Knee Preservation vs. Replacement

Episode 38 - Knee Preservation vs. Replacement

Dr. Chehab: [00:00:00] Welcome to IBJI's, OrthoInform, where we talk all things orthopedics that help you move better, live better. I'm your host, Dr. Eric Chehab with OrthoInform. Our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day today. It's my pleasure to welcome Dr. Alexander Tauchen. We'll be speaking about knee preservation and knee replacement. So Alex, thank you so much for being here. Welcome to Ortho Inform. 

Dr. Tauchen: Good morning. Thanks so much for having me. 

Dr. Chehab: , So tell us a little bit about your background, where you're from. Education, background training. 

Dr. Tauchen: Yeah, sure. So I grew up locally in the western suburb of Chicago. Villa Park specifically lived there my entire life until I went to Washington DC for my fellowship. , So my residency was at Loyola University Medical Center in Maywood, and then I went to Washington DC to a place called the Anderson Orthopedic, , Institute for my joint replacement fellowship, and then came back to the area.

, So lifelong roots in Chicago land. Uh, spent my first five years of my [00:01:00] career at a, different local system, uh, as an employed physician, and then joined the, uh, Hinsdale small business unit of IBJI in 2022. 

Dr. Chehab: So you're about what, eight, nine years into practice? 

Dr. Tauchen: Yeah, exactly. Since, uh, 

Dr. Chehab: 2017. So that's sweet spot of, your recent fellowship training with all the latest and greatest and lots of experience.

Yeah. Again, thank you for taking the time to be here. And, uh, we'll get right into it. We're here to talk about knee preservation versus knee replacement, though I don't think it's necessarily a either or. It seems to be more of an evolution and it's obviously, meant to treat patients with knee arthritis, which is exceptionally common.

Let's walk through, as you suggested, a patient who presents with knee arthritis. What's, what generally happens for a patient to come to you with a, with knee pain and, and with a diagnosis of arthritis? What's a typical patient like? 

Dr. Tauchen: Yeah, so my patient population, majority of folks are probably above the age of 50.

Fifties, sixties and on up,, typical stories that somebody's noticed knee pain for maybe a month or two, and initially they thought they tweaked their knee or did some [00:02:00] kind of silly injury and it just didn't go away. Sometimes the patient then realizes they need to come in on their own.

Sometimes it's their spouse that's driving 'em in or whatever the case may be. You've probably seen that many times. , But yeah, usually paying for a month or two, three, sometimes even longer. And a lot of people are. Surprised to hear after x-rays that they've got an arthritic knee. So sometimes people will present and their knee will already be pretty advanced arthritis, but they're like, well, what do you mean it's only been bothering me for a month?

I'm like, well, these changes have been going on in the background. Then all of a sudden you started noticing it for some reason. 

Dr. Chehab: Yeah. 

Dr. Tauchen: People step off a curb funny, they twist it funny. They do something that makes 'em go to the doctor, and then you get the x-rays. Then the diagnosis is made, which is pretty simple to make on an x-ray.

Uh, and then you take it from there. And then we get into, treatment discussions based on how limited they feel and. Things like that. 

Dr. Chehab: Yeah, , I have a similar experience where patients will really. Be very surprised that they have a diagnosis of arthritis when you tell 'em they have a diagnosis of arthritis.

And I've tried to think of many different ways to explain, , it's kind of like rolling a ball uphill and then all of a sudden it's rolling downhill. Or it's a, you know, [00:03:00] imagine a bucket of water being filled up in the faucet and as it fills, you're not really feeling anything. But once it starts spilling over the gunnels, you start feeling it.

I, I'm, I, you probably have your own set of analogies, but it is really interesting, like arthritis tends to be flying below the radar for a long period of time where patients are fortunately asymptomatic when you think it's kind of a blessing that's the case. And then they start presenting with knee pain and then what's the natural history of arthritis?

What will patients experience, , after they sort of. Are aware that they have arthritis. 

Dr. Tauchen: So usually the first symptoms that they have, they might describe like a, , a dull gnawing pain that's worse with activity, worse with stairs specifically, I'm talking about knees and hips, which is my area of focus.

But really the story similar, whatever joint you might be talking about. But if we focus on lower extremities, which is what I do, , yeah, it's painful when walking longer distances, doing stairs, . Getting down on the ground to play with grandkids, stuff like that. And then whatever they present with initially, the natural history is usually that those things just become more frequent and the symptoms become more severe over time.

And some people, you know, everyone's got different pain tolerance and so it's always [00:04:00] striking. , Some people present with really, really advanced x-rays and their symptoms aren't that bad. Other people with more mild changes. More significant symptoms. Those people are, it's a little bit more challenging to navigate because again, everybody experiences it differently, but that's a general sense.

It's more of the same symptoms. They just tend to magnify and get worse and harder to ignore. 

Dr. Chehab: Yeah. Yeah. I, I agree. And it's episodic to some degree at the beginning, but then those episodes start bleeding into one continuous. Episode and it becomes very limiting for patients when they have knee arthritis like that.

Dr. Tauchen: Yep. 

Dr. Chehab: And then, um, , so obviously the goal is to try and head off some of those symptoms at the past. So what are some of the common ways or common advice that you give to patients to help them manage their knee arthritis? What are some of the things that they can do that can be helpful in the management of knee arthritis?

Dr. Tauchen: So I always frame it from the perspective of, , what we talk about and what we ultimately decide on is based on how limited do you feel and what kind of things have you already tried. And so if you take that patient who's first presenting, right, they've had pain for a month or two, they've not tried anything at all, maybe a little bit of Tylenol over [00:05:00] the counter or something like that.

But otherwise that's it. This is all brand new to them. One thing, I guess to back up a second, even as a joint replacement surgeon, I strongly favor. Non-surgical treatment. And I don't just say that for, website. No, this guy's a surgeon is not gonna cut. No, I actually believe that.

Dr. Chehab: Yeah, 

Dr. Tauchen: because I think a lot of people can get better without a big, huge, major surgery, which we'll talk about later on., So generally speaking, uh. You know, the generic term activity modification, and I, I tell people it's the silliest but best, dumbest advice in the book. If it hurts, don't do it right.

Some people might say, I can walk three miles but it really hurts my knee. Like, well try walking two and a half or two and see if limiting the activity a little bit. Tailor your activities where if something triggers your symptoms, maybe try to back off a little bit. So that's a very simple thing.

Next thing is various over the counter medications provided it's safe with other. Comorbidities that their primary is okay with, , basic things. Tylenol, arthritis. Taking Advil. Taking Aleve. , If someone has symptoms, they can walk 18 holes on a golf course, but it bothers 'em.

We'll keep an ibuprofen in your bag and you [00:06:00] can take one of those every now and then. So simple over the counter medications, activity modification. One thing that comes up a lot in my world is weight management. So by no means a end all be all, but one thing that's common is obesity. And so the importance of weight loss and framing that in a way where , we really talk about , the actual objectivity of it, right?

There's some biomechanical studies that suggest, you know, your knee sees about four times your body weight with each stare you do. So I'm like, if you lose five or 10 pounds, you know, that can be upwards of 40 pounds off your knee. Yeah. When you're doing very basic things. And so if that kind of hits home for people, and of course you frame it in a way like that.

, So activity modification, medications, weight loss, and then you kind of get into the more. Active things that they might have to seek out.. Physical therapy, injections. We can get into that discussion as well. 

Dr. Chehab: Yeah. It's interesting too though, with activity modification, , we know that exercise can help patients manage the symptoms of arthritis, and so if patients just can be, become more strategic about their exercise, they can [00:07:00] get a lot of pain relief from that.

Yep. 

Dr. Tauchen: Totally agree. So you might have a, a runner, for example, right? A lot of people associate running with osteoarthritis, but it's bizarre. I'm sure you've seen the same thing. I've seen people who have run 25 marathons who have perfect looking knees. 

Dr. Chehab: Yes. 

Dr. Tauchen: And I've seen people who have never run a day in their life and their knees are destroyed.

Dr. Chehab: Right. 

Dr. Tauchen: There's a wide perspective. But on that note, a. If people do identify that trigger, right. When I run, that really kills me. I'm like, well consider elliptical cycling, swimming, things that are more fluid motions on the knee rather than the pounding activities. 

Dr. Chehab: Yeah. 

Dr. Tauchen: They can still maintain good cardiovascular fitness.

They're still moving the joint, they're still being active. Uh, so I think that just having that discussion and telling 'em that can be helpful. 

Dr. Chehab: Yeah. And so beyond this, we're doing some lifestyle treatments of knee arthritis again, to help. Preserve the joint for as long as possible so the patients can remain active without significant limitations.

What are some of the interventions that we have that are short of joint replacement that can be helpful in manage in the management of knee arthritis? 

Dr. Tauchen: Yeah, so one thing that's a completely non-invasive, intervention is [00:08:00] physical therapy, which is a lot of our go-to first, treatment plan, 

Dr. Chehab: and why is that helpful?

What, what do you think is happening? 

Dr. Tauchen: , I explained it. It's, it's a little strange with arthritis to be honest, because physical therapy is not regrowing cartilage. It's not doing anything like that, removing bone spurs, but somehow some way between strengthening the quad, strengthening the hamstring for knees, for example, trying to improve the motion and stretching the soft tissue envelope around, I think can be beneficial.

I'd say with hips more than knees. I actually caution patients. I'm like, look, if you got a bone on bone hip and I send you to physical therapy, it's something we can try. But if it seems like it's making you worse instead of better, don't think that you're gonna break through on the other side and it's magically gonna be okay.

It's probably the joint just declaring that it's not gonna get any better with this. 

Dr. Chehab: Right. 

Dr. Tauchen: And that's pretty common with hips. Right. I tell 'em that, you know, the therapist's job is to move the joint and try to get it better. Well, if your underlying arthritis is so significant that it's not allowing that, we will back off of that.

Dr. Chehab: Yeah. 

Dr. Tauchen: So physical therapy is kinda the first thing. It's not for everybody, but more. 

Dr. Chehab: What about for the knee? You have to take the same philosophy with the knee. 

Dr. Tauchen: The knee doesn't seem to do as much of that. [00:09:00] I'd say , the hip seems to bother people quicker with physical therapy. The knee, I'd say that they can tolerate it better, but they , might not notice the relief as much.

Yeah. But the knee or the, hip for whatever reason seems to. Sometimes people are like, uh, I went two or three times and. It made feel worse. 

Dr. Chehab: Right? But it's very common for patients to feel better with physical therapy for knee arthritis that Do you agree with that? 

Dr. Tauchen: I do agree with that. Yeah. Yeah.

And that's a staple of our treatment plan. Now again, if that person comes in and they've got a horribly deformed me with bone spurs all over the place and a terrible arc of motion, like maybe therapy's not even worth their while there weight 

Dr. Chehab: limits, right? 

Dr. Tauchen: Yeah. 

Dr. Chehab: Right. 

Dr. Tauchen: , So getting beyond physical therapy that sort of.

Invasive things, so to speak, very minimally To start would be injections, which are a huge topic in knee arthritis, hips, uh, a little more reservations that we'll get into. But let's talk about knees. So generally speaking, there's the kind of staples, which are cortisone injections. There's a bunch of different.

Subtypes of that, I'd say. But cortisone in general, what's called visco supplementation, some patients might commonly notice gel shots. You hear all sorts of other crazy things, right? Like [00:10:00] rooster comb and chicken gel. I mean, I've heard all sorts of, 

Dr. Chehab: but all describe the visco supplementation. Yep.

Injection lubricating injections, loop jobs. 

Dr. Tauchen: Yeah. Heard all those terms. Yep. Right. So those are kind of the, I'd say more widely accepted, maybe more data driven ones. And then there's newer things like biologics, platelet rich plasma and stem cells in,, lipo gem, some fat in ge, things like that.

So there's a lot of stuff that's out there. , I always start with kind of the more tried and true I'd say, which would be cortisone than gel than if the person is willing wanting, and I think they're a good candidate though. Some of those biologic things are things that I offer and that our practice offers in general.

I try to be very selective with those and be honest with the patients because a lot of those can be very expensive. Their out-of-pocket costs. If the person wants to try it, great. But I think that they should be made aware that it's not always predictable. Who benefits from those and who doesn't? 

Dr. Chehab: Right.

So let's go through. Each one of those injections, I think it's important. So cortisone, what's the upside? What's the downside? 

Dr. Tauchen: Yeah, so [00:11:00] cortisone, when people get a cortisone injection, it's almost always mixed with some sort of local anesthetic. So I explain it to them and say, look, by the time you get out to your car, your knee might feel better because the numbing medicine's taking its effect probably takes 48 to 72 hours maybe for that cortisone to actually kick in.

And then from there. People, one, the common questions is, how long does this last? It's wildly variable, right? Some people swear this stuff is magic for two weeks. Other people disappear for eight months and they're like, that was awesome. 

Dr. Chehab: Yeah. 

Dr. Tauchen: And so, which person's gonna be the one that benefits and who doesn't?

Who knows? Don't 

Dr. Chehab: know till you try, right? 

Dr. Tauchen: You don't know. So that's general cortisone. There's other kind of newer cortisone ish things out there, that's ideally meant to be a slower release, longer lasting that sometimes requires a prior authorization. Things like that. Those might last a little bit longer, but all in the same basket.

Dr. Chehab: Yeah. 

Dr. Tauchen: , Visco supplementation is kind of my next go-to, and I always tell people, and I'm sure every surgeon's got their different preferences. I just think that cortisone iss a bit more predictable for people, in terms of pain relief. A starting point in a pain relief. Exactly. Yeah.

Dr. Chehab: Yeah. 

Dr. Tauchen: Visco, I don't offer it as much to people who already have a horrendously [00:12:00] bone on bone knee 'cause I just don't think it helps 'em all that much. But for more mild cases, there's absolutely people that swear by it. Most Visco supplementation nowadays I'd say is a single injection. It used to be a series of three or five, almost universally, but I think a lot of payers and people have gotten away from that.

'cause the data seems to suggest that the single shots can be just as good. So I prefer a single shot. Fewer visits for the patient, fewer injections, things like that. And then, you know, that's also unpredictable. So I honestly, with Visco supplementation, I tell people it's probably not much better than a coin flip.

If I inject 10 people, five think it's magic, and five think, why the heck did I waste my time and money? And so not sure your experience with that, but that seems to be 

Dr. Chehab: So, it's funny when you're saying that I, I, I actually go with the three injections just in the sense that. Clinical sense has been that there's a little bit more predictability that patients experience pain relief with the three, and maybe it's with one injection, you might shoot an air ball, maybe not.

Um, with three, you're less likely to have three air balls. 

Dr. Tauchen: Sure. 

Dr. Chehab: And then, um, , but absolutely it's a 50 50 [00:13:00] proposition. , Patients either respond or they don't. , We don't know until we try it. . With cortisone, I'll tell 'em, Hey, it's like throwing water on a fire. Let's see if we can put the fire out.

And once the fire's out we'll see how long it stays out. And, um, with the Visco supplementation, use a funny analogy that it's your body's version of maple syrup and that's what we're putting in there. And it may or may not make a difference in terms of how your knee feels, but again, we don't know until we try.

And, um, and then, , when we talk about. Visco supplementation, cortisone, those are typically covered by insurance. Typically, there have been some changes recently. And then, the non-covered ones that have typically always been not covered in more expensive, other platelet rich plasma and the stem cells.

So how do you educate patients about platelet rich plasma and stem cells? We'll talk with the plate. Let's start with platelet rich plasma. 

Dr. Tauchen: Yeah, so I would generally classify those as, you know, what we call regenerative medicine. That's kinda the buzzword that's out there. People say, well, can't you just put something in there that kind of regrows the cartilage?

I saw some ad or read about it on tv, or my friend had it, or whatever. 

Dr. Chehab: Right? 

Dr. Tauchen: And so I would, I would also preface this by saying I [00:14:00] would not consider myself an expert in this. I don't do it. Ton of it. Sure. Um, in, in my field, I'd say it's probably a little bit more in the sports medicine realm, like your world.

Mm-hmm. So you probably have a little bit more experience, but, , the one that we do do in our office is the PRP or platelet rich plasma. So essentially what that is, is a blood draw. So somebody in the office draws the patient's blood. What we do is a system, they draw about 20 ccs of blood. You spin it down in a centrifuge and I'll explain to patients, it divides the plasma and the kind of platelet rich area, and then the red blood cells, and then you actually remove the plasma part from that.

Spin down and then you put it right back into the knee or whatever joint it is that you're injecting. And the idea is that there's healing factors, so to speak in there that can regenerate some of the cartilage and promote healing. So for a knee that's already, again, horrendously bone on bone, a.

We know that there's no great studies that prove that's gonna actually make regenerate anything regenerate, 

Dr. Chehab: right? 

Dr. Tauchen: So those people, I say, look, if you've tried everything and you're really against surgery, fine, I'm not gonna push that. But just understand that we don't have phenomenal data that says this [00:15:00] works.

And it's always interesting. Some people are like, I don't care. You know, the money's not an issue for me or whatever. Let's try it. But I just like to have that honest conversation, say, I don't know what it's gonna do for the people with the more mild disease. I've absolutely got success stories with this where people are like, oh my goodness, that was, 

Dr. Chehab: once again, 

Dr. Tauchen: it's magic.

Dr. Chehab: That 

Dr. Tauchen: was great for a year. You know, you have those people. So again, it's just really, really unpredictable. Who's gonna respond in what way? 

Dr. Chehab: You think it's regenerating anything or you think it's an anti-inflammatory? What do you think the mechanism that is happening that. Helps patients feel better, 

Dr. Tauchen: you know, having operated on tons and tons of knees and knees where the cartilage is completely missing.

I, I just, I can't really believe that it's making more cartilage that's selectively filling in those spots. That's the other thing. You can't really localize this. I, 

Dr. Chehab: I agree with you. Yeah, 

Dr. Tauchen: so it's, it's some intangible, it's probably some combination of all those things. 

Dr. Chehab: I tell people when they're listening to the advertisements about regenerative medicine to listen very carefully because it will typically be, we use the regenerative powers to help you feel [00:16:00] better.

, They're not making claims of regrowing cartilage 'cause I don't think they can. We don't have any of that. Data that suggests that it really is doing that. 

Dr. Tauchen: Yep. 

Dr. Chehab: , And then stem cells, what's your take on stem cells in general? Patients obviously hear about it. They pursue it. , They ask you and me about it.

, What's your take on it? 

Dr. Tauchen: So that, that's the one thing I don't do. So admittedly , not an expert in this area. Either, but to just generally explain stem cells, the idea is that there are cells in your body that have the ability to differentiate into various tissues, right? You have stem cells when the embryo is forming or whatever, and you know, they might become cardiac cells or muscle cells or cartilage or whatever.

And so the idea is that when put into the affected joint, they can be stimulated by various factors to again, regenerate, regrow cartilage. Now, the issue that I have with that conceptually is that if you're doing that and putting it into a bone on bone knee, it doesn't, you know, you put. A liquid, essentially inside of a liquid.

It's not really staying where you put it. So the exact mechanism. I'm not entirely clear. 

Dr. Chehab: Right,

Dr. Tauchen: I think, and I tell patients, , my world is hip and knee arthritis. I think that [00:17:00] some of those things are showing a lot more promise. Again, in your world in sports medicine for things like, , maybe tennis, elbow injuries 

Dr. Chehab: and 

Dr. Tauchen: Yeah.

Plantar fasciitis, patella tendonitis, rotator cuff. I do think that there's some promise there. , But the bone on, bone arthritis, back to what you were saying with some of these other outside companies that advertise all over the radio. Some of these stories actually, they're a bit frustrating.

'cause I feel like there's some unethical stuff going on out there. 

Dr. Chehab: No, it's setting an expectation. Yeah. And trying to promote an idea in a sideways. Advertisement that, yep. Boy, this is really the, an elixir and, and a, a miracle cure for arthritis when in fact, you know how it's really helping people.

It may be from an anti-inflammatory effect, but there's been, as far as I know, not a single clinical study showing that it's regrowing the cartilage. 

Dr. Tauchen: A hundred percent. Uh, one, one example comes to mind probably about. A year and a half ago. I've since replaced both of those women's hips, but she came into the office in a wheelchair and was telling me this story.

She was really frustrated. She's like, you know, I went to one of these places, not to be named, but I think she said she spent like $12,000 out of [00:18:00] pocket, and I get a simple X-ray. I'm like, it's frustrating there. Any reasonable person will look at that X-ray. That's not gonna help this poor woman.

So she wasn't ready for surgery. Fine, I get it. But , to take that kind of money. Some people get to a point where joint replacement's the only thing that's gonna help, and I let them make that decision themselves. Sure. But I, it's unfortunate to hear some of those stories. 

Dr. Chehab: I, it sounds like we have a very similar from the sports world, in the arthroplasty world are very similar path,, for patients who are first diagnosed with arthritis, who are trying to manage their symptoms in terms of.

Weight loss activity modification and strategic exercise, education, obviously injections that can be helpful, ranging from cortisone visco supplementation. PRP, neither one of us is a, a big proponent of stem cells at this point. Hopefully something like that will be something that we can use, ethically and, and in good faith.

But it doesn't, in my practice, play a big role. It plays no role in my practice as it sounds like in yours as well. 

Dr. Tauchen: Right. 

Dr. Chehab: And generally we can get people. We can keep [00:19:00] them moving and living better for a long period of time, and maybe they'll never end up with joint replacement. And as you alluded to earlier, I mean, it's so multifactorial about whether or not someone's gonna need a joint replacement.

They can have a horrible x-ray, as you mentioned, still play five sets of tennis, or they can have an x-ray that doesn't look so bad and be hobbled and. Have a really difficult time getting around and have a huge impact on their life. So is it bone hardness? Is it where the arthritis is? Is it tolerance to pain?

And there's so many different things that go into it that there's not one single factor. We get to a point where a patient's very limited in their life, um, hasn't really responded or, or no longer is responding to these treatments that are meant to preserve the knee., And we get to the point where joint replacement is their best option.

So specifically with the knee, what are the types of joint replacements in general that patients can get? And then, um, let's talk about them a little bit about the pros and cons of each of them so that we can provide a framework to the listener of, okay, these are the. General options. These [00:20:00] are the good and bad for each of them and why we choose or help people choose, , what may be best for them.

Dr. Tauchen: Yeah, so happy to talk about that before we get into the actual implants and stuff, how do you actually make that decision? So yeah, the one thing, you know, every physician, whenever they've been doing it long enough, they find themselves repeating similar things. So the framework that I use, I tell people that joint replacements are basically for people who have lifestyle limiting pain on a daily basis despite trying A, B, C, and D, right?

Yeah. A, B, C, and D could be any one of those things that we just talked about. So if they wake up one day and they're like, look, I've tried this, I've tried this, I'm just sick of it. My quality of life stinks. That's kinda when you make that decision another easier, more basic way. Uh, one of my mentors in residency used to say that joint replacements are for people who are sick and tired of being sick and tired, so that's good.

That really resonates with a lot of people. It's a simple, easy way to say it. So you have that discussion that, all right, well let's talk about replacing my knee. And so first thing, when you're talking about the different types of knee replacements, which I'll broadly describe as partial knee versus total knee or unique compartments, the fancy name [00:21:00] for it is, is the arthritis localized to one particular spot?

So we divide the knee into three compartments. There's the medial compartment, which is the inside or kind of the, the midline of your body. There's a lateral compartment, which is the outside, and then there's what's called the patella femoral compartment, which is the space between the kneecap and the femur.

So. Any of those compartments can be affected in isolation. It's more rare, I'd say that they're completely isolated. There's usually some combination of maybe two or three of those, and then there's also people who come in the first time and their knee is just completely gone everywhere. So when you're.

Deciding partial versus total. The partial knee replacements are dedicated for people, or indicated, I should say, for people who have true isolated arthritis. And the most common pattern that we see, and I'm sure you'll agree with this, would be on the inside of the knee. Yeah. The, the medial compartment.

And probably that's related to the fact that when humans weight bare, you weight bare down the middle of your body and so that inside your knee sees a little bit more low than the outside your knee does. At least that's kinda the theory, but probably not true for everybody. , So you can get isolated arthritis on the inside of the knee.

You [00:22:00] can get on the outside of the knee, you can get in the patellofemoral compartment. So that's kinda the first decision point. And then beyond that, let's say you've got somebody who's got isolated arthritis, you do take into various considerations, their age, their activity level, their weight, things like that.

When you're deciding it and maybe a little bit more. Are too detailed for this discussion here to talk about all the technicalities, but generally, if somebody has isolated medial arthritis and they're, you know, let's say they're a relatively active younger person, I'm a big proponent of partial knee replacements.

I think that partial knee replacements when it's a well done technical job in the right person, they're phenomenal. And they allow people great to get back to really active things, right? People playing pickleball. I've got people who have gotten back to juujitsu and rock climbing and downhill skiing, all sorts of things.

So the partial knee is, is an ideal operation because I explained to people. You keep more of your own stuff behind, right? You keep your own ACL, you keep your own PCL, the whole outside of your knee, , your kneecap, all these things. So the term that we throw around a lot is kinematics, which is basically [00:23:00] how the knee works and moves and absolutely injunction all the different parts naturally.

And so intuitively, if you're only replacing the isolated part of the knee that's affected, makes sense to leave more of your own parts behind. 

Dr. Chehab: Yeah. Right. The kinematic will be better. The movement of the knee will be more natural feeling to the patient. 

Dr. Tauchen: Correct. And that surgery itself, a little bit of a smaller incision, a little bit of a smaller dissection exposure work, you know, and then ideally a bit of a quicker recovery, things like that.

Dr. Chehab: Yeah. 

Dr. Tauchen: Not always true, but 

yeah. 

Dr. Tauchen: So that's a partial knee, 

Dr. Chehab: but what's a knock on it? 

Dr. Tauchen: The knock on it. Said, yeah. Great. I'm glad you brought that up. 'cause I wasn't done. Yeah. Discussing all those things. So there's goods and bads to everything, right? 

Dr. Chehab: Yeah. 

Dr. Tauchen: So I'd say the most common question I get, they're like, well, doc, why would I replace just the inside?

Can't the rest of it wear out over time? Like, what, why would I wanna do that? Like, I'm gonna have to have redone. So I quote a study, I can't remember what year was done, but there, there's some outcome studies out there that in a well selected patient, well done surgery, the survivorship of a medial partial knee at 20 years is like over 90%.

So 

Dr. Chehab: that's excellent. 

Dr. Tauchen: Yeah. , Greater than 90 out of a hundred people,, again, provided it's the right person, good technical [00:24:00] job, that kind of thing. So it can be a very good operation. But that would I say, I would say is kinda the biggest knock is that, what if in five or six years the outside of my knee wears out, or the space underneath my kneecap wears out?

Then yeah, sometimes you're looking at either replacing that part in isolation or removing the partial knee and then converting it to a total knee. 

Dr. Chehab: Right, 

Dr. Tauchen: which happens, 

Dr. Chehab: right? Yeah. I, again, similar take of it. It's a more natural feeling. Knee and knee you'll like better. , It's just not quite as durable when you add it all up.

Dr. Tauchen: Yep. 

Dr. Chehab: Can be, but on average. 

Dr. Tauchen: Correct. Can be, but on average. That's right. And so I'd say one of the other things that can be a bit of a challenge and a partial knee replacement is, , one thing we'll talk about is these surgeries aren't always perfect, right? People have issues with 'em on occasion. If you have a partial knee that has continued pain a year or two after surgery, sometimes it's not explained.

You can't definitively say, , the other side wore out, or it's infected, or it's loose. There's no good reason. And so sometimes the. Decision is, well it still hurts, let's just take it out and put a total knee and that'll fix it. And then sometimes when [00:25:00] that doesn't fix it, then you've gone down a path that's tough,

tough. Yeah, it's tough. It's very tough. 

Dr. Chehab: That's 

Dr. Tauchen: right. So, 

Dr. Chehab: and then what about the total knee replacements? Are there different types of total knee replacements? We've talked about for decades and, , can you explain some of the differences there? 

Dr. Tauchen: Yeah, so if you take, so, you know, you divide 'em into partial knee versus total knee, but even within total knee, there's different designs and different things that are meant to replace different parts.

But every single total knee is gonna replace the inside of the knee, the outside of the knee, and the kneecap compartment. . Now, first point of the, to, to address there, when I say it replaces , the entire knee. The kneecap. Yeah. Kneecap is, it's gonna forever be debated. Do you replace the backside of the kneecap or do you not?

So I'm what I would call a selective resurfacer. So I'll look at the kneecap in surgery. If it looks like it's really worn out, I'll remove it and put a little plastic button on the back of it. Yeah. But if I remove the, you know, open up the joint and I look at the back of the kneecap and it looks fine, I just leave it.

Yeah. Some people are basically all or nothing. They resurface everybody or they leave everybody, right? So that's gonna be [00:26:00] debated. , But with the design of the implants themselves, so nevermind the kneecap. There's a couple of important ligaments. So I would say that in general there was one or two knees on the market across all time that actually left the ACL intact.

It never really caught on. It was very technically challenging. I did a few in fellowship. So that kind of fell out of favor. So most people are very surprised they learned this, right? 'cause the ACL gets so much attention, it's like, what do you mean my knee's not gonna have an ACL? No. Right? No one of the first steps in a knee replacement, unless you're, you know, one of a couple people probably in the country using a knee like that.

Yeah. The ACL goes. Yeah. So the a c L's gone. But then the biggest design thing, I'd say beyond that is the PCL, which is the ligament. Yeah, that's 

Dr. Chehab: the fork in the road, 

Dr. Tauchen: right? The ligament in the back of the knee. So that's also gonna be forever debated. So there's implant designs that are meant to remove your native PCL and replace it with what's called a box and a post.

It's just a way that you stabilize the knee without a PCL. But there's a lot of surgeons who feel that if you leave a PCL, it's gonna be, again, a more normal feeling 

Dr. Chehab: knee. Yeah. 

Dr. Tauchen: On the tibia side, which is the top [00:27:00] of the shin bone, I'd say there's kind of a another, I wouldn't call it 50 50.

I quite honestly don't know what the breakdown is lately, but there's something called a fixed bearing, and there's something called a rotating platform. So the fixed bearing is the idea of the little piece of plastic insert that you put in there stays fixed. And with a rotating platform, it actually rotates when your knee flexes and extends.

So you could argue that's a. In patients, if you didn't tell 'em what they had, they might not know the difference. Sometimes it's a, a technical preference or surgeon preference, but that's , the different type. So I'd say it has to do with the PCL, keeping the PCL or substituting it, and then fixed bearing or rotating platform.

Those are the main. 

Dr. Chehab: What's your preference? Just curious. 

Dr. Tauchen: So what I do is pretty much everybody gets a, what's called a PCL retaining or cruciate retaining knee. So I don't cut a box in anybody, basically. , But actually with the insert I use a bit of a, deeper, more constrained insert. And so I'd say the, the PCL for me, even without cutting the box and formally substituting it, is probably about 50 50.

Dr. Chehab: Okay. Got, 

Dr. Tauchen: so you can do it both ways. And again, getting [00:28:00] a little technical, a little 

Dr. Chehab: weeds, but yeah, 

Dr. Tauchen: a little more in the weeds. But yeah, so I, I'd say I'm about 50 50, but I never, you know, cut the box and put the post in. 

Dr. Chehab: And so what's, what's your overall take when you tell patients, , between a partial knee replacement, a total knee replacement, if they're getting a total knee replacement?

The benefit is durability. The benefit is predictability. What is the benefit over partial. 

Dr. Tauchen: Yeah. I'd say, you know, as we talked about the partial knees, that thing that's always lingering in the back of someone's head, they're like, well, my knee hurts now five years later. Well, we know it's not with a total knee, we know it's not because the rest of your knee wore out.

It's 

Dr. Chehab: because 

Dr. Tauchen: that's already been taken care of. It's already been taken care of. So, right. From a mechanical perspective that's already gone. I'd say, it, it's pretty subtle, but one of the bigger things, it's a bigger surgery, so potential risk of, infection, loosening some of the more catastrophic complications that we talk about, we tend to associate more with total knees.

Sure. Than partial knees. , I'd say that stiffness is probably more common in a total knee than a partial knee after surgery. Yeah, a little bit harder for people to get their motion. So some of the bigger, scarier things can be, , maybe more associated with a total [00:29:00] knee. But the benefits, yeah, like you said, they're, they.

Might last a little bit longer. It's kind of a, ideally a one and done sort of thing. And not worrying about it. 

Dr. Chehab: Yeah. We've covered a broad range from non-operative treatment to operative treatment, , for the condition of knee arthritis. Let's say someone in your family had knee arthritis.

What's the advice you would give them? What would you tell 'em? 'cause they always ask us, , Hey, if I've got this knee, what do I do about it? What do you do about it? 

Dr. Tauchen: Yeah, so I, again, going back to my little parting line, the decision fork in the road, right, with, does it bother you every day and have you tried this, and this?

Again, I, I really try to push the non-surgical things provided that they're, they seem inappropriate candidate that it's fitting the needs of their quality of life. Because with that person who's got, you know, again, take my family member and uncle or something, like Doc said, my knee was bone on bone, but I play golf five days a week.

I do this to that patient in my office. I say. Go on and have a nice day and come find me when I can help you because 

Dr. Chehab: right. 

Dr. Tauchen: I also always tell people commonly I say, we don't replace knees to make your x-ray look pretty. We'll replace your knee to [00:30:00] improve your quality of life and your function and get rid of your pain.

So yes, I can operate on you, but again, we talked about some of the potential risks. Unless there's a substantial benefit to me doing the surgery, it's not worth the risk. So just live with that. Don't wait till you're crawling and you can't walk and do it. You know, there's a, there's a happy medium, right.

But I tell people really try the non-surgical things. Uh, and then when you wake up that one day and you're sick and tired of dealing with it, then find somebody who does a lot of ease and does a good job that you get along with. And do it. 

Dr. Chehab: Yeah. With them. 

Dr. Tauchen: Yeah. 

Dr. Chehab: And when you're sick and tired of being sick and.

That's right's a great take home. 

Dr. Tauchen: Yeah. 

Dr. Chehab: Alright, well listen, um, Alex, thank you so much for being here on OrthoInform. Uh, our guest today is Dr. Alex Tosin. Really appreciate being here. Thanks for taking the time. 

Dr. Tauchen: Yeah. Thank you very much for having me. This was great. Appreciate it.