you're doing. Just give you a chance here at the end. When we think about knee pain and helping folks with knee pain. What's your best pitch?

Dr. Nikhil Pandhi: You know, my pitch is, listen, if you have knee pain, the worst thing to do is ignore it. You don't want to ignore it. See somebody who is a professional, like orthopedic surgeon. You hear orthopedic surgeon, it doesn't mean they're going to cut first. You want to come see me, I'm going to get some basic X-rays, and I'll talk to you, see how long this is going on for, what treatments have you had already, examine you, and then come with a approach. You know, we don't go right to surgery. There's other things I can do to help you. I'm going to do that.

So, I think, the best thing is knowledge is power. You come in, get evaluated. You have a good rapport with that surgeon, great. They can tell you. I mean, we're the arthritis experts, and you want to go see those people. Don't be afraid to get evaluated. And then, you can decide what you want to do after that. And, you know, you get a consult and you just say, "Hey, you know, what are my choices? What is this muscle-sparing approach that you do?" And, you know, you just kind of find out, and then you can do your own homework on it. Just get evaluated, you know?

Host: Yeah, I think it's one of those things we just assume that all surgeons are just kind of sitting there with scalpels in their hands, you know, just, waiting to—

Dr. Nikhil Pandhi: It's changed a lot. It's changed a lot. Absolutely. You know, I just want to say one thing, You know, just if your knees aren't working, it's going to affect your overall health. If you can't be active, that is the number one indicator of lack of longevity in many ways. You need to be able to be active, go for walks, enjoy your life. If you can't, that's why we do this. So, you have function, less to no pain. We want you to get moving so you can keep your heart healthy, keep your muscles healthy, and have a good existence. You know, you don't need to be suffering.

Host: That's right. That's perfect. We'll leave it there for today. I'm sure we'll speak again in the future. Thanks so much.

Dr. Nikhil Pandhi: Anytime. Thank you.

Host: And for more information, go to franciscanhealth.org and search sports medicine. And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.