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What’s New in Knee Replacement
Dr. Silverstein goes over what improvements, changes, alternatives, technologies, and options there are now in regard to knee replacements.
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Learn more about Dr. Scott Silverstein
Scott Silverstein, MD
Dr. Scott Silverstein is a board-certified orthopaedic surgeon with over 20 years of experience. He was honored to be named a Top Doctor in joint replacement, general orthopaedics and sports medicine by Baltimore Magazine numerous times during his 15 years in the area. He sees many patients for second opinions and is always willing to figure out complex problems.Learn more about Dr. Scott Silverstein
Transcription:
What’s New in Knee Replacement
Caitlin Whyte: The world of orthopedics is ever evolving and that includes knee replacements. So today, we are talking all about what's new in knee replacements with Dr. Scott Silverstein. He is an orthopedic surgeon at the Centers for Advanced Orthopedics Associates of Central Maryland Division in practice for over 50 years.
I'm Caitlin Whyte and I've got a bone to fix with you. So Dr. Silverstein, start us off here with some of the overall improvements we've seen in knee replacement procedures.
Scott Silverstein, MD: Well, I think some of the most exciting things in knee replacement come from what we call evidence-based medicine. You know, in years past, oftentimes we did things because that's the way they were done before. But now, really people are critically looking at studies and things like preoperative physical therapy have been shown to make such a great impact in how patients do after a knee replacement that we really ask all of our patients to do that. I don't think I've ever had a patient who was too strong before a knee replacement.
Caitlin Whyte: And what are some new alternatives that we've seen, like you said now, compared to what we had in the past?
Scott Silverstein, MD: So one of the biggest things that I've adopted in my practice is the surgical approach. Typically, in a knee replacement, we would split the quadriceps tendon. And while this gives a great exposure, it is another area that needs to heal. And so what's called a quad-sparing approach for knee replacement, many patients are a candidate, not everyone. But we can sneak underneath the entire quad mechanism, moving it off to the side instead of having to cut it and then repair it at the end of the surgery.
Caitlin Whyte: And how has technology been changing in this field?
Scott Silverstein, MD: Well, I mean, I think certainly the implants that we use have improved somewhat over time, but really the biggest differences in knee replacement are things like the approach as well as anesthesia techniques. And so it's really important to go to a center that has excellent anesthesia as well as where you do your surgery. And about a third of our patients now are having their total joints done as an outpatient even in the surgery center and this can be a tremendous cost savings to the patient. The difference between a total knee in a hospital, which could run as much as $30,000, and a knee replacement in an outpatient center, which could be as little as $10,000 to $12,000. Obviously, if you have a deductible or a copay, this could be a big difference in your bill and you wind up with the same implant from the same surgeon.
Caitlin Whyte: Now talking about patients, why are these advancements so important to their care?
Scott Silverstein, MD: So the main goal is to get people up and moving as quickly as possible after surgery. When I started 20 years ago, the patients spend the first couple of days in bed and really they were awash and we had things like blood clots and bedsores and pneumonia that we really see much, much, much more rarely now. So we really want to get you up right away. And that's where the physical therapy, the pain control through anesthesia are so important.
We also have a much younger population of knee replacement patients. And for those patients, we need this to last as long as possible. And nowadays, we hope that most knee replacements will last 20 years,
Caitlin Whyte: Well, that actually leads me into my next question. You said you've been in the field for about 20 years. What kind of patterns in patients have you seen?
Scott Silverstein, MD: Well, definitely, as I said, there's a lot younger patients now who need knee replacement. When I started, our chairman, who was a joint replacement surgeon, would tell people routinely in the room," Come back when you're 65." Now, unfortunately, if that means that you're miserable for the next five to 10 years, that's not good for you. So now, we have patients who are younger, who need to have surgery.
Caitlin Whyte: And you mentioned pain. What does recovery look like nowadays?
Scott Silverstein, MD: Well, so the day of surgery, most patients wind up receiving a spinal anesthetic along with sedation, along with a nerve block from the anesthesiologist. And there are some pretty interesting new types of nerve blocks, which really do limit the pain that you have right away after surgery, so that we can get you up right away. Most patients who have their surgery in the morning are up and moving around before lunch.
Caitlin Whyte: Oh, wow. That's pretty incredible. We've been talking about how far knee replacements have come. What about the next 20 years? How do you see them progressing in the future?
Scott Silverstein, MD: Well, someday, I hope they look back on us all as barbarians and say, "They put what in who?" You know, metal and plastic parts certainly aren't the endgame. Someday, we hope that we can put new cartilage, new menisci in you, restore the bone quality, restored the alignment. But frankly, that's something we just can't do. And just like we look back on people who bled people with leeches years and years ago as a little bit backward. Someday, I think we'll actually be able to reverse the changes of osteoarthritis. But in the meantime, I think as we continue to practice good evidence-based medicine, we can really improve the lifespan of total joints. We can prepare people for total joints much more quickly and have them more ready to undergo the surgery. And, you know, it's really all about knowing what you're getting into. And so the preoperative physical therapy in particular gets people off to a flying start.
Caitlin Whyte: So talking about different alternatives and where we are now, how do you feel about robotics and knee replacements?
Scott Silverstein, MD: So I think robotics in medicine is a really, really cool idea that as of yet does not have any proven benefits. Unfortunately, all the studies that have really been done so far showed that it does add cost to the procedure, but it doesn't necessarily improve anything besides how the initial x-ray looks. We all hope that eventually it'll lead to better outcomes, knee replacements that hurt less and knee replacements that lasts longer.
But unfortunately, it hasn't been anything but a very good marketing tool for some practices. So we really don't advocate using that at this time. But you know, we'll stay on top of it. As the outcomes improve and we can see a definite benefit, we definitely would adopt it in our practice.
Caitlin Whyte: So we're talking about all these different kinds of knee replacement, but backing up a bit, how does someone know they need a knee replacement at all?
Scott Silverstein, MD: Well, so it's definitely important that you've tried all the first steps. Knee replacement is the last stage in terms of your treatment. And many things from physical therapy to braces, to medications, and even injections can be helpful. Nowadays, we're doing cortisone to hyaluronic acid injections that can give patients relief. We're also doing newer regenerative medicine, injections like PRP and stem cells. Unfortunately, as much as we'd like them to truly be regenerative, they're not, at least not at this point. But in many patients they can offer relief for a period of time. We really want patients to be at the point where their knee is truly affecting their activities of daily living on a daily basis. And when it gets to that point and you've tried everything else and your x-ray is bone on bone, that's when it's time for us to go ahead together and make the decision and replace your knee.
Caitlin Whyte: Well, Dr. Silverstein, is there anything else you'd like patients to know about where knee replacements are right now?
Scott Silverstein, MD: Well, I think when you're choosing a surgeon, I'm not going to sit here and tell you that there aren't a number of other great surgeons in the area. But in our practice, we're a private practice. That means that your surgeon is doing your surgery every time. And that makes all the difference. If you go to an academic institution, the residents and fellows may be doing a significant, if not all of the surgery, that's not the case at CAO in Orthopedic Associates of Central Maryland.
I'm 20 years in practice, my partners also have vast experience and we can do the knee and do it right every time.
Caitlin Whyte: Well, thank you for joining us today. That was Dr. Scott Silverstein, an orthopedic surgeon at the Orthopedic Associates of Central Maryland Division. Find more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. That's all for today. I'm Caitlin Whyte. And that was A Bone That's Fixed.
What’s New in Knee Replacement
Caitlin Whyte: The world of orthopedics is ever evolving and that includes knee replacements. So today, we are talking all about what's new in knee replacements with Dr. Scott Silverstein. He is an orthopedic surgeon at the Centers for Advanced Orthopedics Associates of Central Maryland Division in practice for over 50 years.
I'm Caitlin Whyte and I've got a bone to fix with you. So Dr. Silverstein, start us off here with some of the overall improvements we've seen in knee replacement procedures.
Scott Silverstein, MD: Well, I think some of the most exciting things in knee replacement come from what we call evidence-based medicine. You know, in years past, oftentimes we did things because that's the way they were done before. But now, really people are critically looking at studies and things like preoperative physical therapy have been shown to make such a great impact in how patients do after a knee replacement that we really ask all of our patients to do that. I don't think I've ever had a patient who was too strong before a knee replacement.
Caitlin Whyte: And what are some new alternatives that we've seen, like you said now, compared to what we had in the past?
Scott Silverstein, MD: So one of the biggest things that I've adopted in my practice is the surgical approach. Typically, in a knee replacement, we would split the quadriceps tendon. And while this gives a great exposure, it is another area that needs to heal. And so what's called a quad-sparing approach for knee replacement, many patients are a candidate, not everyone. But we can sneak underneath the entire quad mechanism, moving it off to the side instead of having to cut it and then repair it at the end of the surgery.
Caitlin Whyte: And how has technology been changing in this field?
Scott Silverstein, MD: Well, I mean, I think certainly the implants that we use have improved somewhat over time, but really the biggest differences in knee replacement are things like the approach as well as anesthesia techniques. And so it's really important to go to a center that has excellent anesthesia as well as where you do your surgery. And about a third of our patients now are having their total joints done as an outpatient even in the surgery center and this can be a tremendous cost savings to the patient. The difference between a total knee in a hospital, which could run as much as $30,000, and a knee replacement in an outpatient center, which could be as little as $10,000 to $12,000. Obviously, if you have a deductible or a copay, this could be a big difference in your bill and you wind up with the same implant from the same surgeon.
Caitlin Whyte: Now talking about patients, why are these advancements so important to their care?
Scott Silverstein, MD: So the main goal is to get people up and moving as quickly as possible after surgery. When I started 20 years ago, the patients spend the first couple of days in bed and really they were awash and we had things like blood clots and bedsores and pneumonia that we really see much, much, much more rarely now. So we really want to get you up right away. And that's where the physical therapy, the pain control through anesthesia are so important.
We also have a much younger population of knee replacement patients. And for those patients, we need this to last as long as possible. And nowadays, we hope that most knee replacements will last 20 years,
Caitlin Whyte: Well, that actually leads me into my next question. You said you've been in the field for about 20 years. What kind of patterns in patients have you seen?
Scott Silverstein, MD: Well, definitely, as I said, there's a lot younger patients now who need knee replacement. When I started, our chairman, who was a joint replacement surgeon, would tell people routinely in the room," Come back when you're 65." Now, unfortunately, if that means that you're miserable for the next five to 10 years, that's not good for you. So now, we have patients who are younger, who need to have surgery.
Caitlin Whyte: And you mentioned pain. What does recovery look like nowadays?
Scott Silverstein, MD: Well, so the day of surgery, most patients wind up receiving a spinal anesthetic along with sedation, along with a nerve block from the anesthesiologist. And there are some pretty interesting new types of nerve blocks, which really do limit the pain that you have right away after surgery, so that we can get you up right away. Most patients who have their surgery in the morning are up and moving around before lunch.
Caitlin Whyte: Oh, wow. That's pretty incredible. We've been talking about how far knee replacements have come. What about the next 20 years? How do you see them progressing in the future?
Scott Silverstein, MD: Well, someday, I hope they look back on us all as barbarians and say, "They put what in who?" You know, metal and plastic parts certainly aren't the endgame. Someday, we hope that we can put new cartilage, new menisci in you, restore the bone quality, restored the alignment. But frankly, that's something we just can't do. And just like we look back on people who bled people with leeches years and years ago as a little bit backward. Someday, I think we'll actually be able to reverse the changes of osteoarthritis. But in the meantime, I think as we continue to practice good evidence-based medicine, we can really improve the lifespan of total joints. We can prepare people for total joints much more quickly and have them more ready to undergo the surgery. And, you know, it's really all about knowing what you're getting into. And so the preoperative physical therapy in particular gets people off to a flying start.
Caitlin Whyte: So talking about different alternatives and where we are now, how do you feel about robotics and knee replacements?
Scott Silverstein, MD: So I think robotics in medicine is a really, really cool idea that as of yet does not have any proven benefits. Unfortunately, all the studies that have really been done so far showed that it does add cost to the procedure, but it doesn't necessarily improve anything besides how the initial x-ray looks. We all hope that eventually it'll lead to better outcomes, knee replacements that hurt less and knee replacements that lasts longer.
But unfortunately, it hasn't been anything but a very good marketing tool for some practices. So we really don't advocate using that at this time. But you know, we'll stay on top of it. As the outcomes improve and we can see a definite benefit, we definitely would adopt it in our practice.
Caitlin Whyte: So we're talking about all these different kinds of knee replacement, but backing up a bit, how does someone know they need a knee replacement at all?
Scott Silverstein, MD: Well, so it's definitely important that you've tried all the first steps. Knee replacement is the last stage in terms of your treatment. And many things from physical therapy to braces, to medications, and even injections can be helpful. Nowadays, we're doing cortisone to hyaluronic acid injections that can give patients relief. We're also doing newer regenerative medicine, injections like PRP and stem cells. Unfortunately, as much as we'd like them to truly be regenerative, they're not, at least not at this point. But in many patients they can offer relief for a period of time. We really want patients to be at the point where their knee is truly affecting their activities of daily living on a daily basis. And when it gets to that point and you've tried everything else and your x-ray is bone on bone, that's when it's time for us to go ahead together and make the decision and replace your knee.
Caitlin Whyte: Well, Dr. Silverstein, is there anything else you'd like patients to know about where knee replacements are right now?
Scott Silverstein, MD: Well, I think when you're choosing a surgeon, I'm not going to sit here and tell you that there aren't a number of other great surgeons in the area. But in our practice, we're a private practice. That means that your surgeon is doing your surgery every time. And that makes all the difference. If you go to an academic institution, the residents and fellows may be doing a significant, if not all of the surgery, that's not the case at CAO in Orthopedic Associates of Central Maryland.
I'm 20 years in practice, my partners also have vast experience and we can do the knee and do it right every time.
Caitlin Whyte: Well, thank you for joining us today. That was Dr. Scott Silverstein, an orthopedic surgeon at the Orthopedic Associates of Central Maryland Division. Find more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. That's all for today. I'm Caitlin Whyte. And that was A Bone That's Fixed.