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Dr. Kendal Williams (Host): Welcome everyone to the Penn Primary Care Podcast. I'm your host, Dr. Kendal Williams. So, one of the most common procedures that primary care physicians refer their patients for is orthopedic joint replacement, either of the knee or of the hip. It's a remarkable procedure that actually prolongs life, not just mobility, but actually does prolong life, particularly in the case of knee replacement. And so, we're often managing patients along the spectrum of joint replacement process, both anticipating the surgery, preparing patients for the surgery, and then even sometimes removing their bandages when they come back into our offices, so through the whole process. And they come to us with all kinds of questions.

So in order to sort of educate us so we can educate our patients, I wanted to invite two experts on the podcast. With me today is one of the senior and most respected joint replacement surgeons at Penn, Dr. Craig Israelite. Dr. Israelite is the Co-Director of the Knee Replacement Service at Penn. He is the former Associate Director of the Penn Orthopedic Residency Program and a person known to us as a great orthopedic surgeon. Craig, thanks for coming on.

Dr. Craig Isralite: My pleasure.

Host: With me also is one of my colleagues from the Division of General Medicine, a terrific colleague who has done remarkable work in developing the Orthopedic Co-Management Program at Penn, mostly in the process of preparing patients for surgery. And that is Dr. Laura Kosseim, Laura?

Dr. Laura Kosseim: Hi. Thanks for having me.

Host: Yeah, thank you for being here. When I was at Penn Presbyterian as a service chief, we founded a hospitalist program. And one of the things that we did was roll into that, an Orthopedic Co-Management Program. So, I was able to work with Dr. Israelite on setting that up. But it turned out that I think we really moved the statistics in terms of the quality of the experience for patients, but also just the outcomes when Dr. Kosseim got involved, and did a lot of the prep work in preparing patients for surgery and frankly also selecting folks. And that role has grown and evolved, and Dr. Kosseim now does it not just at Presbyterian Hospital, but at Pennsylvania Hospital, as well as the Director of the Orthopedic Co-Management Program. Did I miss anything there, Laura?

Dr. Laura Kosseim: No, I think that you touched upon it all that I've worked with Dr. Israelite for many years now, probably 12 or maybe 15 years with the Orthopedic Program at Presbyterian. And it's been fantastic for me to see the changes for our patients having surgery. I remember, and I'm sure we all do, that patients would get admitted to the hospital for knee replacement or hip replacement and be in the hospital for many days and then go to a rehab facility. And now they are having often same-day or one-night surgery, one night in the hospital and going home. And it's rare for our patients to go to a rehab or skilled nursing facility. So, there's been a lot of wonderful changes in this surgery and joint replacement.

Host: Yeah. And Dr. Kosseim is also a primary care physician or was for many years and has a great deal of experience in the broader perspective of prepping patients for joint replacement.

So, I want to set this up. When I went back into primary care, I had an older patient say something I thought was very profound. He was 82 or so, and he said, You know, Doc, I get the literature from my college, from my high school and other places. And I always look at the obituaries, you know, and I see the folks that I went to school with who have passed away." And he said, "When I was in my 60s, it said so-and-so passed away from a heart attack or whatever. He said, "But now in my 80s, I noticed that when people pass away, the most common reason is complications from a fall." And what I think that insight brought home for me is the recognition as primary care physicians, we're often worried about the cardiac stuff. And we really can do a good job in protecting people if we get on it ahead of time, and we do a good job at preventing cancers. But what happens as you get older in life is that people actually succumb to frailty. And that was the first thing that helped me to understand why knee and knee and hip replacement in particular are lifesaving, right? And not only just improve quality of life, but the length of life. So, this is an important discussion here today.

So, I wanted to start this out by just framing it for a patient that comes in first to Primary Care with a knee complaint. Where I start usually is a patient comes in with a knee issue, I suspect they may have osteoarthritis as the cause of their knee issue. Usually, these are older folks. I do an x-ray. It may say moderate DJD, it may say severe DJD. And then, I go through the process of sending them to you, Craig. And it is offered you actually I do send them to. So, when you are evaluating a patient as to whether or not they would be appropriate for a knee-- and we could talk about a hip as well-- what are some of the factors in that decision?

Dr. Craig Isralite: It's primarily their chief complaint. Just like medicine, you take a history. And we do rely on films. But being the program director forever, I taught medical students, residents, rule number one is you don't operate on x-rays, you operate on people. And that's just not a saying, that is the absolute truth. And there are people with horrific x-rays who don't need an operation, because they're functioning quite well. And there are people with mild degenerative changes on x-rays, and they have no independent lifestyle. And so, you have to take the history and see what exactly is causing their inability to function independently. And it's different for different people. I have people in the office who come in and demand a knee replacement because they can't golf seven days in a row. They can golf six days in a row, but they're really upset they can't do it on that seventh day. And I have people who literally are afraid of surgery or wait until they're almost wheelchair-bound. So, we see the whole spectrum. But the most important job I have is to determine, along with the patient, at least from an orthopedic standpoint, will this enhance their activities of daily living and lifestyle? That's the most important question that films actually are secondary.

Host: I wanted to just get into the knee issues a little bit because, generally, if I see mild on there as in terms of the OA, I generally think, "Oh, well, maybe have a meniscal issue" or some other issue that's impacting here. And I'm not the most sophisticated examiner of the knee and determiner of exactly is it patellofemoral? Is it a medial meniscus or something like that. But, you know, I think there are clues, I think that OA can also mimic other things, right? It can be felt more medially, it can be felt more laterally and so forth, right?

Dr. Craig Isralite: Correct. Well, first you want to determine is it from the knee or is it referred? And so, people with hip pain can have knee pain. People with back pain can have knee pain or back pain. So, an examination usually will discern that. But again, Orthopedics is very simple, which is one of the reasons why I went into it. I mean, there's only a few things that can cause knee pain. It's bone, tendons, ligaments and cartilage. I don't have a differential diagnosis of 500 things. And so, by physical examination, a lot of times you can determine that. But the biggest thing is, is it from the knee or is it from some extra-articular source?

Host: Is it true that you probably aren't thinking about joint replacement unless it is moderate or severe?

Dr. Craig Isralite: Well, radiologists do not read films like orthopedic surgeons and they have different scales. And so, we look at those films and sometimes I will look at the reports and they'll say mild, moderate. But many films, first of all, are not weight-bearing. You'll see a joint space because the standard x-ray that most primary care physicians order is just an AP lateral and maybe a merchant view, or just three views of knee. But if you don't get a standing view, it's very difficult to determine if they do have to joint narrowing. And you'll see a difference between a weight-bearing and non-weight-bearing. And so, we get these reports all the time that say mild or moderate osteoarthritis. And when they stand on it, you can see it's essentially bone-on-bone. And so, the radiologists are very good, but they interpret films very differently than orthopedic surgeons. And as I said before, a paper cut can hurt. And there are people with bone-on-bone, terrible arthritis who have mild symptoms. All it will tell you is that they have some. So, you look for osteophyte, subchondral sclerosis. But if there's joint space, people say, "Well, there's not too much arthritis," but you have to look at the secondary characteristics.

Dr. Laura Kosseim: So, what film should we be ordering when we have a patient that we're thinking, "Oh, I think this is bad OA, and I think you might need to see the orthopedic surgeon. He's going to want films to see. Let me order them in advance so that everything's ready"?

Dr. Craig Isralite: So when you order a film, a standard x-ray-- if you just check x-ray right knee-- it's generally for primary care physicians and other physician's order x-rays, it's generally an AP, which means from the front, a lateral and a merchant view, which is a patellofemoral view. You really want to specify weight-bearing or a 40-degree flexed AP. And so, what that does is it gives us a better view of that three-dimensional space. And so, you really should order a minimum four-view x-ray, one of which would be weight-bearing. So, that'll give you a lot more information, and you will see the difference.

Just as an anecdote, like when you go an airplane, there's always this ad which shows a space of cartilage. And then, they take some miracle drug, glucosamine something or other, so it shows no space. And then, three months later, it shows open space. Now, how's that possible? It's the same person's knee, so there's no false advertising, but they took an initial weight-bearing x-ray, and then they take a non-weight-bearing x-ray. It's genius, but when you go into any airline, and these magazine, every time I sit there and I just chuckle.

Host: So, we're going to get to the actual surgery of joint replacement, but I think we should talk about options other than joint replacement. And I think one of the things that comes up for me that I've seen more data about recently, and you kind of alluded to this, is exercise that people who tend to be more active tend to have less pain with the same type of x-ray. And, I guess, weight loss fits into that, which of course has become something we can actually help patients with nowadays, which we couldn't do in the past, to help people get through this process, at least prolong the time to when they need a new knee replacement or a hip.

Dr. Craig Isralite: You know, exercise. And again, orthopedics is very simple. If it hurts, don't do it, obviously. But if you can participate in exercise, walking, riding a bike, particularly lower impact activities that has been shown with many studies to be beneficial. And when you go on non-operative treatment recommendations from the Academy of Orthopedic Surgeons, physical therapy is there, general exercise is there. It's not to say if you have a knee problem, you should be running marathons or playing tennis five times a week. But absolutely, it's multifactorial. So, it's better weight, better cardiovascular conditioning. There's a lot of other things that go into it, but exercise in and of itself is generally recommended for the treatment of at least mild to moderate osteoarthritis.

Host: Laura, I don't know if you're seeing this as well, but patients who are going on GLPs and losing weight, but even in the process of going on GLPs, they come back to me and say, "You know, doc, my knees hurt less." And I wonder if there's some dietary aspect to this. I notice when I have a bad weekend where I eat a lot of sugar, my knees hurt more than when I've been good and disciplined. So, I don't know if we may find more about this in terms of inflammation and some other aspects.

Dr. Laura Kosseim: Yeah. I don't know about the food choice part. But certainly, weight loss, I absolutely agree, everything gets better, right? Their sleep gets better, their mood gets better, their diabetes, their blood pressure, their joints. It's fabulous.

Dr. Craig Isralite: Well, Kendal, lemme just say, as a primary care physician, we study physics in Orthopedics, it's a 1:6 ratio. And so, people say, "What's a couple of pounds?" But every pound you lose is magnified by six. So if you lose 10 pounds, which is significant weight loss, but doesn't sound like much for a patient, that's really 60 pounds of pressure on their knee when they descend steps. So if you told somebody they were going to feel 60 pounds less of pressure on their knee, they would say that's probably a significant amount. And that truly is.

So, it doesn't improve the cartilage on the end of the bone. But because osteoarthritis in general is a mechanical weight-bearing entity, the less weight you have on it, the better you're going to feel. So, weight loss is absolutely a recommendation. And remember to tell them it's a factor of six. You multiply it by six.

Host: I did not know that. So, the other thing we send you to, and we send patients to you for, is if they don't want knee replacement surgery or they're not ready for it, some of these, I would refer to them as temporizing measures: steroids, hyaluronic acid injections, and so forth. I guess saying that they're temporizing lasts maybe six months, that's probably an accurate way to think about them. Craig, would you correct me on that?

Dr. Craig Isralite: In 2025, there is no way at this point to reverse cartilage damage. So, everything else is temporizing. And so, essentially, to go along with the question, there's three ways to treat everything in life when you're an orthopedic surgeon. Treatment number one is just benign neglect. That's like your father saying, "Just rub dirt on it, it'll go away and just live with it." Treatment two is treatment, but non-surgical treatment, which is all the things you talked about: weight loss, gentle fitness; anti-inflammatories, including Tylenol, which sometimes gets stopped; injections of which there's a myriad of injections out there. Some with good signs, some with not so good signs, but some of them do help quite a bit.

But again, none of the substances that we inject induce cartilage repair. And so, it is a temporizing, but that's good too. I mean, it's a non-surgical treatment. Eventually, the only way to truly treat it is a joint replacement. But again, we're not stupid. We don't go out in the waiting room and say, "Who wants an operation?" Nobody wants an operation. Patients definitely don't want an operation, and we want patients to get better. But there are those standard non-surgical treatments. There are some though that are in the literature, or not in the literature, but advertised very heavily, which really have no prospective randomized controlled studies that show they work. And so, you don't want to go down that pathway and have patients waste a lot of money.

Dr. Laura Kosseim: It might be interesting since it's a relatively new therapy to talk about who you would refer for radiation therapy for their knee osteoarthritis.

Dr. Craig Isralite: Yeah. So, that is relatively new, although radiation therapy with radionuclide that they used to inject in the knee. There used to be radiation synovectomies years ago. So, we know radiation will reduce inflammation. Again, it doesn't help with the osteoarthritis. But over the last several years, there's been a renewed interest in our radiation oncologists that they actually give very low dose radiation, I think, it's over six or eight sessions, and there's purported to be no significant long-term effects, particularly in someone who's elderly and it helps with their symptoms. So, there is some evidence to show that that does help. Again, it doesn't cure anything. And people are worried, "Well, what if they have surgery afterwards? Will it affect their wounds later on?" Because we always worry as an orthopedic surgeon about wound healing. But they've said in their literature, there's really no significant downsides. And so, your primary care physicians who are listening, it is Medicare covered. So, it's not like PRP or stem cell, which is a fortune, but very limited effect in my opinion. But it is a relatively newer treatment that's offered by our radiation oncologist here at Penn.

And so, someone who's elderly patients on dialysis, you know, people who are really not surgical candidates, moderately advanced osteoarthritis, I have-- again, because it's relatively new, this is all anecdotal from my standpoint, although the literature would support that it has some effect. some of them have said that it has helped their symptoms. Unfortunately, it's not long lived, and so they can repeat it. But we don't know the long-term outcome yet. But for someone, if they're not a surgical candidate, it's certainly in the armamentarium.

Host: And the other thing you mentioned, and I think it's probably worth at least bringing up because it comes up, patients ask about it, and that's platelet-rich plasma. You mentioned stem cell therapy as well. I mean, I know, I suppose there's a lot of different circumstances in which patients are getting PRP. I see high level athletes being described as getting PRP, and I had always thought it was a little voodoo. Is that kind of still where we're at with it? Or maybe there are some sort of non-OA of the knee indications in which it may be valuable, but where are we at with that?

Dr. Craig Isralite: I am not sure. And again, I'm a little bit prejudice because obviously I see the failures. So, I have personal experience, but then I'm supposed to read the literature. And so, if you really read the literature when you're really looking at prospective randomized controlled studies for the treatment of advanced osteoarthritis, really no significant benefit. And it's very expensive. There are anecdote studies of athletes who do get these for different tendinopathies and they seem to have some accelerated benefit. But you could look at it and say, "Well, they are professional athletes. If you put them in the room, they're just going to do well anyway." There are studies both ways. But specifically, for osteoarthritis, it does not induce cellular activity that's going to regrow the cartilage on the end of the bone. And because of that, to spend thousands of dollars is a lot of money when studies show not that much difference between that and a cortisone injection.

Host: So, we send a patient to you. And you feel that they're appropriate from an orthopedic perspective to have a knee or hip replacement. And we'll get into those procedures in a little bit. The next question, I think, that patients will come back to me with, come back to Laura with, and then we'll explicitly go to Laura for, is whether or not this is a good idea for them medically. And I think that, a lot of times, there's a factor you have to think in your head of there's an opportunity cost if patients don't get the procedure. You know, I'm worried about if they don't get it, how frail are they going to get, because now they can't walk as far and they're not keeping up their other performance on their other joints and other cardiovascular performance.

And so Laura, you've seen this from that primary care perspective, but also now you're also evaluating patients more specifically. So with that long-winded introduction, I'll ask you a question. What are the primary factors that go into your decision as to whether or not you recommend somebody medically could get a knee replacement or a hip replacement?

Dr. Laura Kosseim: So, I guess I would start by saying I don't view my role as deciding whether or not they can or should have surgery, but it's to risk stratify them and to optimize them. So, providers listening may not realize that our orthopedic surgery department is doing knee replacements and hip replacements on patients with active cancer, patients with LVADs for destination therapy, heart transplant recipients, liver transplant recipients, patients awaiting liver transplant with MELD scores of 16, 18, really sick patients. And there is a lot of care taken to optimize those patients for surgery between coordinating with the LVAD nurse to be in the operating room with the patient, making sure that the anesthesiologists are aware that this patient is coming in who has had malignant hyperthermia, gene testing and is positive. There's so many interesting patients. And it's really a privilege to be able to work at an institution where we can provide the surgery for patients that are not getting operated on anywhere else, whose life is really negatively impacted by their joints. Somebody has liver disease, for example. We now have the Penn score for evaluating their risk for decompensation with surgery. And I'll go through the survey with patients and I'll print it out for them and I'll show them like, "Your risk for decompensation or mortality is x," 10%, some high number, when a normal healthy patient, it's less than 1%, right? And they will say, "I cannot live with this. This is so negatively impacting. This pain, I'm now on chronic narcotics. I can't walk. My quality of life is zero. I would rather die than live with this." And so, it's, "Okay, well, let's see what we can do to make you as healthy as possible for this surgery. And make sure your platelets are okay and make sure you're on all the right medicines and that you're really well compensated and have a team waiting to embrace you when you got through that surgery."

Host: A common issue that comes up is age. Just how old is too old? I have a friend who is also my patient who is 85 years old. He has absolutely no limitations at all. He plays tennis five days a week. He just went to his granddaughter's wedding in Guatemala and hiked mountains. No limitations at all. So, I mean, obviously, not every 85-year-old is like that, but I'm curious about that aspect, the age aspect, because this is actually becomes up a lot getting to the frailty issue. Because oftentimes if people don't get the surgery, they're going to die within the next couple of years, right?

Dr. Laura Kosseim: So, frailty is such a great point. And you brought it up a few times. So, the 2024 American Heart Association, American College of Cardiology Perioperative Guidelines for non-cardiac surgery identify frailty as one of the risks that we should be evaluating and addressing, because it's well-known that patients that are more frail are at increased risk for more complications postoperatively for non-cardiac surgery, with the least impact actually of frailty being on patients getting joint replacement surgery. So as opposed to patients needing abdominal surgery or CT surgery with frailty, the patients needing knee replacement do much better, or hip replacement, because their frailty is due to their joint issues. And that improves postoperatively. So, frailty should be something we should take into consideration, but part of the treatment is going to be their joint replacement, as opposed to it being an impediment to joint replacement.

And as for age, as our population ages, so the patients that make it to 80 or 85, their life expectancy is actually longer because they've selected themselves out. It's sort of survival of the fittest. They're the fittest. If he is doing great at 85, you would expect that his life expectancy may be late 90s and still doing well, right? So, I don't think that age should necessarily be a barrier.

Things that could be a barrier, if he's 85 and he has memory issues, that's something that we don't always think about. We think about diabetes and blood pressure. But post-op delirium is real. It's very dangerous. It can have long lasting side effects or consequences to patients. So, mental acuity is as important as physical strength.

Dr. Craig Isralite: That post-op delirium is a real issue. And I think that's much more of an issue in the elderly than their physical ability. Most people can handle the surgery and rehabilitation. And I warn families that, you know, when you're in a hospital, there's sundowning, there's a lot of those issues. It's a real thing and it doesn't clear when they leave the hospital in many times. So, it's really the cognitive.

On a physical basis, I look at patients a little bit differently. And because I know what's coming, if they miss their opportunity, the window of doing it, my personal view is, once you're in your 60s, you're as healthy as you're ever going to be in your entire life-- I hope you stay that healthy forever, but nobody gets healthier-- the pain and arthritis gets worse with time. It's not reversible. You're not going to be crippled tomorrow. But it gets worse with time. And one surgery, the surgery we do is usually one and done. With hips, it's now down in the 50s. But even with knees, which don't have the same expectancy, if you're 62 or 63, the actuaries and there's data out there, because the number of steps, et cetera, et cetera, et cetera, it's probably a one and done. So for me, it's easy to say you're as healthy as you're ever going to be. The pain's going to get worse with time. One surgery should fix it. You should consider an operation-- I don't say you have to have an operation-- consider it. And then, we send them to one of the best things at Penn, which we have an amazing co-management team who will tell me they can't have it. They have to be medically optimized. So, it's a team approach to see if they can then have the surgery.

But I hate when patients come, and I don't know if cardiologists listen to this, but they say, "Well, my cardiologist says maybe next year." They're not going to be healthier in a year unless they do some optimization strategies. And age, you know, one of the oldest patients I did was the mother of one of our former Chief Medical Officers at Presbyterian, where I actually called that doctor, said, "Really?" And she told me that her mother did this, this and that, and lived many years after her knee replacement, dancing and traveling. So, age isn't the factor. Delirium is a real issue. But if they're healthy enough to undergo surgery, I'd rather do them at 82 than when they come into my office at 90 and the cortisone shots aren't working and then they might not be a candidate. That's a real problem.

Host: This window of opportunity issue, there's a window, right? And beyond that, they just get too far along. It gets harder to manage.

Dr. Craig Isralite: Unfortunately, that's true.

Dr. Laura Kosseim: And their recovery, you know, if they have not been walking, if they're mostly staying in their house, because they're worried about falling outside or they're embarrassed to be using a walk or they're scared to use a walker or a cane because they're scared about falling. They get more and more deconditioned. And I think Craig will speak more to this than I, but I think that they can recover from hip replacement surgery a bit easier. But knee replacement surgery, it's a bit more physical, that recovery. And if they don't have full extension afterwards, if their muscles aren't strong enough and they're weaker, it's not going to be as successful an operation.

Host: There are four medical factors I want to just bring up real quick, before we go into the actual surgeries themselves. And this was highlighted by a talk I was listening to by an orthopedic surgeon, and he was talking about smoking, diabetes, uncontrolled diabetes, obesity, and undiagnosed sleep apnea, were the four things that he most worried about. And then, Laura, of course, at Penn we have high MELD scores, transplant recipients and those other aspects. But when you are evaluating somebody, Laura, these are folks that you say, you know, "You're not quite ready, go back and then come back in a little bit." And Craig, you can chime in on this aspect. Are there sort of things that you say, no, no, not right now. Let's work on a few things.

Dr. Laura Kosseim: Absolutely. If somebody has poorly controlled diabetes, right? That's a very modifiable risk factor. If their A1c is 10, they need to postpone their surgery and work on their diabetes. And we actually have at Penn a group in Endocrine who they just do pre-op diabetes management. So if you're struggling with your patient-- the primary care doctors out there-- if they're struggling with a patient who really the surgery is going to be very beneficial to them and you're not able to get their A1c under control, surgery's a great motivator for a lot of patients. We can get them to get their diabetes under control. We can get them to see the dentist. We can get them to start taking their blood pressure medication because they want this surgery. So, diabetes, big modifiable risk factor.

We have a long conversation with all of them about smoking cessation. And talk to them about the risks of tobacco use with especially knee and hip surgery, because that already puts them at risk for DVT and tobacco use further increases that risk. And that often is eye-opening for them. They're like, "Oh, yeah, I've heard that DVTs can be fatal, so I don't want that." And we prescribe Chantix to them. We prescribe nicotine patches or nicotine replacement.

In terms of sleep apnea, that's sometimes a little bit harder. If somebody has already been diagnosed with sleep apnea, we have them bring their CPAP machine into the hospital with them and we monitor them on continuous pulse ox in the hospital postoperatively. But if they haven't been previously diagnosed, we are encouraging those patients to get tested before surgery.

Host: So, let's dig into the surgeries themselves. Craig, I'm going to punt it back to you. I guess, is there any prep work other than what Laura has just described in her group that the patient needs to do before going to surgery? Then, what happens when they come to surgery now? What does a modern-day knee replacement look like? And we can talk about hips separately, but what does that look like and what happens immediately afterwards?

Dr. Craig Isralite: Well, from a surgical standpoint, the procedure, the actual technical procedure is the easiest part of the whole process. It is a 45-minute to one-hour procedure, and that's from the incision to the bandage. And so, not to say that if your surgeon does a two-hour procedure, that's not good, but we do a lot of them. And so, it's a one-hour procedure. It is not a replacement.

So, that's the other thing I tell people. We are doing a resurfacing called an arthroplasty. So, people hear the word knee replacement, they think we chop their thigh, they chop their tibia and take everything out and put everything in. All we are really doing is covering the ends of the bone. So instead of the bone rubbing on the bone causing friction and instability, we're putting metal and plastic and ceramics in there to allow the joint to move freely. And it is a technically very reproducible procedure. We now do a lot of robotic surgery, which makes it even more precise. But from incision to bandage, for most procedures, it's 45 minutes to an hour. With knees, there's no blood loss, because we use a tourniquet. With hips, a little bit. There's been advances with blood conservation too, with if you're familiar with TXA and other additives. Even 10 years ago, almost all of our patients either pre-donated blood, or they would get a transfusion postoperatively because we made them anemic because of the preop donation. It is rare now that our patients even get postoperative blood transfusion. So, the procedure in itself is very streamlined and very reproducible. And again, it's called a replacement, but the technical name is arthroplasty, which means we're just covering the surface of the joint.

Host: One little pearl you taught me years ago was that, after most surgeries, like GI surgery, somebody gets sutured up, cauterized, all the bleeding is done when patients leave the OR, but you taught me that in orthopedic surgery, the marrow can continue to bleed. And so, you'd have people dropping their hemoglobins within the day or two afterwards. But now, you said with tranexamic acid and some other product, that's less of an issue, right?

Dr. Craig Isralite: That, plus we've changed our anticoagulation. And so, I don't want to get into the whole political aspect of it, but we were overcoagulating, based on recommendations from many drug company-sponsored trials where we were giving them a lot of low-molecular-weight heparin, a lot of Coumadin. Most patients, unless they have significant risk factors, get baby aspirin. And so, that is better than putting people on anticoagulation afterwards, because that caused a lot of bleeding as well. But yes, the general surgeon, they coagulate everything. It's perfectly dry when they leave. For surgery, it's also dry. But the bone marrow, that's where you make your blood, you can't put a stitch in bone. And so, people generally, post-op day one, have a minimal drop of their hemoglobin. But then, day two or day three, which we no longer keep people in the hospital that long, but they would drop in on day two or day three, they would get their blood transfusions. But I won't say it's non-existent, but it's rare now that patients postoperatively, if they have a hemoglobin above 12 to start, rarely need postoperative transfusions unless there's something specific to their procedure.

Host: And you're doing more spinal anesthesia now, right? I mean, we talked about delirium risk earlier. Certainly avoiding general is better for reducing delirium risk. There's a lot of more efficient aspects to the procedure now.

Dr. Craig Isralite: There's still some debates about that. But generally, most people get a nerve block to their extremity in addition to a regional or a spinal anesthetic. At Penn Presbyterian, probably about 70, 80% get regional anesthesia. And the less sedation, the better it is postoperatively. I don't think there's any question about that.

Host: So, I know there are circumstances, of course, where patients have both knees that need to be done. And you can do that either as a staged procedure. I seem to remember there were some patients that would elect to have them both done at the same time. Can you talk us through what happens when you have both knees that are in bad shape? Which is often a case I imagine, because both knees are bearing the same weight.

Dr. Craig Isralite: Yes. And that's changed over the years as well. So, I did do a lot of what's called simultaneous bilateral total knee replacements. And it makes sense for the patient. You know, it's one procedure, you get one episode of care, and you don't have to go back for your second knee. And so, we've slowed that down because of many advances with total knee replacement. So, most of our patients go home, so that's number one. if you have both knees done simultaneously, it is difficult to go home from the hospital. And to go to a skilled nursing facility, which is what now qualifies as postoperative care, it's not some fancy rehab. In general, most patients do not want to go to a skilled nursing facility. Increased readmission rate, increased infection rate. I mean, the data's pretty significant. Now, those people do have a little higher risk for blood transfusions. When you talk about morbidity and mortality, really not that much. It's statistically significant, but not to the point where it adheres. So, bilateral simultaneous is much less common than it was for those reasons.

At Penn, I actually do something a little unique, is that I do staged knee replacements at one week. I do their procedure, they go home that day or the next day. And as long as they're able to stand on it, get around and mobilize. I do their other procedure, the other extremity the following week, and they can go home from that as well.

And so, a lot of people like that. It is two surgeries. And we have lots of data on it and some publications that shows no real significant adverse outcome. And it's one episode of care. So particularly, the patient who has to work, they only want six or eight weeks off of work, they don't want to do it again, it's really a very good choice for them. So, there are still simultaneous bilateral knee replacements, but there are some significant risks to that and social risks for them as far as postoperatively as well.

Host: So when a patient goes home, they're in the home, do they-- for a knee-- we'll talk about knee first-- do they get physical therapy right away? What are the goals of the physical therapy in the short period and so forth, short term period?

Dr. Craig Isralite: So, we have Penn Home Health and Physical Therapy visit them at their home for the majority of patients, just to get them up, get them mobilized because it's hard to go to an outpatient facility. And so, the general population goes home within a week or so. They then can go out to outpatient physical therapy. There are some patients who don't need any physical therapy, particularly patients in their 50s, 60s. They have decided that they can do it on their own. And so, we don't force it on people. But our fallback is to send physical therapy to them.

There are some outfits in Philadelphia that don't prescribe physical therapy, for one reason or another. And they have data to show that it helps, you know, or they're able to recover from their operation. But I think for the typical patient, having a physical therapist demonstrate their range of motion strengthening, make sure there aren't any problems postoperatively, we get calls from physical therapists and home nurse, the wound looks like this or whatever, because people do go home now. When I was a resident in the '90s, everyone stayed in the hospital 10 days. We basically took out their sutures in the hospital and then sent them home. It is the rare patient that spends more than overnight or two days in the hospital. It's usually a medical issue. And so, we rely on these home physical therapists and home nursing, which generally is a week or two. Then, they do outpatient therapy.

And to go to your next question, well, how long does it take? I tell people they don't like me for two months. That's the bottom line. It hurts like heck for the first couple days. By a week or two, most people are getting around on a cane, doing reasonably well. But it's that two-month period that most of the population is going back to work and doing their activities. We have outliers at two weeks who could go back full duty, and we have people at six months who still want to punch me in the nose, but the generalization is about two months.

Host: And do they go home with staples now?

Dr. Craig Isralite: Well, you can have staples or glue. There's differences. Believe it or not, cosmesis is about the same. There's risks and benefits of either. But at Penn, it's probably about 50/50. They could have staples or they could have glue closures.

Host: So, how does everything we just talked about differ when it comes to total hip replacement?

Dr. Craig Isralite: Surgically, it's a different operation because it's on a different extremity, but it's generally a little bit less painful. For hips, there's less physical therapy, rehabilitation necessary. So for knees, you need motion. Hips, as long as it can get up and walk, they don't really need much physical therapy except for gait training, is really the big difference, and the amount of physical therapy and the recovery period.

But the time is similar. It's in that less than two-month period where people get better. But the pain has been described as much less intense, and the therapy is a little bit more advanced and quicker, because there's not as many range of motion and strengthening exercises. It's more of a time element and safety.

Host: I know for hips, there's at least two different approaches, right? There's a posterior and anterior, I suppose there's only one way to get at the knee. I haven't thought about this too much.

Dr. Craig Isralite: There's just an anterior approach to the knee, but there's actually anterolateral and posterior. And the reality is, at two weeks or so, they're all fairly equivalent. Unfortunately, Orthopedics because it is a big market procedure, there's a lot of advertising out there. And what I tell patients, and I tell them there's three different ways to do this, but you want the components to be put in correctly, you don't want to have a complication, and you want it to last your lifetime. That's really the most important discussion.

And the discussion has somewhat gone to the, "Well, you can go back to work in three days. That'd be with this approach." If I were a patient, that would be lower on my list. And you know me, I like to work. But you don't want a complication and you want to be able to see what you're seeing. So when I talk to patients, I say, "Go to the surgeon." And if they feel, in their hands, a posterior approach is better or, in their hands, an anterior approach is better. It is a great operation.

In Lancet, which is a medical journal, it rated hip replacement as the number one procedure of the last century. It is a great procedure. My advice is don't screw it up by taking shortcuts. Use the approach that the surgeon is comfortable with. And if it takes you five days more or a week more, early on, that the results are very similar.

Host: You mentioned complications and there are medical complications that I think Laura and I know about, you know, and we have managed in the past. That's sort of in our domain. Then, what we need to know more about is the surgical complications issue. I know top among that is infection. but what do you quote patients about, A, the complication rates, and what are some of the complications that we can see?

Dr. Craig Isralite: Well, there are complications with any surgery, obviously. And the big ones that are quoted are infection, dislocation, fracture, nerve, artery. But believe it or not, those are very small at this point. Nationally, infection rates after total joint hover around 1%, that's pretty good. That means 99% of these very sick patients, morbidly obese, et cetera, et cetera, on LVAD as Laura mentioned, very low. At Penn, we know what ours is. I know what mine is, it's 0.2. I think that's pretty good, but it's not zero. And so, that's always talked about.

And so, blood clots is another one that's always commonly talked about. Many people do get DVDs, but fatal embolism has hovered around 0.15% for decades, even with all the chemoprophylaxis we've given. And some people just have a genetic predisposition is what we're finding out. But with early mobilization and just plain aspirin, people have been doing well, but those are the larger ones. And then, for me, it's not really considered complication where most people expect, but I tell them stiffness, that is my biggest complication. It's not what you would say is a complication of surgery, but when patients complain to me. It's usually about stiffness. And it's multifactorial why that happens. But you have to do your therapy and straighten your knee, bend your knee. And if you don't do it early, the knee heals and it heals with a scar, which contracts.

And so in my office, that's probably the biggest complaint that I get, that patients say their knee feel stiff. But infection, dislocation, fracture, tendon ruptures, I have to tell you, it's probably in that 1-2%, which means 98% of all-comers do pretty well from those standard dislocations.

Host: You alluded to this earlier, but with modern materials and so forth, we're seeing these things last 20 years. You said that there's a cutoff point in the 50s and the 60s. I forgot which was which for hip or knee.

Dr. Craig Isralite: So, hip materials have really improved in the last decade or two, where we now use ceramics and what's called crosslink polyethylene. It's a very strong plastic. And so, one of the primary failures of hip replacements when I was resident earlier on in my career was wear of the mechanical devices. We don't really see that in the hip anymore. It's extraordinarily unusual. And so, I can't say your hip replacement will last forever. But again, when I was a resident many years ago, we wouldn't operate on people who are under 60. It's not unusual for someone, even the 40s, and certainly in their 50s, if they have significant disabling arthritis, hip replacement, I think, is probably a one and done. We don't know that because we haven't been using these materials for 30 or 40 years, but bench data and radiographic data look very good.

For knees, we still don't have mastered yet. So, the quoted data is still that 15 to 20 year. And so, that's why I try and tell patients if you can wait until age 60 or longer, it's probably a one and done. But I operate on people in their 30s and 40s occasionally, because they just can't wait, we do do revisions, but we don't like to because they're much harder and more difficult for the patient. And we have other fixation techniques. So, one of the failures of total knee replacements has been lack of fixation because we use cement in knees as opposed to hips. And around the early 2000s, we started using uncemented knee replacements as well. And this new generation knee replacements look like they're going to last a lot longer. And that's what the data shows. But since I've only been using it since 2002, I have 20-year followup, which is good, but I don't have 30 or 40-year followup. But it looks promising. Hopefully, it will work out as well as the total hips.

Host: How much activity is okay after a knee or hip replacement? So, for instance, you mentioned the patient who golfs six days a week, wants to golf seven days a week. But what if somebody wants to run a marathon? I mean, is that doable on a replaced joint?

Dr. Craig Isralite: Well, it's certainly doable and I get all these pictures sent to me from presumably happy patients hiking Machu Picchu and Broadstreet Run. Every year, I get 15 cards from people who run the Broadstreet Run, who tell me, "Look what you did for me." Actually because of my personality, I don't really look at that as a good thing, particularly for younger people. People in their 60s, 65, particularly over 70, you could do whatever you want. We don't really give them restrictions. But if you're 50 or 60 and you're really doing these marathons and running, it is a mechanical joint. And so, there's some data to show earlier failure. But you have in your practice people who are runners. I eat candy all day. I'm not supposed to do that either. We all make choices, but I discourage that. But lower impact activities, like anything with your foot on a pedal, it's called a closed chain exercise, like on a bicycle, elliptical, those type of things, you can do as long as you want. Swimming, great. But running and jumping, we don't have data on 55-year-old people who run marathons because there's not as many of those people.

So, I tell people, you get a joint replacement, number one, for the relief of pain. Number two, for function. If someone comes in and they have moderate pain, but their goal is to play tennis or run a marathon, I tell them, "This operation is not for you. You should wait until you become much more disabled." And most people will tell me, "Oh, I'm not going to run anymore. I'm not going to do this anymore." But it's not that you can't, it's that you shouldn't, or we don't know and you could get injured.

The analogy I use is actually very passionate about very few things, but I'm a skier and I love downhill skiing. And I have patients who ski and I tell them I wouldn't recommend it because you could get hurt. And then, I say, "If I had a knee or hip replacement, I would ski" because that's part of my being because. But I know the risks and I'm willing to take those risks. But it is an at-risk behavior for someone who's never even had a joint replacement. If you tear your MCL scheme, if you did it today, you heal up in four to six weeks. If you tear your MCL with a knee replacement, it doesn't heal. You will need a revision knee. And so, that's a risk. I would take that risk because I love to ski and I have grandchildren now and I want to ski. But I tell my patients, do as I say, not as I do. It's one of those.

Host: I did not grow up skiing and I took my kids up. I have two generations of kids. I have older kids who have excellent skiers, and then I have the younger kids that I'm trying to teach. So, I decided I would learn with the younger kids, and I went up and I went on the slopes a couple times, and it just goes too fast for a man. My age, unless you've been trained at it. I was like, "These people are moving too fast. Everything's happening too fast. I need to go back to the lodge and work on my laptop." That's what happened. But cycling, golfing, tennis, I mean, I think those are all-- pickleball-- those are the most popular sports in America right now.

Dr. Craig Isralite: All my patients play pickleball. And again, if someone hits a great shot, you say good shot. You shouldn't be diving for the ball and those type of activities. But, you know, it's, "No, no, no. Hey, take this," but I just say just don't be a knucklehead. I mean, that's the bottom line. Everyone knows their own limitations and it's very individualized. And I do have patients seriously, who I've had a couple Ironmen, real Ironmen-- not marathon --real Ironman patients who've had hip and knee replacements. And I am worried about it. But I could talk from here to eternity and they're not going to listen to me. And there's not great data because there's not a lot of Ironman competitors who've had joint replacements. So, I like to try and tell people what's opinion and what's data, and there's a big difference between the two.

Host: So before we close, do you think there's any issues that we've missed? Laura, I don't know if you have any closing thoughts and things that we might have missed? And Craig, if there's something that you think of that I haven't hit on.

Dr. Laura Kosseim: Stop SGLT2s and GLP-1s before surgery. If your patients are having surgery, they need to stop those medications beforehand or their surgery will be canceled.

Dr. Craig Isralite: I have one point which you semi mentioned about x-ray versus MRI. So, I actually wrote a paper on this, so it's one of my soapbox things. Don't over-order MRIs. If someone has arthritis, an MRI's not going to change the treatment at all. It's $1,200 and we all need to be stewards of healthcare and cost. And so, that's one of my biggest pet peeves with primary care physicians who are listening to this podcast, is that it's not going to change their treatment. And it is very expensive. And that's one of the common things that I see, is that people will order an MRI for someone who's 72 years old, who was doing great, twisted their knee. Get a plain x-ray. I mean, that is the number one study. And so, we pulled primary care physicians at Penn, and the response was, isn't an MRI better? And the answer is no. It is not better. And it's very costly. So in this kind of a podcast to primary care, that would be my number one. If I could encourage people just not to do that, I just would save the thousands of dollars, healthcare dollars that could be spent for something else.

Host: I tell my patients when they ask me for an MRI, I say, "I don't order tests that I don't know how to interpret." Because I'll get a result back, and now, you know, maybe they have a medial meniscus thing going on, but is that the cause of their symptoms? I don't know. You know, it may be a degenerative meniscus thing that may been there forever. I have no idea. So, I just say, "You know what? I'll send you to the orthopedist. If they think you need an MRI, they'll order the MRI."

Dr. Craig Isralite: Fifty percent of everybody over age 50 has a meniscus tear of some degree, and we're not operating on 50% of the adult population in the United States. So, most of them are asymptomatic. And MRI findings at, particularly at age 60 and above, it would be unusual not to have at least a meniscal degenerative signal. And so, you go down this rabbit hole. They get arthroscopy and all these other things that probably aren't really helping. So, that's part of what I see a lot of in my joint practice

Host: I think more than I should about meniscal injuries, mostly because I'm a Sixers fan. And that there've been a couple of those recently that I've been thinking about. So, this has been a great discussion. I really appreciate the both of you coming on. It's probably long overdue that I did have you on. And Craig, at some point in the future, I'd love to have you or one of your colleagues on to talk about some of the meniscal injuries, the non-OA injuries that can happen to the knee and how we might evaluate those.

Dr. Craig Isralite: _____ those actually an expert on cartilage regeneration too, which is a newer hot topic. But if you email me, I can give you several of their names, you know, well, you'd know them all since you were here. So, I would talk to them, I'll let them do that.

Host: That's great. Well, thank you for coming on again. Thank you, Dr. Kosseim, Laura. It was wonderful having you.

Dr. Laura Kosseim: Kendal, always a pleasure to see you.

Host: Thank you everyone for joining another Penn Primary Care Podcast. And please join us again next time.