Melanie Cole, MS (Host): Welcome to Flushing Hospital MedTalk, a podcast with the specialists from Flushing Hospital Medical Center. I'm your host, Melanie Cole. And today, we're learning about joint replacement surgery and specifically hip, knee, and shoulder arthroplasty.

Joining me is Dr. Andrew Bi. He's an orthopedic surgeon with Flushing Hospital Medical Center. Dr. Bi, thank you so much for joining us today. So, tell us a little bit about the most common types of joint replacement surgeries that you see and generally the reasons, the injuries, the conditions that go along with them.

Andrew Bi, MD: Yeah. Thanks so much for having me, Melanie. This is a really exciting topic, because we're making significant changes here to make modern outpatient joint replacement surgery the standard. Joint replacements have changed tremendously over the last decade, and many patients are surprised to learn how much faster and easier the recovery has become.

You asked what's the most common type. The most common joint replacement performed in the United States, it follows the most common joint affected by osteoarthritis, which is knees, so total knee replacement or knee arthritis. Second is the hip, so hip replacement for hip osteoarthritis. And then, last is total shoulder replacements. However, these are becoming increasingly common as our quote-unquote, "older population" remains more and more active later in life.

Melanie Cole, MS: Well, that's certainly true, and thank you for that. And we know that surgery is a last option. So, I'd like you to speak a little bit about conservative measures first. And as we learn more with you today, Dr. Bi, shoulders are a big deal, and they're a little bit harder to work with than knees and hips. But when we think of these conservative measures for all three of those things, what are we talking about here?

Andrew Bi, MD: Yeah, absolutely. Even though I am an orthopedic surgeon, surgery is almost always considered only after we've exhausted all non-operative treatments, and I rarely recommend surgery the first time I meet a patient unless they've been suffering for a long, long time and tried a bunch of treatments prior.

Vast majority of conservative measures that I use involve simple things like activity modification, weight loss when appropriate, physical therapy, anti-inflammatory medication, and occasionally braces. After that, we typically go up a step to a variety of injections, of which we provide precise, minimally invasive ultrasound or X-ray guided injections.

And here at the Orthopedic Office of Flushing Hospital, injections range from something as simple as corticosteroids, which is a very powerful anti-inflammatory medication, to hyaluronic acid, which is a naturally occurring joint protein commonly known as gel injections, as well as a variety of biologic injections that include powerful growth factors such as platelet-rich plasma or PRP.

There are other kind of minimally invasive procedures that we can refer patients to that most orthopedic surgeons don't typically perform, such as like nerve ablations or these newer genicular artery embolizations, all of which are non-surgical options to decrease pain in cases of arthritic joints. They don't necessarily fix the arthritic joints, but they kind of decrease the pain to allow patients to be as active as possible.

You mentioned shoulders being more difficult to treat. The benefit of shoulders is that we don't walk on our shoulders. So oftentimes you can see patients with bad arthritis on X-ray, but they have really minimal pain or their limitations are really in motion. But as we kind of touched upon before with patients getting more and more active, especially with pickleball and tennis and later in life, they want to have that high activity level, shoulders can be more tricky to treat. And, you know, I'm fortunate enough to be trained to be able to offer a variety of shoulder procedures, including both anatomic and reverse shoulder replacements that allow patients to preserve as much range of motion and as much function in their shoulder even after replacement.

Melanie Cole, MS: Well, I agree with you. I've seen so many golfers, and as you say, with the advent of pickleball, shoulder injuries, you know, we see a lot of those. And with so many tools in your armamentarium now, this is a really exciting time in orthopedic surgery. But one of the things that is most important, Dr. Bi, is patient selection. So when we think of who is really a good candidate for these types of surgeries after we've tried those conservative measures and injections, as you say, and even PRP, which is a pretty exciting field in itself, what do you want patients to know about selection for surgery when it comes down to it? Lifestyle factors you mentioned, weight loss as a possibility, especially if it's knees or hips. What are you looking at when you are looking to say, "Yes, we can do a surgical intervention for this person"?

Andrew Bi, MD: Yeah. The most common reason for any joint replacement is osteoarthritis, which is essentially wear and tear of the joint over time. So obviously, we're not offering surgery for anyone who doesn't have debilitating severe arthritis, both symptom-wise and on their X-rays. So, you know, objective measures of their arthritis.

Most patients are over the age of 60, but we certainly see younger patients who have arthritis from prior injuries, rheumatologic conditions like rheumatoid arthritis, or even congenital conditions. Really, anyone's a candidate who basically has a painful joint that limits them from what they want to do in life, and whether that be just simple day-to-day tasks or running a marathon or even weightlifting, or sports like tennis and pickleball or golf.

Lifestyle factors that you mentioned that increase the risk of arthritis in the future and needing surgery include obesity, that's number one, prior joint injuries like fractures or trauma, physically demanding occupations over decades, as well as a family history because there's a genetic component.

Maintaining a healthy weight, staying active, and strengthening the muscles around the joints can all help reduce stress on the joints and potentially delay this need for surgery. And one point that I really want to emphasize to patients is I never tell patients, I never want patients to limit themselves during their life due to fear of developing arthritis.

Besides maybe, you know, like repetitive, heavy, quote-unquote, "max power lifting," over years, no form of exercise or sports has been proven to be linked to developing arthritis, not even like marathon runners. So, my recommendation to patients is always to go out, stay active, stay strong and fit, as that is the best way to keep your joints healthy for the long term. You know, movement is medicine.

One of the encouraging things about joint replacement is that today's joint replacements are lasting longer than ever. There's a, you know, stigma that like, "Oh, if I get a joint replacement in my 60s, I'll have to do a revision when I'm 70." But joint replacements, knees, hips, and shoulders, they're lasting twenty, thirty years. So, potentially, you know, life-changing procedures that you only need once.

Melanie Cole, MS: Well said, Dr. Bi. Movement is medicine, and it certainly can make a big difference in that active lifestyle. So, tell us about some of the exciting things in joint replacement surgery today, what types of procedures that you perform, and what's exciting in your field right now?

Andrew Bi, MD: Yeah, it's super exciting time to be an orthopedic surgeon and to, hopefully, be a candidate for joint replacement. These involve both the procedure and technical points themselves about the joint replacement, but also the perioperative care and how we're doing these procedures and getting patients ready for it.

So, you know, at Flushing, we're building a modern outpatient joint replacement program using many of these innovations. It starts well before the operating room, you know, nutrition optimization, including dietary counseling and increasing protein intake before and after surgery, sleep hygiene, prehab, getting the muscles strong before surgery.

For all joint replacements around surgery, I use a medication called tranexamic acid perioperatively, which decreases bleeding during and after surgery, which decreases the postoperative complications such as pain, low blood pressure, and dizziness. It helps patients, you know, leave the hospital the same day and recover at home, which we have all found and all the studies have shown improves outcomes in the short and long term.

Technically, for technical developments of joint replacements, for hip replacements, I use a direct anterior approach, which is a muscle-sparing technique that allows patients to recover more quickly with less pain and improved early mobility. This often allows patients to walk out of the hospital, same day and start resuming their activities much earlier than traditional approaches.

I use robotic assistance for both hip and knee replacements and key emphasis on the words both robotic and assistance. A lot of people think that, "Oh, like I'm just having a robot, like cut my joints, like what's the need for a surgeon?" In reality, the robot is like an extension of us. We do the planning, we do the whole surgery to expose the joint, but the robot basically helps us create very precise custom cuts to the patient's anatomy, which helps decrease the amount of surgical time, decrease the amount of blood loss, decrease the amount of soft tissue trauma, to allow patients to have more precise joint replacements and less pain after surgery and improve their early recovery.

For shoulder replacements, robotics is on the horizon. It's not quite there yet, but we're on the precipice. And we're going to start implementing that soon. But I use custom three CT printed patient-specific instrumentation to kind of guide the shoulder replacement to be as close to the patient's anatomy as possible, as well as I perform a number of anatomic shoulder replacements. The most common shoulder replacement in the country right now is reverse, which does distort the patient anatomy a little bit. But anatomic shoulder replacements, while a little bit more technically demanding, can help preserve patient's function and allow them to optimal return to function in sports.

Biggest advancement isn't just one technology or one change. It's combining all of these techniques and trainings and preoperative counseling into a single enhanced recovery program for a patient that get patients up and walking sooner and home safely, often the same day.

Melanie Cole, MS: Isn't that amazing how it's changed over the last even just 10 years, Dr. Bi? So when we think of hips and knees, if it's bilateral arthritis or something going on there, do you typically recommend having them done together or one at a time? I know it's certainly situational and dependent on the specific patient, you know, condition, but do people get them both done at the same time?

Andrew Bi, MD: Yeah. Just like you said, it really depends on the individual patient. But for most patients, they are better served by staging surgeries at least six weeks, typically three months apart. This just reduces the physical stress on the body from recovering from a joint replacement and allows one side to recover before addressing the other.

You know, I did my training at NYU, in Manhattan and Rush in Chicago. Our chairman at NYU, Dr. Joseph Zuckerman, he's been famous among all the trainees where he's one of the last people that regularly does bilateral knee replacements at the same time. These are reserved for patients with really severe bilateral knee arthritis that's debilitating.

If you did one knee, they'd still be limited on the other one, and they have to be young, healthy, robust patients to withstand the hit of a double joint replacement under the same anesthesia takes. So, I would say it's a very, very rare scenario in which we're doing bilateral joint replacements. Vast majority of patients are better off doing one at a time and recovering from that before the other one

Melanie Cole, MS: Yeah, that's great advice. Now, let's discuss recovery, because you mentioned minimally invasive and robotics. So obviously, depending on what they have done, and as you and I said, shoulders are a little bit more complex because, just because of how much movement the shoulder has really. But as you said, it's not a load-bearing, it's not a weight-bearing joint. So, it does recover differently. Tell us about recovery. You mentioned an outpatient clinic and going home the same day. What does that recovery look like? Is physical therapy involved? Tell us what it looks like.

Andrew Bi, MD: Yeah, excellent question. Recovery has definitely improved dramatically over the past several years. Like we talked about before, many of our hip and knee replacement patients are now able to go home the same day or after just one overnight stay, compared with often, you know, several day or even a week stay in the hospital years ago.

We do the minimally invasive procedures. We do robotic assistance. I typically avoid tourniquet in my total knees to avoid that thigh pain after surgery. And so, patients can begin walking within hours after surgery with the help of physical therapy in the hospital, short-acting spinal anesthesia, and the perioperative pain kind of regimen I mentioned previously.

Most people still need a walker or cane for a short period at the time when they get home and gradually transition back to normal walking over several weeks. The first two to three weeks after surgery, I use a "quiet joint protocol," and this makes the first couple week recovery super easy. It just involves primarily resting, constant icing, elevation, and other modalities to reduce swelling after surgery for the first couple weeks. So, patients don't really have to worry about getting to and from outpatient physical therapy or setting up home PT for the first two weeks.

Now, this is a little contrary to, you know, some people are saying we need to get them into PT right away, but especially for total knee replacements, what we've found is that very early aggressive PT, which we thought was standard before, can sometimes flare up the knee joint and cause a lot of swelling, which can set patients back for months. And so, just really focusing on getting that swelling down, reducing the bleeding, reducing the amount of inflammation can get them a big head start when they do start PT about two weeks after surgery.

Shoulders, like you mentioned, is a little bit different animal. We don't walk on our shoulders, so really the recovery has not changed much. It's a sling for anywhere from two to six weeks, depending on the procedure. And then, after that, they come out of the sling and start doing light daily activities and therapy to get their motion back.

Melanie Cole, MS: Once surgery's complete, tell us about your outcomes. Tell us about what you've seen, whether they're young and athletic or whether they are older individuals and what that looks like.

Andrew Bi, MD: Yeah. The biggest long-term benefit obviously depends on the patient and their goals. Like you mentioned, a young patient with bad arthritis may want to go back to weightlifting and sports and running, even marathons, whereas someone in their 80s just wants to walk pain-free.

Regardless of what they want, the well-done knee or hip or shoulder replacement, the biggest benefit is long-term pain relief and an improved quality of life. Patients often tell me they wish they had surgery sooner because they're, you know, they're finally able to walk or run without pain, sleep through the night, play with their grandchildren, and return to all the hobbies that they'd given up previously, such as tennis, swimming, and even running.

I tell my patients, like, there's really no restrictions after these procedures anymore. Hip replacement, knee replacement, I let them go back after the recovery process, of course, but I let them go back to sports, weightlifting, running, even marathons. Shoulder replacements, depending, you know, this depends a little bit on the patient, but I let them go back to all overhead sports and activity.

The only real restrictions after a shoulder replacement is, like, the heavy, heavy lifting, in which case depending on the shoulder replacement, I do restrict patients a little bit in terms of heavy weightlifting.

Melanie Cole, MS: Dr. Bi, you've given us so much great information. This is so exciting to hear about all the new technologies and ways for joint replacement to really, really improve the quality of life of people suffering with various forms of arthritis. And if someone wants to learn more about joint replacement surgery or wants to schedule an appointment with you, what do they do? How can they reach you?

Andrew Bi, MD: Thanks, Melanie. Patients can reach me in a number of ways for a consultation. Our office is located in Flushing Hospital Medical Center. The address is 146-01 45th Avenue, Sixth Floor, Flushing, New York 11355. The office number is 718-670-5370 to call to make an appointment. Patients can also make an appointment on my websites, which we'll post, as well as the phone number and the address as well. But I try to make myself very easily reachable, open to consultations for any and all patients. My passion is getting patients back on their feet doing all the things that they love.

Melanie Cole, MS: I can certainly hear that, Dr. B. And thank you so much for joining us today and really sharing your incredible expertise. So, thank you again. And for more information about the services Flushing Hospital Medical Center offers, please visit our website at flushinghospital.org. I'm Melanie Cole. This is Flushing Hospital's MedTalk, a podcast from Flushing Hospital Medical Center.

All content of this podcast is intended for general information purposes only, and is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. Please consult a medical professional before adapting any of the suggestions discussed in this podcast.