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Alyne Ellis (Host): It happens all the time now. Someone has a joint replacement. I'm Alyne Ellis and I had a hip replacement this year. I know two people with new knees and someone else with two new shoulders. So I can't wait to find out more about all these procedures. Dr. Michael Wagner is the co-director the McLaren Macomb joint replacement program in Michigan. What are the main reasons patients consider joint replacement?

Michael Wagner D.O. (Guest): That is a very loaded question, and there’s a lot of reasons why we eventually make our way to that surgery discussion. It’s a very individualized approach, and that’s why I like to treat each and every patient as a separate individual case from just wanting to get back to being pain free to other patients that wants to return to golf, tennis, hockey. I even had one patient return to slalom water skiing. So it’s all those reasons that we can give the patient that freedom and independence that they’ve been craving.

Host:   In my case, I had pain that just kept increasing. I assume that’s a typical symptom that people have. What are the other kind of symptoms that people experience in their daily lives before the procedure?

Dr. Wagner:   Well, pain is definitely a big driver and a lot people deal with that pain in different ways. Some people can avoid the pain by giving up activities like walking, golf, or playing tennis, but it’s also the loss of mobility. Most people that have a hip replacement have difficulties even putting on shoes and socks. So regular activities of daily living that we otherwise wouldn’t even think twice about, as we lose that it can be frustrating and cause more than just a physical pain and make people emotionally and mentally painful as well.

Host:   I assume that’s true of the other joints as well that you lose motion and have pain.

Dr. Wagner:   100%. Yeah. The hallmarks of arthritis are loss of range of motion, loss of strength, swelling. It can all go hand in hand. You can have one symptom; you can have every symptom.

Host:   But it’s not just people who are older now who are getting joint replacements. It’s younger people too.

Dr. Wagner:   100%. The average age of patients that gets hip and knee replacements is falling almost on a daily basis. I've had patients come in and other surgeons have told them they're not 60 or 65 years old so they're not a candidate.  So I've replaced hips and knees for a multitude of reasons down to the age of 18.

Host:   Some of the other reasons could be things like runners get knee replacements a lot.

Dr. Wagner:   Running is a very difficult activity on the knee. While we don’t love it after hip and knee replacements, if that’s what makes you you and gives you joy, I allow my patients to return to all sorts of activities like that.

Host:   What are the various options and procedures for replacement? You seem to be an advocate for robotics and assisted joint replacement procedures.

Dr. Wagner:   When I was in my fellowship, which is a subspecialty advanced training in hip and knee replacements, the director of the practice I was at said, “There has never been an industry where a robot has come in and subsequently left.” By increasing the technology, we can make these procedures more reproduceable with better results. That is what the Mako robot provides for us for partial knees, total knees, total hips. We can essentially do the entire hip or knee replacement before we even touch the patient in the operating room. It allows us to change things on the order of half a millimeter to provide the patient with individualized results so they can get back to moving and get back to their lives quicker.

Host:   So robotic assisted surgery is probably a new term for a lot of people. What exactly does that mean? Can you go into a little more depth and describe it?

Dr. Wagner:   Robots have been making their way into the medical field for some time now. The da Vinci robot was probably one of the first big ones to come out. It’s utilized by a lot of our general surgeons. The Mako robotic assisted platform is a little bit newer and it does seem to be evolving very frequently. Basically myself, as the surgeon, I'm still in charge of the room and the robot doesn’t do anything without my input. But the robot allows me to move in much smaller fractions of integers such as millimeters instead of centimeters. In doing so it allows me to assist in individualizing each individual patient’s care.

Host:   Does that mean that the robot can actually delve into doing something that you as the doctor couldn’t be as precise with? Even though your qualified and good and all that, it would still be very difficult to be the precise.

Dr. Wagner:   Yes. There are a lot of people out there that have very, very good results, but there are outliers. While I think it is possible to do hip and knee replacements without the robot, I believe that the robot makes the results more reproduceable. I have seen major difference in patient recovery since I began using the robot way back when I was a resident into my fellowship and now as I'm running my own practice.

Host:   In any one of these particular surgeries, the joint has to be replaced. So the robot is the one that then makes the decision with your guidance on where to actually make a cut in a joint or place something in particular and it will put it in for you? I'm still trying to understand a little of exactly what the robot does.

Dr. Wagner:   Absolutely. I'm happy to talk about that because I talk about this almost daily in my office. The robot is not making that decision. To give a good example, on a patient we were going to do say a robotic assisted total knee. Prior to that patient even rolling into the operating room, I would confer with my what we call Mako product specialist to review the pre-op CT, which is advanced imaging that we would get on that patient. The computer then generates a 3D model of the patient’s knee as it is in it’s arthritic state. From that we can overlay where the knee replacement is going to go. I know what degree it’s going to be put in at, how much resection level I need to go, how much bone that I need to take off, what size the implants are going to be. I can essentially do the knee replacement on the computer prior to the patient rolling in.

As the patient comes into the operating room, it’s very standard setup to what historical knee replacements have been, the same surgical approach. We then utilize the robot to help us make those cuts. I position the saw, but the robot assists us in keeping the saw in that perfect plane so that the cuts are more uniform with less variation. From that, I am the one implanting the implants. It’s kind of like building the foundation of your house. If the foundation is built crooked, it can lead to a whole slew of problems. So the robot allows us to kind of keep that foundation solid every time.

Host:   So then the recovery of the patient, perhaps, might be different now that you're using the robot? In some cases they recover faster? What is recovery like when you use robotic surgery?

Dr. Wagner:   When I began my residency training about 10 years ago, the average person stayed for hip or knee replacement three days. 60% of those patients went to what we call a subacute rehab facility. We use that term, but in reality it was a nursing home. As hip and knees have evolved of sorts, the average length of stay for hip and knee replacements from the second you walk into the hospital to the second you walk out is about 1.2 days. I particularly operate on Monday and Wednesday. Most of my patients go home the very next day. And our discharge to home versus those rehab centers has gone from 60% to 5%. That means 95% of people are sleeping in their own bed one day surgery.

Host:   This, I assume, is true for shoulder replacements and elbows or anything else too.

Dr. Wagner:   Hip and knees are the most common joint replacements that we do. Shoulders follow closely behind. Others like wrist, elbow, and ankle are not done as commonly. But yes. That is the goal. It’s anticipated that 50% of all hip and knee replacements will become outpatient procedures in the next five years.

Host:   So do you envision that more patients are going to be opting for this enhanced technology? In fact, does a patient have a choice? Can someone come to you and say, “I don’t want to do it that way.”

Dr. Wagner:   Absolutely. My personal approach is I will never tell a patient they have to have a surgery. I will tell them when it’s an option. I think of my self as their expert witness in that stance. It is a conversation we’ll have with every single patient as far as what they hope to get out of the procedure, how bad their arthritis or joint deformity is going into the procedure, and what they're looking to get out of it.

Host:   But you do expect that more and more people will opt for this enhanced surgery in the future.

Dr. Wagner:   I see it as an inevitability, yes.

Host:   Thank you. Dr. Michael Wagner is the co-director of the McLaren Macomb joint replacement program. To learn more about Dr. Wagner or submit a question, visit mclaren.org/wagner. I'm Alyne Ellis. ‘Til next time.