Dr. Michael Smith (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build healthier futures. Today I am sitting down with Dr. Dustin Hambright and we're going to be talking about if we're ever too old or too young for a joint replacement surgery.

But before we get started, Dr. Hambright, I always like to ask my guests what made you dive into this specialty? What was it about orthopedic surgery?

Dr. Dustin Hambright: Orthopedic surgery just spoke to me. I grew up in a blue collar family. I have always been really interested in carpentry, rebuilding cars, growing up, digging ditches, building with my family and my dad. So, when I saw my first knee replacement while in medical school, I'm like, this is definitely the field that I'm going to go into. And it, it just was exactly linked to what I was good at and my traits.

Host: Fantastic. I love the personal story there, digging the ditches, and it kind of trains you for all this because I know, listen, orthopedic surgery is a lot of work and I appreciate what everyone does. Aside from age though, what factors determine whether someone is a good candidate for knee or hip replacement? Again, aside from age.

Dr. Dustin Hambright: Basically their overall health. Are they well enough for surgery? I mean, that's sort of the bottom line of all this is if they're indicated for surgery, if they have significant hip or knee arthritis or other pathology with surgery as the next option; are they healthy enough? Before that, is the hip or knee arthritis bad enough for surgery? And have they done conservative care measures? So that's another, important topic before going to the surgical option.

Host: I guess it's safe to say, right. Traditionally speaking, joint replacements were pretty much associated with older adults. Is that still the case today or are things changing?

Dr. Dustin Hambright: I think in the past we have sort of stood by the dogma of waiting till people are 65 years old. So I think in the past you would see this, this age group of 65 and older as the age group having arthritis and having replacement. People have arthritis before the age of 65, and I don't think it's that more people have arthritis, I think we're just more attuned to it, and we are treating it younger. I think that's what we're seeing. I think we're just, we're treating people that are younger with bad arthritis.

Host: Why do you think that is? Why has that shift happened We've always had young people being athletic and running and sports and stuff. What's different today than say 20, 30 years ago, in developing arthritis? Or was it always there and maybe young people 20 years ago just didn't bring it up.

Dr. Dustin Hambright: I think it's always been there. I think that we have, as orthopedic surgeons sort of tried to push patients off because, because the technology and the components weren't up to speed. Now we have great data showing that the lifespan of these components are up to 30 years. So, and I think previously we were just concerned putting these replacements into patients because they'd be coming back for a revision, prior to the end of life.

 That revision surgery is a way bigger surgery and a bigger hit on a patient. So I think that was the big concern. That we're seeing these, these components last long, we have new plastic that doesn't wear as quickly. We are more inclined to treat these younger patients.

Dr. Michael Smith (Host): Yeah, I kind of have a personal story there. A friend of mine, I think he was maybe around 45, definitely needed a hip replacement. Now, this is maybe about 25 years ago or 30 years ago, and they said, well, we want you to hold on for a few more years.

Let's see what we can do. And I guess that's because of, what you just said, the equipment wasn't quite as well, didn't last as long. Is that true?

Dr. Dustin Hambright: Exactly true. I think, that and obviously yeah, the equipment and the, just the dogma. We gotta wait till 65. It's interesting. There was a study in the Journal of Bone and Joint Surgery, that was published and was also published in the Boston Globe, I think as well; 90% of patients with knee arthritis waited too long. So the study sort of looked at there's a sweet spot of how long people are affected by arthritis and how it impacts their life. 90% of people that have bad enough arthritis for surgery are delayed way past the time they should have had the surgery.

So the dogma's still there. We are waiting too long for these patients. The arthritis is affecting their life, their function. We need to get better at it, obviously.

Host: With the younger patients, I would assume they're facing some different challenges than say maybe an older patient. And generally speaking, younger patients are going to be in the middle of their careers, most likely right. Busy lives. What are some of the things you talk to them about in preparing them for this?

Dr. Dustin Hambright: Before even going to surgery, I just make sure their arthritis affects them. Is it affecting their quality of life, their activities of daily living, and is it affecting their ability to do things they enjoy? If they answer yes to all those, and their arthritis is bad enough, they're ready for surgery and when they're ready for surgery, if they're in the middle of life, I need to see is there a good time in the year to have this. Is there a slower time in your work? Is there a time where you have extra hands at home to help? Is there extra people to help you at home? Is the summer a better time? Is the winter a better time? So, knee and hip replacement is great because it's elective and the patient can help me figure out when the best time of the year is.

 That's something to think about for a patient that is in the midst of work and family life to think about.

Host: Moving towards the older adult older patient, I'm assuming there's some differences in surgical risk overall, right, between younger and older. So what are some of the risks that you have to speak about with the older patient that maybe you wouldn't with the younger patient?

Dr. Dustin Hambright: So age is what the debate has come to is it's not age, it's about their physiology. Not every 80-year-old is the same. There's some 80 year olds that could probably run a marathon faster than me, or lift more weight than me.

So it's all about are they healthy enough? And I would say with an older population, yes, that does correlate with more medical issues and comorbidities. I always question my ask my patients, do they have cardiac issues, you know, kidney issues, pulmonary. And what we do is we ask, do they have any of these physicians?

And we send them back to all the physicians that take care of them and sort of to give me guidance on, what should we look at in regard to their cardiac status around surgery, their kidney status, et cetera to see if they're healthy enough in regards to those systems for surgery.

Host: So if you take a younger patient and an older patient who are equal in overall health, right? No major issues, heart, whatever, et cetera, et cetera, both need this surgery. One is 45, one is 65, 70; if they're equal into in their overall health; do you see any differences in outcome then and, and how long it takes to recover, rehabilitation, all that kind of stuff?

Dr. Dustin Hambright: I don't. If their physiology is similar, they both will recover quite similarly. Also in regard to older patients, they may physiologically look the same, but sometimes older, their bone may not be as strong. Their muscle may not be as strong.

So for those small characteristics, it may delay your recovery a little bit, more than somebody that's younger. But overall, I, I see them bouncing back just as quick.

Host: So, an older patient though with osteoporosis, for example, if they're overall healthy, they have osteoporosis, you can still go forward with this, just knowing that maybe their rehab is going to be maybe a little longer simply because of the lack of mineralization in the bone?

Dr. Dustin Hambright: Correct. I'll check patient's vitamin D level and if they have concerns for osteoporosis, I send them back to their primary care doctor to see can we optimize this patient. Is, is there anything we can do to improve the possibility of their outcome? If they have undiagnosed osteoporosis, can we send them back to their primary care doctor or endocrine physician to optimize it?

If, they're already optimized, if they're already on a medication, they're taking their vitamin D level that they should be taking, then we will proceed with surgery. In patients that are osteoporotic, I, you just have to be a little more careful, obviously, during surgery because their bone is a little more brittle.

Host: You touched on this a little earlier, and I kind of want to go back to the idea of advancements in technology, robotics, surgical techniques, you know, all this kind of stuff is fascinating to me. What stands out to you the most that has happened, say, over the last 10 years or so, that has really revolutionized how you perform the actual surgery?

Dr. Dustin Hambright: The technology in terms of the components, has obviously gotten better. We've gone into technology for knee replacements that are now the cementless replacements have come to the forefront as showing good outcomes. Same with hip replacements, but what I would say is just the perioperative pain management has revolutionized replacements, and the fact that patients used to come in a week before and would stay a week after for replacements. Now people come in the morning and they're going, they're home for dinner, because of how amazing the perioperative care has become, from the pre-op pain medications, to the intraop medications we give, the injections. The anesthesiologists are amazing in terms of the spinal anesthetic they give, the postoperative blocks and then the postoperative pain regimen and, other management of symptoms has allowed patients to go home a few hours after surgery. I mean, that's the incredible thing that we're doing these replacements almost the same day and with minimal pain. So that's what blows my mind compared to what I saw when I was a medical student to now.

Host: What about the actual surgical time now? And I know this is a hard question because it's case by case, I get that. But, with the robotics sometimes that are being used, better equipment, all that put together, is the actual surgical time decreased?

Dr. Dustin Hambright: Would say the surgical time has decreased. There's lots of new technology that's coming in. Robotics approach, surgical approach you take to the, the hip and knee. A lot of that hasn't panned out yet on long-term data is this increasing function and in improvement in the long term outcomes.

But yes, I feel like, we are getting, quicker in the OR. This is not like a five hour case anymore. This is an hour to an hour and a half surgery. And some of the, the new components, like the cementless components; you're not waiting for cement to set. You're cutting time off the regular old surgery, taking some of those out of the equation.

Some of the technology has helped, some of the robotic technology early on there's a learning curve. It does slow surgeons down, but as you integrate it and with time, it will sort of speed you up in the long run.

Host: So what's your advice then here you got, let's say somebody, a patient in their forties or fifties, you know, a lot of joint pain. Someone like you, an expert like you, Dr. Hambright has said, you know, I really think a replacement is what we need for you. It's affecting your life. but they're hesitant.

They're just like, I don't know about this, that surgery, that scares me. I've heard about bad recovery stories, all this kind of stuff. What do you say to that patient?

Dr. Dustin Hambright: The patients that are younger and are a little reluctant, I always feel like, I always feel bad seeing them for the first time and, and saying you need a replacement. So, if they have borderline arthritis and they're young, I'm lucky that I'm surrounded by experts in preservation of knee and hip and sort of, I'm able to refer them to these surgeons that are able to preserve joints.

And sometimes we'll get their opinion to say, Hey, I know this guy or gal has some borderline arthritis. I think it's too far along to preserve, but will you take a look? And I think after that preservation surgeon kind of can give them a, a second look, sometimes it will put their heart at ease.

Say, Hey, this thing's too far along, you need a replacement. And I think when they come back to me, I think they feel a little, a little more at ease. There's nothing else really to do with this. If they're still reluctant, you know, I like giving anecdotal stories of patients that I've done that are young and how, how much it's changed their life, I think that helps a lot to say, Hey, like I have done a, a hip replacement on a 17-year-old, girl who had deformity of her hip and it changed her life. That's like at the one end of it, and I, you know, I've done it on a knee replacement, a 35-year-old who now runs marathons.

I mean, I love telling those stories because I think it kind of, it says you're not alone. There's other people that have had this issue and have done amazing.

Host: It's the personal stories that people remember the most, that encourage the most than maybe the clinical data that you and I like to look at. Right. So I think that's fantastic. Dr. Hambright this has been great. Thanks for coming on.

Dr. Dustin Hambright: Oh, of course. Thank you very much.

Host: To find a physician, you can visit novanthealth.org or for more health and wellness information from our experts, you can visit healthyheadlines.org. Thanks for listening.