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Dr. Adam Rosen Presents Treatment Options for Chronic Knee Pain

– [Dr. Adam Rosen] So I’m hoping today to give
you guys some information. It’s actually really humbling
to see that this many people turn out just to hear what I have to say so I’m hoping that when you leave here, in addition to the packet
that you can take two, three, four tips, go home and start a
program that you can use to treat your knee pain and, for those of you that a little
bit further along that path, this might give you some more information on where you may be headed. My staff has probably heard
this a whole bunch of times and for those of you that I’ve
seen that are my patients, I have all my analogies. Can you hear enough? – No. – Okay. We’ll adjust and if you can’t hear, let me know and I’ll
stay behind the podium… just so everybody can hear. Yeah, that’s turned up all the way. And then at the end we’re
gonna have time for questions. So anybody that’s got questions, I’m hoping, I’m pretty good
at getting through stuff. Got it. (laughs) Jeff’s gonna follow me
around and hold that up but I’m pretty good I think at the end of, let me just do this. Is that any better? No. (audience chatters) Okay, I’m usually pretty good at the end where people say once they
look at their sheet of paper and they go through one,
two, three, four, five, and say oh, you answered them all. So, hopefully, that’s the case but if not, we have plenty of time. Let me just go through here. So here we are and like Jeff was saying, I went to college on the East Coast, did two years at Muhlenberg
which is a small private college in Allentown and then
finished up at SUNY New Paltz and did a lot of biology
there, and then back to where I was born and
raised in Philadelphia, did my medical school,
internship, residency at PCOM. I was lucky enough to get
into a fellowship here and did an entire year here just of hip and knee replacement surgery
with the docs that were here and I was really taken aback
and felt very privileged at the end when they offered me a spot. So this was an easy no-brainer. When I went home, my wife and I, we were looking for places all
over the country and I said, “Do you like it here? “Do you want to spend the
rest of our life here?” And she said, “Yeah, yeah.” “This is really nice.” So she loves it, my kids love it. They get spoiled by all
of the different things. Every time we go away, they think there should be
a Sea World and a LegoLand and a zoo and a Disneyland
all within driving distance but they get to live here. So I’ve been here since
2006 predominantly doing hip and knee replacement,
and this is probably one of the big questions that I get asked. So what is a DO? Where I grew up on the East Coast, I heard there was a
Philadelphia person there, a lot of people, Philly,
New Jersey, tons of DOs. When I grew up, my doctor was a DO, my orthopedic surgeon was a DO. So we do our four years of college and then a four-year medical school. The main difference is
more the philosophy, looking at the body as
a whole organ system, not as individual parts. So if you have a stomach problem, it may also lead to back
pain so we’re trying to focus on you as a person not just the one organ that has a problem. So they really focus on
the musculoskeletal system, which I think really
leads itself to help you become an orthopedic surgeon
because for four years, you’ve learned about all the intricacies of the musculoskeletal system
before being sub-specialized, but what’s interesting, and I found out a lot of people don’t even know this – in California, a lot of MDs
actually were DOs by training but there’s a whole issue. Prop 22 in 1961 and I forget the exact, it had something to do with
the billing and insurance and Medicare but they
switched everybody over. So if you were a DO, you sent the state $65
and you became an MD and that’s what happened. So UC Irvine actually was an
osteopathic medical school and for reasons to change over the degree, they sold it and it became, for $1, became an MD school overnight. So this is the goal tonight – I’m gonna talk about knee arthritis. We’re gonna talk about what it is, how do you treat it and then beyond that, if you need a knee
replacement, what is it? What happens? And we’re gonna go through
some of the details. So arthritis, I get asked all the time, what is arthritis? Do I have rheumatoid? Do I have “osteo”? So osteo-, bone, -itis, inflammation, so osteoarthritis in its general terms is an inflammation of a
joint and it’s typically due to loss of cartilage. Rheumatoid arthritis is different. It’s still pain of a joint
but it’s a systemic disease. These people are born with
a disease that affects all of their joints. It destroys the joints and
it works on both joints, symmetrically both right and
left where osteoarthritis, it’s not uncommon to
just have one bad joint and the rest of the joints
in your body are okay. So basic anatomy, because I’m sure everybody
has been on the Internet, everybody has a friend and
everybody knows was a meniscus is but there’s a whole bunch of
other stuff inside the knee. So the kneecap, what we call the patella, that is actually a bone within the tendon. It serves as a pulley system
so not only does it protect the front of your knee, but it makes your quad muscle stronger so it can straighten out your
leg and it acts as a fulcrum. The thigh bone, or the femur,
that’s capped in cartilage. So if you look up here, the cartilage, that’s what typically
goes away with arthritis and you also have a three
millimeter cartilage cap on the top of the shin bone here. So three millimeters of what
we call articular cartilage, that’s the cartilage that’s
smooth, that’s shiny. It almost looks like a hard-boiled
egg when you look at it but between those
cartilages is the meniscus. The meniscus is another
type of cartilage that acts both to cushion the knee
and it stabilizes the knee from going forward and
backward, secondary to the ACL. So that’s the second
most common thing I find that most people know about in the knee. The ACL, they’ve all heard of sports
players injuring their ACL and the second one’s the meniscus, but they both serve a function
to stabilize the knee. When you get arthritis, typically it can just be a wear and tear, more commonly if someone injured their ACL or someone injured their
meniscus years ago, they may or may not have had surgery, but when you lose the structure
that supports the knee, the knee starts to
microscopically slide around, and when that does, it starts to wear down the cartilage, so what you start to see, I don’t know if that’s coming
up on the white as much, but what you’ll see is the
cartilage starts to wear away, so you lose that three
millimeters of cartilage and now you have exposed bone. So when you stand it hurts, when you bend and straighten
your knee it hurts and when you start to do things, those are the things that
cause the inflammation and the swelling. So I threw these in here. I hope you like ’em. My staff, I’m sure they’ve
heard every one of my analogies, but what I found is, over time,
these make sense to people. Most common question I get – “Why does my knee make noise?” When I stand up it cracks and crunches, everybody in the room hears it. So this was the best
analogy that I’ve used, which helps you understand
that if you drove your car down the street, it’s asphalt or concrete, the car doesn’t make much noise. The tires are running
over the smooth surface but now there’s a rumble strip. It’s still asphalt or
concrete, but it’s irregular. So as your car goes over it, it wakes everybody up that
was sleeping in the back seat and that’s what happens with your knee because as you bend and
straighten the knee, the cartilage is irregular. So when you get up from
a squatted position and you put more force on
those little cracks and bumps, it goes snap, crackle and pop. So it’s not a bad thing. Sometimes, it smooths itself
out, so it will go away but that’s what’s gonna
happen when you stand up and that knee cracks and crunches. Now, who gets arthritis? This is the other common question that I get from a lot of people. “When am I gonna get it? Who’s gonna get it?” Baby boomers, our biggest generation right
now as far as population. So in that age group, you just happen to be lucky
enough to be in that peak of when people get arthritis. Older patients also get it,
and we have lots of patients that are living longer. I have lots of patients that I operate on that are in their 90s. They’re healthy, they’re playing golf, they’re playing tennis and
then their knee deteriorates and they don’t like their quality of life. So these patients are starting
to just get wear and tear after being on this earth for 90 years. Post-trauma, these are
my youngest patients. So the 40-, 50-year-olds, these are people that had a fracture or a bad injury at some point, damaged the cartilage at an early age and now they have a
progression of arthritis. So they have the arthritic
knee of an 80-year-old but they’re 45. We treat them the same. And obesity, obesity epidemic is a huge
reason that we’re starting to see lots of health conditions
and health problems, but it does affect arthritis. So what do you feel? Any of my patients that have been in, they’ll see I have half of my intake form has a whole list of adjectives because everybody
describes it differently. So I hate to say, “What
kind of pain are you in?” It’s better to say, “What
sort of symptoms do you have?” because a lot of patients
tell me, “I don’t have pain. I have instability, I have
burning, I have giving way.” So there’s all sorts of
things that people will feel. So none of them are wrong, and
you may not have all of them, and you may not have
all of them at one time. You might have one this month
and another one next month. So don’t worry about it. Don’t try to figure it out. It is what it is so
you’re not gonna fix it by trying to predict the
symptom, but it will come and go and these are some of
the things that you may have already seen. This, I think, explains a lot. The reason I get all the time, patients come in and “My knee gives way.” “Why did my knee give way? “What’s wrong with it? “What unstable with it?” When we as surgeons look at a knee, there’s an instability that we
perceive based on your exam. So if I pick your knee up and you fell and you had torn your
medial collateral ligament I would describe that as unstable. So the structure on the
inside of your knee, a strong ligament that’s
supposed to be sturdy, when I bend your knee, it bends in a way it’s not supposed to. That is what we would call instability but a lot of people have a stable knee and they describe their
knee as being unstable and what happens is that
when you step on something, the tack is my best example, so if you were barefoot
and you were over there and I said, “Hey, come on over here. “I wanna show you something,”
and you were barefoot, walking slowly and stepped on the tack, most people before their
brain recognizes ouch, that’s a tack, that tack’s sharp, and if I put full weight on
it, it’s gonna hurt a lot, before any of that
happens, your brain says, “Hey, that hurts. “I’m gonna shut your leg off,” and your quad muscle
reflexively gets weak and you fall to the floor. So your knee’s not unstable, there’s nothing wrong
with the actual mechanism, it’s a pain generation thing
that bypasses your thinking and that’s what happens in the knee. So when your knee hurts, and you
step or turn or twist wrong, your brain says, “Hey, that hurts. “I’m not gonna squeeze
anymore ’cause if I do, “it’s gonna hurt.” So your knee gives out. So that will happen. I’m sorry, I can’t predict when. Yes, you might fall, so
be careful if this is one of the things that you notice, but the more that you’re aware
that it is a possible thing and the more that you
notice that it can happen, makes you a little bit more
cautious in certain situations. Now X-rays, this is a big thing, so we will examine
knees and a lot of times without an X-ray, I can tell if someone has arthritis or not just by what their knee exam is, but when we look at an X-ray, what you’re looking at
here is on the right side, you’ll see a pretty normal looking knee. That’s the patient’s left knee. So when you come to the office, we always set the X-ray up
as if you were the doctor looking at the patient. So your right is the patient’s left. Pretty normal looking knee. You see the end of the
thigh bone and that space which is equal between the
thigh bone and the shin bone is the cartilage space. So three cartilages – cartilage on the end of the thigh bone, three millimeters thick,
cartilage on top of the shin bone, three millimeters thick, and then a meniscal cartilage in between. So on the left, the patient’s right knee, that’s a severe arthritic knee. So they’ve lost all the cartilage space, both on the thigh bone and the
shin bone and the meniscus, at this point, is shredded. So that’s why everybody with
arthritis has a meniscus tear but these are the meniscus
tears that we don’t care about because you’re bone on bone. The meniscus tear is
obsolete at that point. People will also get bone spurs. So the bone spurs that
you see on the side, those are the bumps that people will feel and when those bumps happen
in the back of the knee, that’s why it hurts for people to bend. They go to bend and the
knee won’t bend all the way. So this is similar to a trailer. So if you had a boat on a
trailer, the wheels spin, but when you get to where you’re going, you put some chock blocks
in front and behind the tire and that trailer doesn’t move
and that’s what can happen to an arthritic knee. You go to bend it and it just doesn’t bend like the other knee. It’s because those bone
spurs are in the back and blocking it. So do you need an MRI? No. You don’t. Don’t ask your primary
(care doctor) for one. You don’t need it. It’s a lot of times, a waste
of your time to get it. There’s very, very few
instances where we need it. So an X-ray is the way
that we diagnose arthritis. Everybody with arthritis
has a meniscus tear and a lot of times we see
the bruising of the bone. You can see all the white on the left. That’s white fluid because
there is no cartilage left, it’s gone. So by the time that you wait
three weeks to get it approved by your insurance, sit in the MRI scanner for 45 minutes, wait for your primary (care
doctor) to call you back and then show up at the doctor’s office, we look at it and go, you have arthritis. So a lot of times, the
X-ray is a better option. We do use it if someone
falls and we suspect they have a fracture. So that’s one indication
and with arthritis where we would use an MRI but an MRI is not typically needed for arthritis. There was a study, Wayne
Goldstein that I know in Chicago, and we did one here
recently just a year ago. We were curious, but patients
that I saw in the office, these were patients here
that had knee replacement that were referred to me
for knee replacement – 42% of those patients
showed up with no X-ray but almost 35% of them had MRIs. So we can actually do the less expensive, better test for arthritis before you kind of run through the mills. So I just try to use that
’cause a lot of people think the MRI’s the better test, and it is for a back if you’re
looking at a disc herniation or a younger patient that
you suspect has an ACL tear but it’s not something that
we need for an arthritic knee and the other important
thing too is the X-ray and how it’s done because when you stand, people notice if their
knee’s getting bow legged or knock kneed. When you lay down on a
table and you get an X-ray, you don’t see that. So when people go to
the ER or their primary and they get an X-ray, you can be your best advocate and say, “Hey, I think I should be standing.” ‘Cause we want you standing, because the standing
gives me the alignment. This is an X-ray of a
patient that had her X-ray only two months before
I saw her lying down. So you see that one X-ray on the left. It looks pretty good. So the primary’s trying to
figure out why she’s hurting, I can’t remember if she
saw the primary or the ER, and the radiologist reads it
and says minimal arthritis but the patient was in horrible pain and she’s wondering what’s
wrong with her knee. So I had her stand up and
do one X-ray and you can see she’s bone-on-bone,
completely explains her pain. So if you ever get an X-ray
for arthritis on your knee, just remind people and say, “I think I should be standing for this.” It’s gonna show better what
your knee really looks like. And everybody’s talked about
this, we talked about meniscus, everybody knows about a meniscus. Everybody knows about an ACL. Everybody else knows about a Baker cyst, probably the most common
thing that people know about in the knee second to the meniscus, but it was first described by William Morrant Baker in the 1800s. He noted the swelling
in the back of the knee and what they found back
then is even if you cut it, lance it, operate and their
surgeries and antibiotics weren’t anywhere near like ours today, I think three or four of
the patients in a series had amputations because
they got infections but what he realized
is that it’s not a cyst like in other parts of the body. We have cysts that develop,
but this is truly a swelling of the back of the knee
due to your arthritis. So when your knee’s swollen, the path of least resistance
in some people is out the back and you’ll have a fullness
or a pain back there. So we can’t take it out. It’s not a separate structure. It’s just some people get
swelling in the front, nobody has a name for
that, that’s knee swelling. Some people have swelling in the back. That’s called a Baker’s cyst. So you treat it just like
you would treat swelling anywhere in the knee – compression, ice, elevation
and it’s important to know that if you don’t have any reason not to, you can take an
anti-inflammatory but this way, if that happens to you,
I hear it all the time, people are in pain for
weeks waiting to get in to see the doctor or go in to the ER, so start treating this right away. You can wrap it, you can ice it, you can use anti-inflammatories
and some people find in 24, 48 hours, they’re already feeling better. This is not what we do here. So there’s lots of ways around the world that people treat knee arthritis
and we’ve come a long way. So things that we can do. There’s an Academy, our American Academy
of Orthopedic Surgery, comes out with guidelines
for every indication, every diagnosis, every surgery. This is the brief view of their guidelines for treating knee arthritis. Top three, anybody BMI over 25,
weight loss is a huge thing. For every pound that we carry, that is about four or
five pounds of pressure on your knee joint. So if you lose five pounds, you just took 25 pounds
of pressure off your knee. That’s an entire backpack. If you hurt a little and
you have a little arthritis, you might make all of your pain go away. Some of my patients that
have severe arthritis, they’ll lose five or ten
pounds, they’ll still hurt. So there are still
other treatment options. Low impact exercise is key. So here’s too much exercise – so I’m not asking people
to do a triathlon. Here’s no exercise. This is laying on the sofa. Both of those are bad if
you have knee arthritis but there’s a huge gray zone in between. So you have to do something,
and if you think about it, most people, not everybody,
but most people will tell me, probably most of you after
sitting here listening to me for 45 minutes, when you get up your knee’s gonna hurt, everyone’s gonna stand there and be stiff. So once you get moving,
your knee feels better. So all the patients that
I see that exercise a lot, they say, “Yeah, I get up in
the morning, my knee hurts “but once I get moving, I feel better. “I have to keep moving.” So that’s the key. So if you exercise, exercise everyday and
if today’s a good day, exercise more but if today’s a bad day, just exercise a little. Try to do something ’cause
something is better than nothing. And the other thing that
I get asked a lot is can’t you scope it? That was really common in the ’80s. So a scope is the surgery where
we make two small incisions, go into the knee with a
camera and a few small devices and trim that up. It’s great for a meniscus tear that happens from a sports
injury but what we thought was a good idea in the
’80s where we’d go in and wash out the knee
doesn’t work really well. Most people get worse because your knee has 3 millimeters of cartilage. Underneath that three millimeters is bone. So if you have two millimeters
left and I scrape it down, guess what? Now you’re bone on bone
’cause it’s not like the old cutting board that
was passed from generation to generation in our family. If I had a seven inch block of
wood that was really beat up I could take it to the
garage and belt sand a quarter of an inch off. Now I get a six and a quarter
inch of a block of wood. It’s brand new. The knee doesn’t work that way so we try not to scope the knee unless there’s a very, very specific narrow indication. This is important. Old is not bad. In America, for whatever reason, everybody thinks old is bad. You go to many other
countries and the old, they’re revered. They’re special. There’s a lot of respect there. So an old knee’s not a bad thing. An old knee’s like your Model T Ford. It takes a little bit
longer in the morning to turn the engine over, makes a little bit of noise
going down the street, doesn’t go as fast as the
new car, but it still gets you to where you’re going. So don’t think that just
because you have arthritis, it’s a bad thing. It’s just, it comes with the territory. But treatment and this
is one of those things I want everybody to take away from this if you haven’t done enough
for your knee arthritis. So the top three – you all
have control of those things. These are all in your power. So, one, exercise. We’ll go over a few, but exercise
and strengthening are key. They will lessen your pain. Studies show that if you
can strengthen your quad, which is the muscle above
your knee, this muscle here, you can reduce pain by 40%. The other thing is weight loss. Weight loss is amazing for decreasing pain and I harp on it all the
time and patients hate it ’cause I’ve been this
weight since high school, I do exercise a lot, I eat
healthy but when my patients that have struggled with weight for years hear it coming from me, a lot
of ’em give me a hard time, “Oh, it’s easy for you.” It’s hard to lose weight but if you do it, I have enough patients
that come back and say, “I did it. “I did it and I feel better.” That’s the reason I keep pushing it but it will lessen the pain
that you have in your knee and over-the-counter medication. So, Tylenol and other
anti-inflammatories like Motrin, Advil, and Aleve if there’s not
a reason for you to take it. So anybody that’s concerned if
you’re on things like Plavix, Coumadin, all the other
anticoagulants for your heart or for your brain, you have to check with your primary first. Things that are in my control? We can do prescription medications. We can give you injections
and then braces. I saw a couple people
walking in with braces, we’ll get to that and then the other stuff. I had a few people stop
me and ask me about others so I’m gonna try to cover all the others, probably won’t get to all
of ’em but most of ’em. So my top three. Walking is great, but a
lot of people tell me, “It hurts when I walk.” So walking is about 1 1/2 times
your body weight every step. So if you can’t walk, get in a pool. If you don’t have access to
a pool, get on an elliptical. It’s like walking, but you
don’t get the pounding, and if you can’t use an
elliptical, try to get onto a bike, a stationary bike is a great way. Sit on, recumbent, doesn’t matter, whichever one’s more comfortable, you just wanna pedal and start
with just five minutes a day. The big thing that I ask
with a lot of my patients is just to try. So if Monday, Wednesday,
Friday they get on a bike for five minutes, they think that’s silly, but in reality, I ask them what they did last
week and they said nothing. I say well, five minutes is more than nothing and it’s not 30 minutes
but maybe in two months we can build up to 30
minutes so start somewhere. Usually the first week or two hurts but my patients that decide, it’s always January 1st,
I’m gonna go to the gym, New Year’s resolution, I went to the gym, worked out with a trainer. I couldn’t get off my sofa for two weeks. So don’t go overboard, but you
wanna make a lifelong change. The other one is strengthening. So this exercise, and it
should be in the packet, it’s super simple. Everybody has a leg,
everybody has a floor. Lay on the floor, the reason in the picture
you bend the back knee is to take some of the
pressure off the back and then what you’ll do is
you just lift the leg up and lift it down. Up, down, up, down 10 times,
and I have my patients do it actually in the office with me ’cause I’m in the office
Monday, Wednesday, Friday so I tell them that if they
did 10 with me in the office, they’re done for the day. That next day, Wednesday
or Friday, they have to do 10 more for the week and
then the week after, 20, the week after, 30. When you get up to 50,
most people tell me, the knee felt better. But the big thing that’s in
a lot of people’s control is the weight loss. If you don’t know what your BMI is, just calculate it and when
you go home, on your phone, you can Google BMI, Body Mass Index, and figure out where
you’re at. It’s scary, but it is a huge reason for
medical problems and conditions. We’re great at lots of things, this is not a chart that
we wanna be at the top. So compared to all other countries, we have one of the highest
obesity epidemics in the world. So you wanna try to get
that down and people say, “Well, does it matter? “Does it really affect my arthritis?” Yes. So, a normal weight person, the risk of arthritis
in their lifetime, 16%. An obese patient, double that. Now if you get rid of the
weight, unfortunately, the arthritis is already there. It’s not gonna disappear
but you’re gonna hurt less. So the earlier you start, the less pain you’re
gonna have in the long run and you can slow down the risk
of progression of arthritis. I’m not a dietician,
I’m not a nutritionist, so I’ve told people things over the years, the big thing is diets, for
me, listening to people, they’re crash diets. I hear it all the time, I
went on Weight Watchers, I lost weight, I gained it back. I did Atkins, I lost
weight, I gained it back. I did this one, I gained,
so don’t go on a crash diet. Change the way that you
eat forever and try to lose a little bit of weight. Don’t set a goal weight. So I always tell my patients,
give me a pound a week. Most people can lose a pound. In a year, that’s 52 pounds and
that’s a lot more reasonable for people then trying
to set a goal weight and weighing yourself everyday
’cause it’s gonna fluctuate with your clothes and water weight. So just weigh yourself
once a week and figure out where your issues are. For some people, it’s
too much, it’s snacking. So figure out where your little thing is but the two things that I
wanna talk to people about, the plateau, ’cause my patients, when we’re watching their
weight decline before surgery, everybody hits a plateau. They all say, I hit this point. I’m eating what I’m supposed
to eat and I’m exercising and I just stop losing weight. Well, that’s great. You just became a more efficient machine. Just everything that you
do, going to the bathroom, getting the mail, going
to work, going shopping, because you weigh less,
you’re burning less calories. So now you have to do one
of two things or both. You increase your exercise
or you lower the amount of calories that you eat
but the plateau is a normal and a good thing because
it shows that you actually have become more efficient
but don’t be surprised. I have patients that come
in and they say guess what? I lost 10 pounds. My knee feels better and
my back and my cardiologist took me off one of my
blood pressure medicines and my other primary took me off one of my diabetes medicines. So all of those things are
factors and you can actually make yourself healthier
by doing all those things to address each of those problems. Over the counter medications. So Tylenol, ibuprofen, naproxen, and we have a whole bunch of
prescriptions that we can use. The thing that I want
people to remember though is that when you use these medicines, they take a little time to kick in. So the analogy that I like to use, in medical school everybody sees this ’cause this is the therapeutic
range of most antibiotics and most drugs. They don’t work right away. So the mistake that I hear
from a lot of people is, “Oh, I took Tylenol once. “It doesn’t work for me,” and “I took ibuprofen once
and it doesn’t work for me.” Well, if your primary
gave you a prescription of an antibiotic for 10
days and you took one pill and you called them the next day and complained that you were still sick and that antibiotic didn’t work, you want another one, they would laugh at you and they’d say, “Whoa, whoa, whoa, stop. “You gotta take it everyday.” And that’s the thing that I
have people do with Tylenol or an anti-inflammatory, if you hurt and I don’t want you to take medicine for a long period of time, months and years, but if
you hurt today or this week, take it for a week. And if
you take it for a week, every time that you take it, you’re building up those
blood levels of the drug and then the pain and
the inflammation go away and then you might be in less pain for two, three, four months
but when you have a flare up, you take it again for a few days. So I like my patients to take
this in little mini bursts and then stop those drugs. But the narcotics are bad
and I’ve harped on this for a decade and people always
thought I was the mean guy and I don’t want people to be in pain, so I don’t say take nothing. There’s just other options
and finally we’re starting to realize, and the rest
of the world has realized, that there’s an issue. 99% of Vicodin in the world
is used in our country. 80% of Percocet in the world
is used in our country. So if you have knee pain,
you don’t need a narcotic. That’s not the first line treatment. So I always kind of tell my friends that if you and I went duck hunting and you were out in your waders
and I showed up in a tank you would kind of laugh at me. It’s a little bit overkill
taking a duck out with a tank and it’s a little overkill to
use a narcotic for knee pain. So start with the other
medicines and you may find that after three, four,
five days you feel better because we know that patients
that are on narcotics before knee replacement surgery, whether or not it was
because of their neck pain or their shoulder pain or their back pain, but if they take narcotics
regularly and then have surgery, they have worse outcomes. They don’t do as well. Their pain is not relieved as much. They have more complications. They have more revisions. Someone’s gonna ask why, I don’t know. We don’t know yet why but we
do know that it is a factor so even my patients that
are on high dose narcotics before surgery for other reasons, I try to wean them down
before we do surgery. But injections, so cortisone’s a great
option after you fail pills. So pills, exercise, strengthening, all first line treatments. If that fails, cortisone’s a great option. It reduces pain and inflammation. A few people asked about the lubricants. I only have a few of these. Someone else showed me another one. There’s a lot of brands. There’s Coke, there’s
Pepsi, there’s RC Cola. I mean, you go to Baskin
Robbins, you got lots of flavors. They’re all variations on a theme. They’re all what we call viscosupplements. So these are lubricants
that are meant to lubricate the remaining cartilage in the knee. They do not reverse arthritis. They do not make your cartilage healthier. They do not prevent arthritis. There are a lot of misconceptions
that people hear sometimes but it may improve the pain
in about 40% of people. So that’s the honest statistical truth is that a lot of studies show
it doesn’t help everybody and it usually helps people
with early arthritis. So even our academy doesn’t recommend using it on a regular basis
so it’s just another option that we have to control pain. As far as the ultrasound or the X-ray, it’s not necessary for the knee. A lot of people ask about that also. Do you need the X-ray or the ultrasound? You do not need it for the knee. In the small joints of the hand, the foot, we can’t see them. People do use it in the
knee, but it’s not necessary. Braces. I saw a few people walking with braces. If they help you, they’re good. If they don’t help you,
you don’t need to wear ’em. I have a lot of people walk
in with a Nordstrom’s bag and they have the question, they start pulling out
brace one, the copper, brace two, the magnets. This one’s got the straps,
this one’s got the hinges, and they said they’ve tried
’em all, none of them help. Do they need them? The answer is no. There’s not a brace that
will prevent arthritis. There are some braces that people wear that make them feel
better and a lot of times, it’s the simple little
slip-on knee sleeves, the neoprene ones and
it makes you more aware of where your knee is in space. So if you wear it, you’re more likely to be
aware when I turn or pivot, not to twist my knee bad
or when I squat down, not to bend it too much. So if it makes you feel better, wear it, but if you tried
it and it doesn’t help you, don’t feel that you’re
making your knee worse. All the other stuff. So I brought the cane for two reasons. So if you can’t hear me for a little bit, I’ll speak louder. If my left knee hurts, who thinks the cane
should be in my left hand? Raise your hand. And if my left knee hurts, who thinks the cane should
be in my right hand? And who didn’t raise their hand? (laughs) (audience laughs) So it should be in the opposite
and it doesn’t make sense to a lot of people because
if their knee hurts, everybody kind of leans on that side. The center of gravity is right here. So if this knee hurts and I lean over that knee onto the cane, I just put more weight on my bad knee. So it’s awkward for a lot of people, but if you put it in the
opposite hand that, as I walk with my good leg, and then
I walk with my bad leg, I can lean away from the
bad leg and take the weight onto my hand, off my bad knee.
And it’s an awkward thing. It’s sort of like
learning to do the waltz. It takes a little bit of
time, so practice at home, but by people doing that, I
have it in the office everyday. I watch people get up and
I say, “Give me the cane. “Take two steps,” and they go, “Oh, it feels better already.” So just that one little trick. The other one, whether or
not you’re using the cane, that I get asked all the time are stairs. So the thing that we always tell people, up with the good. So if you have to take ’em one at a time, it’s up with the good, down with the bad. So this way you’re always
leading with the bad and one of my favorite therapists here, she has a great way to remember it. Good ones go to heaven,
bad ones go to hell. So that way, you’ll never forget it. She teaches all of her patients
and they always remember, but that’ll prevent if you
need to use those stairs, that’s the best way to take it. So creams, patches, Voltaren gel, Flector. Those are anti-inflammatory
patches or creams, they do help some people. All of the over-the-counter stuff, if you use it and it makes
your knee feel better, that’s great. You’re just, again, treating symptoms. glucosamine, chondroitin, there’s not a whole lot of strong evidence that it really does
anything for arthritis. That being said, if you do it
and it makes you feel better, that’s okay. We don’t know of any harm. So my feeling is, if it doesn’t
cost you a lot of money, if it doesn’t hurt you
and you feel better, then it’s a good treatment for you. A lot of herbal remedies. People have used arnica,
tumeric, there are options. Acupuncture, I have some patients
that use and swear by it. It makes them feel better and diet, people always ask about
anti-inflammatory diets. There’s not a whole lot of
proven stuff for me to say you need to do this or
try that or eat this, but if you try it and you feel better, then it’s a good option for you. This is my tip, so all of my
patients, when they travel, four things I tell them to bring – a Ziploc freezer bag. In the Ziploc freezer bag,
put a bottle of Tylenol, and if you can take an anti-inflammatory, your anti-inflammatory of choice. This way you don’t have to spend
$40 for a bottle of Tylenol at the hotel with three
pills in it, but you have it and you have your anti-inflammatories and most people in the hotel
can find an ice machine for their sore knee but
they can’t find a bag. So now you have a Ziploc freezer bag, and the other one is go to REI or one of the local outdoor shops and get a collapsible
hiking pole and this way, if you need it, it is in your luggage. So I have patients that are
always going all over the world traveling to places that
I’d like to travel to when I retire and I say, “Bring the pole,” and they’ll say, “Yeah,
I went to Machu Picchu and I was able to take
the cane and my knee hurt but I made it through. I’m glad that I had it.” So just throw it in your
luggage and forget about it. Now this is the other
one people always ask, “Is it gonna get better?” I’m sorry. Your arthritis is not gonna get better. It always gets worse, but it may not get worse quickly and you may have good days and bad days. So the stock market is sort of predictable over a 30-year-period. We know it starts there and it goes there. But we know that today something
good happened in the world and it goes up, and today
something bad happened and it went down, but even
the guys on Wall Street, something happens and they have no idea why it went up or down. So your knee’s the same
way, just reversed. So your knee’s gonna get worse over time. You’re gonna have good days and bad. Some days you’re gonna do a lot, you’re gonna expect it
to hurt and it doesn’t and other days you’re gonna do nothing, you’ll wake up and it’s killing you. So don’t try to figure it out. Just if it hurts, treat it
but just know that over time, it will get worse and we
deal with it down the road. So can you scope it? This is a question that we
kind of broached on before but I get asked all the time. This is a pretty normal
looking knee that if you look at the picture on the left, the cartilage, that little ball shaped thing up top, that’s the thigh bone, the bottom is the shin bone, pretty smooth looking cartilage. And then you look at the second, that’s the other half
of this person’s knee, that’s a torn meniscus. It’s frayed and the third picture
is after I’ve resected it. The problem is, no matter how
bad your meniscus tear is, if you don’t have the
cartilage above and below and I clean up the meniscus, you’re still bone on bone. So you still hurt. So that’s the reason why when
someone comes to us and says, “But I have a meniscus tear,” yes, but by fixing the meniscus tear, it’s not gonna fix the fact
that you’re bone on bone. So that’s the reason we
don’t typically scope arthritic knees. And then partials. I get asked about this a lot. Partials have been around for a long time. They are a little less invasive because the knee has three parts. There’s a kneecap part, there’s
an inside or medial part, there’s an outside or lateral part. So the partials replace just
that, just 1/3 of the knee, and patients that have a
knee replacement on one side and a partial on the other, they all tell me the same thing, “My partial feels more
like my normal knee,” and you’d expect it to
because it only replaced 1/3, not 3/3. It is a slightly shorter recovery. It’s a slightly shorter
longevity meaning that if you have a knee replacement
on one knee and a partial, a lot of times, the
partials don’t last as long as a full knee replacement, but
you can still get arthritis in the other parts of your knee. So for us, if you put a
partial in a very young person that only has arthritis in one spot, you can predict that they’re
probably gonna get arthritis in the other parts of the
knee as they get older but if you have arthritis in other parts and we replace just 1/3, those patients come back and say, “But my knee still hurts. “It’s a little better.” So that’s where we would
err on a knee replacement. So don’t feel that a
knee replacement’s bad. It’s just different and
if you do a partial, surprisingly, you convert it to a total, you’d think it would just
be like any other total, but the results are not as good. So that’s why we really have
to pick and choose carefully who are good candidates for a partial because we don’t wanna put
you through two surgeries. This is a partial. So this is what we call a medial partial where the outside half
of this person’s knee and the kneecap joints were fine, so there’s just a metal
part and a metal part, sandwiched between is a plastic part and that makes up for the arthritis on the inside of the knee, but we can also replace the kneecap joint. So you can see the picture on the left is a severely arthritic kneecap joint. The kneecap is almost 50% out of the way, what we called subluxed
and almost dislocated and then when you go in there and shave off the bad
cartilage and realign the knee, you’ve replaced their kneecap joint, but the thigh bone, shin
bone areas were okay. So those are partials. But this is sort of the
stuff that everybody always wants to know. Is there anybody that needs to stand? Stretch a knee? Everyone’s okay? So this is the knee replacement stuff. So this is the stuff that I try to tell all my patients about
because the more information that you have, the more you understand what
you’re getting yourself into, the better you’re gonna do. Most common question
I get, “Do I need it?” Luckily, no. The cardiologists are
different that if you showed up in the ER with a heart attack and a blockage in two
arteries, guess what? You need a stent or a bypass,
you’re gonna die otherwise. Luckily no one died from
arthritis but, it can lead to other problems where
people just don’t like their quality of life. So it’s an option if you’re
not happy with things, and we’re always gonna tell people, you’ll know when it’s time. And some of you may have heard that, and it’s hard to figure
out what that means. What do you mean I’ll know? You’ll know when it’s time. I try to narrow it down
though. So if you’ve done an exercise program and if
you’ve lost weight if you had to and if you tried pills or shots, that’s first line treatment. Everybody should do that first. I have patients who say,
“I don’t wanna do that. “I wanna have surgery. “I don’t like those pills they
have lots of side effects.” Well, the risks of
surgery are a lot greater than the side effects of
Tylenol, so I’m a very big fan of try the simple things first. Second thing is quality of
life because if you can do everything that you wanna do, I have guys that come in with knee pain that are surfing and playing
golf five days a week and tennis the other two days and they’re hiking up mountains, I can’t make that person better. I can make their X-ray better,
but I can’t make them better. So quality of life is within
reason for a knee replacement. It’s not a normal knee. The way that I describe
it to a lot of people is that if your normal knee’s
a 10 on a scale of zero to 10, a great total knee’s an eight. So if you’re a seven or an eight, you’re not gonna be happy with the outcome of a knee replacement but
if you’re a three or a two and we put you from a two to
an eight, you’re ecstatic. You’ve got your life back. The other thing and luckily
rarely do I see this, but you have to be medically stable. It is a big operation, so
we don’t wanna put someone under anesthesia and through
the rigors of surgery if you can’t tolerate it, and
you have to do the therapy. It’s the thing I tell
people over and over again. It’s so important, that this surgery works really well if I do my job and you do yours. If neither one of us do our
job, the knee does not work well and I stress that because I
see a lot of second opinions. I see a lot of people that come to me with a knee replacement
that was done somewhere else and 99% of the time,
the knee was done well. It was aligned well. It was positioned well. It was sized well, but
they didn’t do the therapy and they got stiff. And if
you’ve talked to some people, the worst stories that
you’ll hear are the people that had a stiff knee after
surgery and they tell you, “My knee’s worse now than
it was before surgery.” They’re miserable and
there is no going back and I tell them all the things that I’m gonna tell you tonight and the thing that I hear from everybody which is the reason I stress it is, they say, “Why didn’t someone
tell me this before surgery? “Why didn’t they tell
me I had to work harder? “I would’ve worked harder if I knew,” and I don’t know, I don’t
know, maybe they did tell ’em, maybe they didn’t hear it,
maybe they didn’t stress it, but it’s really important
that you have to give 110% And I tell people that
if you’re not willing to do the therapy, don’t have the surgery. If you’re gonna have the surgery, you have to be willing to do the therapy and that’s what’s gonna
make the knee work well. Now, you’re probably
ready if you have trouble getting off the toilet. Count how many steps, none of my patients that
don’t have knee pain count, they’ll come and tell me, “I have 17 steps in my house
separated by a landing.” So those are things that only
people with knee arthritis, sometimes hip arthritis deal
with and even today, I mean, everyone’s gonna get up and, dinner – you stand up and everybody starts walking to the front of the restaurant and you’re stuck there
holding onto the table because you gotta loosen up your knee and kind of get it moving. So those are all things
that people run through if they have knee arthritis. It’s common. Everybody gets it. The medical things, the things that I think about that you don’t necessarily
have to think about, but we’ll talk about is, if
you’re a smoker, you gotta quit. Luckily, Southern California,
there’s not a lot of smoking, but it increases risks of
infection, wound complications, blood clots. You gotta quit. Diabetics, there’s a certain number
that diabetics follow for their sugars and anything over seven increases their risk of complications. So that’s a modifiable problem. We fix that first. The weight is a big factor that
people that are overweight, over a BMI of 33, your
complications increase. The last thing you ever want
to deal with is an infection in a total joint. It’s a disaster, so anything
we can modify, we do. You have to have good teeth,
and people wonder about that, but the mouth is a source of infection. So if you have a rotten tooth or a cavity, that is a source of mouth bacteria getting into your bloodstream, and those bacteria love artificial things. So they like heart valves and
they like knee replacements. So if you have a cavity, we fix that first before
you have a knee replacement just so you don’t develop
an infection in the knee from the mouth. Good nutrition’s really important
too so we check this lab called an albumin because
people think about malnutrition as people a lot of times
over in Africa when some of these epidemics, people look really skinny,
but you can be heavy and you can be malnourished, and if your protein stores are low, you actually can’t heal as well. So they have more wound complications. And we have to have good tissue. So things like psoriasis, some people have swelling
problems where the skin is not healthy, that if you make an incision through that, you increase the risk of a complication so these are all the
things that I think about separate from the things
that you think about. So big operation, 600,000 are done every
year in the United States. So it’s a really, really
big and it’s growing fast. 3.5 million knee replacements
we anticipate will be done every year in the United
States by the year 2030. So I got my work cut out for me. (audience laughs) But there’s lots of people
that are needing this and the good news is they work well, which is why people keep having them done. So once you’ve decided, if you say, “Okay, I’ve done the pills,
I’ve done the exercise, I’ve maybe had shots and I’m hurting. I’m not happy, my quality of life is
not what I want it to be. I’m ready for knee replacement.” Couple things that you need to do – talk to your primary ’cause
they would give you a once over to make sure that you’re
healthy enough for anesthesia. If you have teeth problems
like we talked about, you go to the dentist,
take care of that first, and if you have other issues, a lot of my patients if they’ve
had pacemakers or stents, we get them into their specialist first ’cause they might wanna do special tests. My office, Veronica takes care of
just about everything that I do except operate. So she’s gonna call you, she’s gonna get your
insurance authorization, she’s gonna set up your
pre-op appointments, the date of surgery. She’s gonna send you all the
stuff that you need to read and fill out, and then
set up your appointments for even after surgery. And then you’re gonna
come in for your pre-op. So usually two or three
weeks prior to surgery, you come and you meet with my nurse. We do a wash that you do on your skin and your body before surgery, again another way of decreasing
the risk of infection. She’ll give you instructions
for both before and after. We give you the after again after surgery. We try to be very repetitious
because people lose and misplace things. You’ll meet one of our orthopedic fellows. So they’ll go over your exam
again, talk to you again. We do labs, EKG and a nasal swab, so anything your primary didn’t do and we always tell people, when you go to the hospital, look for the cafeteria
because you need to go to the left of that. So that’s where that sign is. So you’ll look at the cafeteria, the room you need to
go is just to the left and they’ll do all those tests. We do a nasal swab and the
reason is that certain people are carriers of MRSA. So people have heard of staph infections and there’s a small group
of people in the US, about 4-5% that are carriers of MRSA and if we don’t know that, we don’t give those people
the correct antibiotics. So we do a swab on everybody,
and if you come back as a carrier, you’re not
sick, you’re not ill. It just means that you need
a very special antibiotic and we wouldn’t know that otherwise. So that’s the reason we do the nasal swab. And then you see the account rep upstairs which checks your insurance and goes over any other paperwork that you need for the hospital. Then you come in for surgery. So this is the big day. Everybody’s nervous the night before. Most people don’t sleep well. That’s normal, but you’ll get up early, you’ll come in. Nothing to eat or drink
except certain medications. We will tell you take your medications and that’ll be given to
you on your instructions before surgery, those you’ll take. And then you’ll come in usually about two hours
prior to your surgical time. And then when you come in, you’re gonna come to this room
downstairs by the cafeteria. This is the waiting room. You’ll check in and then
they’ll take you back but it’s where your friends
or family will wait. There’s an information
board so they can follow you through the whole process. Nowadays they can watch and say, okay, she’s in the holding area. Now they’re in the OR Okay, now they’re in recovery room. Now they’re waiting for a bed. So you’ll know where they’re
at, and then I will come out and talk to your friends
or family after surgery to let you know how everything went and it’s usually about an hour after that before you would wake up. So from there in the morning, you’ll go back to a pre-op holding area. So here we keep you busy. You’ll see your pre-op nurse. She’ll put you in one of
our lovely hospital gowns, check your vital signs, check
your paperwork, do labs, and then pre-op meds. So this is a little cocktail. This is a cocktail of a pain pill. This is a cocktail of
an anti-inflammatory. It’s a cocktail of Tylenol. It’s an anti-nausea pill. I’m not a genius, I
didn’t come up with it. Everyone in the world’s
using some form or fashion, but what we know is that
if you can treat pain before it starts, and a
lot of these medicines take two or three hours to kick in, you will have less pain afterwards. So we really try to
start the process early. While you’re also there
you’ll see me again, you’ll see my fellow, you’ll see the nurse that works with me in the actual operating room and then you’ll also see
the anesthesiologist. So the anesthesiologist
will go over your history, they’ll talk to you about the anesthesia and they do a nerve block. So the nerve block will control
about 60, 70% of the pain in your leg. That reduces
the pain that you feel during surgery so you
don’t have to go as deep and it also gives you pain
relief for about 24 hours after surgery. So again if we block the
pain before it starts, the pain never gets as bad
and this is not a new thing. I got involved with a
lot of the pain stuff about 10 years ago and if
you look at the very bottom, The Lancet’s a very
famous medical journal. This was published in
1913, over 100 years ago. So if you study history, a lot of times you can learn
things that we forgot about. So we now know that the
preemptive analgesia, giving you medicine to
prevent pain before it starts, your pain never gets as bad afterwards, as compared to the old days
where you’d have surgery, wake up in horrible pain and they just pump you full of
morphine ’til you’d throw up. That’s not good. It doesn’t help with recovery, so we do this all before surgery. But this is the important
thing that I like people to think about because I am
very big into making sure that people’s pain is controlled but that doesn’t mean pumping
you full of narcotics. So the top, the central sensitization, so that is giving a little bit of narcotic, but blocking it with the numbing agents both in the knee and the nerve block. Inflammation is controlled
by anti-inflammatories, and then the tissue injury
we control with other stuff, managing the soft tissue
well. And the other big thing is anxiety, and that’s where
I really spend a lot of time teaching all of this because
if you know what to expect, then you’re less likely to be
anxious. And it’s interesting, they did a study in one
of the nursing journals where they had two groups of patients having knee replacement, exact same thing, but one
group had this formal process like we’re doing now, the other group was told you’re gonna have a knee
replacement. And the group that had more information, they all perceived that
their recovery was easier, that they had less pain, that they had a quicker
recovery and when they looked at how much narcotic the
groups used, it was the same. So people can feel better just
by getting the information. When you come back to the operating room, this is one of the rooms you’ll see. We have three rooms. I have a great staff that works with me. So you have the trays on the
back, we have all the implants, everything’s made sterile. We use the space suits. People hear about the space suits. Some of that is for our protection, it’s also to protect you. We don’t want to get our
bacteria anywhere in the room and we also have these special rooms. That back wall that you see, there’s actually air
that circulates faster than any other operating room. So these are super-clean rooms
to lower the bacterial load in the room which lowers
our infection rate. But a knee replacement, hopefully everybody had a
chance to see in the back, I like to call them a resurfacing because when you see the
implants you get an idea, now, I think a lot of people
think we chop your knee in half and we drop a hinge in
there and we have that for complex cases but what
we do is just shave off the end of the thigh bone,
top of the shin bone, and put the metal and
plastic so you’ve resurfaced the bad cartilage with metal and plastic. You preserve your ligaments. So this is the thigh bone
part once we prepare the bone. Normally takes off about eight, nine, 10 millimeters of bone, so a small amount and then it gets capped with that piece of metal. The shin bone gets planed flat, about two or four millimeters
of cartilage gets removed and then the metal part with
plastic goes inside there. And then the last part is the kneecap. So on the back half of the kneecap, we shave that flat and
put a plastic button so when you bend and straighten your knee, it’s the plastic that rubs on the metal. Now one of the things that
I like to do afterwards is, I take a picture. So when you’re all done
and the dressings are on, I bend your knee up and I take a picture and I give that to you and I let you know that even though it hurts, that you’re not breaking anything. You’re not damaging the
implant and that little piece, I think for a lot of patients, let’s them push through some pain because they’re confident to know that they’re not gonna hurt
the thing that was just put in. And that one little picture,
when I started doing that, it was amazing how much
easier people got motion without changing anything that I did in the actual operation. So it’s just that peace of
mind that you can do it. So after surgery you go to recovery and that’s what you’re gonna see. You’re gonna stare at
the ceiling and come to and the nurses are gonna be on top of you checking your vital signs
but this is where you’ll be. (audience laughs) They’re gonna make sure
that you’re comfortable. They’re gonna make sure
that you can take ice chips. They’re gonna make sure that
you can have some crackers, and you’ll be there for about an hour, and then we’ll get you upstairs. So the day of surgery, you are getting up. You’re gonna do therapy and a lot of people, they
look at me and they say, “No,” and I say yes, you’re gonna get up. So the quicker that you get moving, the faster you recover. So we do start with bed exercises
the day of the operation, stand and if you’re
comfortable you can walk. We put you on a pain regimen
so it’s not that you just don’t get narcotics, it’s that we put you on
Tylenol around the clock. I put you on anti-inflammatories
around the clock. We put you on a nerve
pill around the clock before you ask for it because
if we can beat the pain before it gets there, the pain never gets as
bad, and by doing that, people use a lot less narcotic. Everybody tells me, now
compared to five years ago, if I’ve had patients that
had a knee replacement before we did this, they
all said, I felt better, I was less constipated,
I was less nauseous, I was less foggy, and I recovered better and I only used like 10
or 20 of the narcotic where years ago, people would just pump
themselves full of narcotic and they would feel terrible for a month so we try to get away from that. The day after, so post-op day
one, I see you in the morning, we change your dressing,
we do more therapy, once in the morning,
once in the afternoon, and 90% of people if you’re comfortable, you can walk the hallway,
walk up and down the stairs, you get to go home, sleep in your own bed, eat your own food. You don’t have someone
knocking on your door at two in the morning to
check your blood pressure ’cause my blood pressure would be high if someone woke me up at two
in the morning, so go home. The motion machine. This is the other question
I get asked all the time. No, we don’t use it. Old stuff. It was actually introduced down
the road at Sharp Hospital, Dr. Coutts, 1982. So do you want anesthesia
or a knee replacement or anything from 1982 if
you can have something that’s more 2017? It’s an old way of treating
the knee because before that, in the ’70s, if you
had a knee replacement, you probably spent two or
three weeks in the hospital but you woke up in a cast, you didn’t bend your knee for two weeks, and then after two weeks, you went back to an operating
room, they took the cast off, they bent your knee, they did
what’s called a manipulation, and then you started doing your therapy. So it’s sort of a no-brainer. Cast versus motion machine. Who has better motion? No-brainer, but nowadays
since we get you moving early, you using your muscles will
make your knee recover better than laying in bed and being on a machine. So we don’t use those anymore. Motion, this is the other question I get. I get a lot of people tell me, I can bend my knee back all the way. Most of the implants on the market now, they all will get more motion
than you will ever get. They can usually get about
140 to 150 degrees of bend. Most people never get that. So if you have a very
stiff knee before surgery, you’re not gonna get 130 but
if you have a lot of motion and arthritis, you have a better chance
of getting that motion. So how much motion you have going in is a really good predictor
of where you’re gonna be. An average knee replacement when you look all over the world, all different implant
designs about 115 to 120. The exercises like we
talked about before are key, but what you describe as
stiffness and what we measure as stiffness are two different things. I have a lot of people
that, after surgery, have 10 degrees more
motion when I met them, but they will say, “My knee is stiff.” So a lot of times it may feel stiff but it will still move more and a lot of the stiffness
early on is inflammation and that goes away over
a number of months. Two weeks at home, you’re doing therapy, you’re responsible for this. We tell you therapy’s really important but I always have my patients
stop and think about it. Yes, therapy’s important
but don’t go bonkers because your knee does two things – your knee straightens and your knee bends. That’s it. So you don’t really need
a therapist to tell you what to do with your knee. You just have to straighten and bend it. Your therapist and me, we’re there to help you because sometimes one of
those exercises is hard so we might show you a variation on how to do the straightening or a variation on how to do the bending. The Tylenol and Celebrex,
you’ll take at home, or some anti-inflammatory, those medicines are around
the clock for two hours. That really controls the pain well and then we use the narcotic just for breakthrough pain only. That is the option of last
resort because that has all of the side effects. Icing, elevation, as simple as they sound, they work a lot. And really
a healthy, high fiber diet because anesthesia, pain medicine, dehydration all lead to
constipation and you need to heal. You’re gonna burn through
so many calories healing so eat and eat well. You’ll see my nurse back at two weeks. We take out the staples,
we check your motion. You should have 100 degrees at that point. If you don’t, I’ll call you out on it, she’ll call you out on it. We want you to work harder
because the more work you do in the beginning, the easier your recovery is. The next two weeks at home, more therapy, more and more therapy. You’ll go from home
therapy, you’ll feel good, you’ll start to go to outpatient therapy. You’ll go from the walker
to the cane to nothing and everybody’s off the
narcotics at that point. Usually most people decide
at that point the Tylenol works better for me or
the anti-inflammatories work better for me so most
people pick on or the other. I’ll see you back again in a month. We check X-rays, we check your motion and then almost everybody,
everybody walks in with a cane. Everybody that I see and I
ask them are you using it, and they said, “No, I thought
I was going to get in trouble, “so I brought it anyway.” (audience laughs) But you don’t need it at that
point so when you’re okay going off of it, you can get rid of it. We’ll go over some things
that are common at one month because you’re better but
you’re not fully recovered. Most people can drive four to six weeks so if it’s your right
knee, four to six weeks. If it’s your left knee, by four weeks most people
are driving the car already. One to three months is just more therapy. You’re getting back to your normal life. You’re walking, you’re exercising, you’re doing outpatient therapy and everything’s getting
better, day by day. Your motion’s getting better,
the swelling’s getting better. You’re sleeping better. Patients that are still working,
you’re going back to work. I’m sorry but you do
have to go back to work if you’re still working. But those people are starting
to get back into living their normal life. I see you back again at four months. We check more X-rays,
check your alignment. We talk about going back to the dentist ’cause I do recommend
that you take antibiotics before you go to the dentist
for the rest of the life just because it lowers
the risk of mouth bacteria getting to your knee replacement. It’s extremely rare, but it does happen. So we do recommend it. Now, all the scary things. These are all bad. Luckily, they’re all rare. So infection, the risk in the US is between one and 2%. Here our risk is less than 1%. You can have a wound healing complication which is again why we
look at making sure you’re as healthy as possible going in. Blood clots are a concern so
we do get you up and moving, put you on squeezers, put
you on blood thinners. We typically use aspirin unless
you have other risk factors. We put you on stronger medicine. Blood loss is very rare nowadays. Luckily, the risk of needing
a transfusion is less than 1% so you do not have to
donate blood ahead of time. All the other things are really rare. Fracturing, injuring ligaments,
dislocating the knee, they’re all extremely rare,
but if there’s a problem, it can be revised. So the other pictures that you saw, the difference that you
notice here is that post that goes up and down the leg. So if the first knee replacement
fails for any reason, we can put another knee replacement in but we have to add to it. So if you had a cavity, that’s
just like a little shaving, like an orthoscopy of your knee. If you had a crown, that’s like a knee
replacement where we actually cap your tooth with something artificial but if that crown fails and
now you have an implant, the doctor put a post into your jaw and then put an artificial
tooth on top of the post and that’s what a revision is like. Normally after surgery
everybody has some pain and stiffness at night. That’s normal. It’s typical. It’s more because your knee’s not moving the first two or three weeks at home. Once you get up and move it goes away. The knee will feel warm for a couple weeks and a couple months in some people. That’s normal. The knee will click a
lot more in the beginning just because it’s swollen and when that metal touches the plastic, you’ll get the (clicking sound). You’ll hear it or you’ll feel
it more than you’ll hear it, but most people are aware
and it goes away over time. And anytime that we make
an incision over the front of the knee for a fracture
or a ligament rupture, a knee replacement, the little
skin nerves on the outside, they always get cut. You can’t see them, they’re microscopic. So you’ll have a little patch of numbness and it goes away over time. I follow you forever. So, well, as long as
you’re here and I’m here, we’re gonna see each other. So every year, every five years, every five years after
that we keep an eye on it because if there’s a
problem with the implant, a lot of times we pick it up on X-ray before you feel symptoms, but
luckily most of these implants we think should last 20 or
30 years in most individuals but we do keep an eye on it and I want you to get back
to a healthy lifestyle. I mean, that’s the whole
reason for doing all this. We keep an eye on this. So if someone says,
“Well, how good is it?”, we know and luckily we know
because of Dr. Colwell. When he started here in 1978, he started, he saw this coming from a mile away. He started capturing data on every one of his hip and knee replacements,
and we’ve continued that. So we actually have over 20,000
joints in our registry here. So when someone says
how did that knee work or how did that hip work
or how long does this last, we know it ’cause we have
it all in the database. We have over 600 publications. The new thing that you may
see in the news occasionally is there’s an American joint registry that only started a few
years ago so there’s a million patients. Sounds impressive except
there’s a million joints done in the U.S. every year. A lot of other countries, they started these registries
in the ’70s and ’80s so we’re a little bit
behind the eight ball, but we’re catching up. So now we’re gonna have outcomes. So if you are here and then
move halfway across the country and there’s a problem with the implant, we will know about it and
that’s the important part of collecting all the data on
the knee and hip replacement. So that’s everything in a nutshell. You guys got everything
that I possibly can tell every one of my patients in
the office all at one sitting. So hopefully you kind of walk out of here with two or three things
and learned a little bit about knee replacement, but I’m
sure there’s some questions so I’m happy to stay. If people are tired and wanna
stand or people have to run, run. Thank you for coming. (audience applause) Thank you.

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