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Alejandra Rodriguez-Paez, MD
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Alexander Gordon, MD
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Alexander M. Crespo, MD
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Anand Vora, MD
Andrea S. Kramer, MD
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David Schneider, DO
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Douglas Solway, DPM
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Eddie Jones Jr., MD
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Jonathan Erulkar, MD
Jordan L. Goldstein, MD
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Vidya Ramanavarapu, MD
Wayne M. Goldstein, MD
Wesley E. Choy, MD
William P. Mosenthal, MD
William Vitello, MD
ACL

Total Knee Replacement

Episode 8

Total knee replacements are one of the most common and successful orthopedic procedures. The modern total knee replacement started to emerge in popularity in the 1970s and 1980s. Dr. Jeffrey Goldstein explains, since then, improvements in materials and techniques have helped extend the success rates and longevity of replacements. Learn more about the history of knee replacement surgery and what patients having surgery can expect.

Hosted by Eric Chehab, MD

Dr. Jeffrey Goldstein

Featuring
Jeffrey Goldstein, MD

Orthopedic Surgeon with Fellowship Training in Adult Hip and Knee Reconstruction

Episode Transcript

Dr. Eric Chehab:
Welcome to IBJI Ortho Inform where we talk all things ortho to help you move better, live better. I'm your host, Dr. Eric Chehab. With Ortho Inform, 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. Jeffrey Goldstein, who will be speaking about total knee replacement surgery. As a brief introduction, Dr. Goldstein graduated from the University of Pennsylvania with a degree in biological sciences in 2004. He received his medical degree from Rush University Medical College in 2008, and stayed in the Chicago area for his residency training at the University of Illinois at Chicago. Dr. Goldstein completed a surgical residency at UIC in 2013, and then received his advanced fellowship surgical training in joint replacement surgery at Ortho Carolina in Charlotte, North Carolina in 2014.

Upon completion of his fellowship, Dr. Goldstein returned to the Chicagoland area and has performed hundreds of total knee replacements a year at Illinois Bone and Joint Institute. Dr. Goldstein is a member of the Emerging Leaders Program for the American Orthopedic Association. He's been the recipient of numerous awards, including the Leo Weinstein Award for Clinical Excellence and Patient Care in 2013. Dr. Goldstein has been a leader within Illinois Bone and Joint and at spearheading IBJI's clinical research efforts. Dr. Goldstein helps his patients achieve improved function and pain relief with total knee replacements. He's here to help us learn more about the operation.

So, Jeff, welcome to Ortho Inform, and thanks for being here today.

Dr. Jeff Goldstein:
Thank you for having me.

Dr. Eric Chehab:
Let's get into it. Jeff, in terms of knee replacement, specifically, take us through a little bit of the history of knee replacement. It's relatively, I guess it's not even a new procedure in the early seventies was basically when the modern total knee replacement was designed.

Dr. Jeff Goldstein:
The modern total knee replacement really started to emerge in popularity in the seventies and really the 1980s. And that's where kind of the modern day implants came. What's interesting is that really the principles between back then and now have really not changed because arthritis, which is the breakdown of cartilage, which of course causes pain, the goal has always been to resurface the joint to manage the soft tissues. Now we've gotten better at that throughout time. But the evolution of the implant design, for example, they look pretty similar to the way they looked back in the late seventies and early eighties.

Dr. Eric Chehab:
So take us through those components in the implants for the typical primary total knee replacement.

Dr. Jeff Goldstein:
The femur bone or thigh bone is the top of the knee. And then the bottom of the knee is the tibia or shin bone. So the ends of those bones, where the cartilage wears down, cartilage being the white at the end of a chicken bone, if you will, when they wear down, you want to resurface the ends of the bone and the way we do that, it's almost like capping a tooth.

A lot of people think that we just sort of lop off bone, halfway down the thigh and halfway up the tibia. It's not that. We cut less than a centimeter off the ends of the bone and we cement a metal prosthesis, occasionally there's ceramic prosthesis, but generally speaking, we use metal prosthesis, in between the metal components is a polyethylene dish or insert, which is like a plastic. And so what happens is instead of having bone grinding on bone, as arthritic patients have, you end up having an articulation of metal gliding on plastic. There's no nerve endings in metal and plastic, and that's why the pain goes away, but it's not just the resurfacing the ends of the bone.

So if you can imagine patients as they wear out their knee, they don't wear out symmetrically. Sometimes they wear out the inside. Sometimes they wear out the outside and as a consequence of that, some of the soft tissues that surround the knee can get contracted. And so it's always been said, it's a soft tissue procedure because it's not just about resurfacing the ends of the bone.

It's about managing the soft tissues to create a mechanically aligned knee that is well balanced in both bending flection or straightening extension. And so those principles, which really came from New York and Boston in the late seventies and early eighties, they still apply to this very day.

Dr. Eric Chehab:
It's interesting that you say many patients come in with the concept of a knee replacement being, you know, a big hinge that's put in there and they're frequently surprised to see that the components are basically caps at the end of the bone, like you said, and so I think that's reassuring for patients to know that they're not getting this massive resection of bone, like you said, less than a centimeter most of the time.

In terms of conditions that are treated with total knee replacement, go through some of those conditions. You mentioned arthritis. What are some of the other conditions in addition to arthritis?

Dr. Jeff Goldstein:
So arthritis is sort of a larger general term. There's different types of arthritis. far and away the most common type of arthritis is called osteoarthritis or degenerative joint disease. That's sort of your typical wear and tear type of arthritis with cartilage breakdown. And it's, multi-factorial what causes that, but it's extremely common. There are other types of conditions that can cause damage to cartilage and the surrounding soft tissues to the knee.

There's rheumatoid arthritis and other inflammatory arthropathy. Yeah. Sometimes patients have a trauma earlier in their life. So for example, a fracture at the end of the femur or the top of the tibia that can lead to what's called post-traumatic arthritis. And then sometimes once in awhile, just by nature of deformity.

So certain deformities from development or early on in life, uh, which just need correction. We can use knee replacements for those purposes as well.

Dr. Eric Chehab:
So a patient coming into your office who may be in need of a total knee replacement. What are some of the typical symptoms that they will report? What are some of the signs that you see on your exam?

Dr. Jeff Goldstein:
Far and away, the most common symptom that leads a patient to come in to pursue knee replacements is pain. But there's other reasons as well, sometimes limping, stiffness, the aesthetic appearance of being bowlegged or knock-kneed that bothers a patient. All of those would be reasons that patients would come in to pursue knee replacement.

Dr. Eric Chehab:
And short of knee replacement, what are some of the typical interventions that we can do to help patients manage the pain or the stiffness or the recurrent swelling and these symptoms that you mentioned?

Dr. Jeff Goldstein:
There is a pretty broad spectrum of treatments for the management of arthritis of the knee.

And it starts from most conservative to most aggressive, of course, most aggressive, ultimately as knee replacement surgery. Short of that, we tell patients to ice. We tell patients to use over the counter pain medication, including Tylenol, but more typically the nonsteroidal anti-inflammatories, that'd be ibuprofen and Naproxen.

Beyond that, when patients have pain, not really responding to those very conservative modalities, that's when we enter, the intraarticular injection territory and that would include corticosteroid injections. So patients getting cortisone injections two to three times a year is very common. There's other types of injections as well.

There's viscosupplementation, which is a lubricant shot or gel. There's some experimental injections that exist now. And then physical therapy would be the other non-surgical treatment just to get patients strengthened around the muscles around the knee. It also helps with some lack of range of motion, improve their balance and coordination with walking.

Dr. Eric Chehab:
Okay and so a patient's gone through these iterations of treatment. They feel better temporarily, but over time, eventually the decision is made for total knee replacement. Now, is that decision based on you or on them typically?

Dr. Jeff Goldstein:
So it depends who you ask. I can tell you philosophically from my standpoint, it's up to the patient. Let me explain why. Degenerative joint disease only goes in one direction. It degenerates, it doesn't regenerate. And every patient's clinical threshold for them wanting to intervene is different. Everyone's pain threshold is different.

What I tell patients is whether or not they are a candidate for knee replacement surgery. When patients ask me, when will I know when I need it, the answer is you'll know when you know. In other words, patients come to me wanting knee replacements and it's the patients that come to me wanting it that have better outcomes.

If I try to talk a patient into a surgery and tell them that they should do it, they might be apprehensive. It can be anxiety provoking because at the end of the day, even if someone has a terrible bone on bone x-ray, we don't operate on x-rays. We operate on people. And so for the patients that have failed and come to that internal decision that they're ready to fix their knee, those are the patients that do very well. And so what I would say is because it's elective procedure, it's not a cancer, it's not an infection. It's really up to the patient, if any when. No one ever died from knee arthritis. And so patients, when they reach that internal threshold, those are the patients that do great.

Dr. Eric Chehab:
I will frequently tell patients that the typical person coming in for a knee replacement is having a hard time walking three or four blocks. Really can't get up and down the stairs without a lot of pain, tried anti-inflammatories injections without sustained success. And are basically at a point where they're just had it with it. Is that reasonably accurate?

Dr. Jeff Goldstein:
That's absolutely accurate. So that's exactly the point is that everyone reaches their limit and listen, maybe not everyone. There are some people that just, they have an arthritic knee, they have some pain, maybe they're reluctant to have surgery for a myriad of reasons and they just say, I never want knee replacement surgery and that's okay.

But by and large, the patients and there's many of them that reach that level, they come in and they say, I've had it. I'm done.

Dr. Eric Chehab:
Are there any patients you try to talk out of knee replacement?

Dr. Jeff Goldstein:
So I think one of the big topics of discussion, particularly in the last seven, eight years is kind of risk optimization.

So there was a time in an era where orthopedic surgeons would kind of operate on any patient without really consideration of what their sort of modifiable risk factor profile is. That is evolved significantly. So we know now that there are certain risk factors that put patients at risk for what we call peri-operative complications, where a patient can be rendered worse than where they started.

And so the answer to your question is yes, there are patients that really shouldn't have knee replacement surgery because the risk of the surgery and the consequences of the surgery outweigh the perceived benefits. Got it.

Dr. Eric Chehab:
If I'm a patient coming in your office, we've discussed it's time for knee replacement. What are some of the things that the patient will be doing ahead of time to get prepared for surgery?

Dr. Jeff Goldstein:
There's a lot of preparation that goes in prior to knee replacement surgery. So. We've been talking about just the indication towards agreeing to surgery or, or scheduling someone for surgery.

Once that happens, number one, a patient typically needs to see their primary care physician. If they have a history of cardiac issues, we have them seen their cardiologists. There's a battery of lab tests that usually are ordered to make sure, for example, that they're not anemic with low blood counts going into surgery.

Usually they end up having a chest x-ray and EKG. And so they need medical clearance. On top of that, we want to really maximize their nutrition going into surgery. So for example, you don't want to see rapid weight gain or weight loss prior to surgery. That actually puts people at risk for negative outcomes and complications.

There's other things that we do to minimize infection risks. So we use a chlorhexidine wash prior to surgery for about five days every day in the shower, we have patients wash their bodies and particularly the surgical site with these types of chlorhexidine washes to decolonize the skin of bacteria, all with the intent of reducing risk at the time of surgery.

Because of that knee replacement surgery is not the type of surgery that you come in and see an orthopedic surgeon and expect to have your surgery later that week or next week. It's usually at least a month out if not longer, depending on scheduling.

Dr. Eric Chehab:
That's super helpful, so patients have the understanding that there is preparation that goes on prior to surgery, the medical clearance, things that happened very close to surgery with decolonization, everything is intended to reduce the risk of having any complications, postoperatively, and obviously extend the lifespan of this knee replacement. So let's go to the day of the knee replacement. So what can patients expect coming in on the day of the procedure? What typically happens for them?

Dr. Jeff Goldstein:
Typically, whether you're having your surgery at a hospital or an ambulatory surgery center, you come in a lot earlier than your surgical time slot, because they have to get you changed. They need to do a final wash. They need to put their IVs. And nowadays, as we have gotten better at managing post-operative pain, we've learned that it's advantageous to give patients certain pain medications prior to surgery.

So on the day of surgery, you come in, they get you prepared. The nursing staff and the surgeon sees you and marks you, answers your questions goes through the informed consent part of the conversation. The anesthesiologist comes in and discusses the way they're going to do anesthesia, whether it's a spinal anesthesia or generally anesthesia, whether they're going to do a nerve block.

And then you're also given some relaxing medication just to ease your anxiety so that you're ready to go, within an hour, hopefully.

Dr. Eric Chehab:
How long does the procedure take? Typically what's a reasonable timeframe for the procedure?

Dr. Jeff Goldstein:
I always tell people that it takes plus or minus an hour to do. You're in the operating room for more than an hour, because of course, administering anesthesia, getting the patient positioned, getting them prepped and draped. Those all take time. The actual skin to skin time is roughly an hour give or take 10 to 15 minutes, depending on the complexity of the case. Some are easier than others, depending on patient anatomy, deformity, et cetera.

But I like to say it's about an hour long procedure. And, Eric, what's important here is that the surgery is the easy part. The hard part is, the aftermath of the surgery. Those of us that do a lot of knee replacements, we're pretty fast. I'll add it. We do a lot of them. We follow the same sequence of steps. There might be certain nuances, patient to patient, but by and large, we usually, it usually is very streamlined from a technical standpoint.

And patients usually do very well within the surgery. The anesthesiologists are very good at keeping people stable and healthy and because it's a pretty efficient surgery, they come out of it feeling good. What's difficult about it is the aftermath, that rehabilitation period.

Dr. Eric Chehab:
So let's go through that. Break it down into the first week, first month, first six months. So let's talk about the post-op period in the first week.

Dr. Jeff Goldstein:
So what I would tell patients, consistently, is that knee replacements hurt. And anyone who says otherwise is really being disingenuous. Now we've gotten much better at managing post-operative pain. We've realized that it starts pre-op and intra-op, and post-op, and there's different pain pathways to address.

The worst day after a knee replacement is not the day of surgery and it's not the day after surgery. It's day 3, 4, 5, 6, when patients are home anyways, and they start really mobilizing with physical therapy. Sometimes at that point, you see some increased swelling because of internal bleeding. You're starting to push yourself a little more.

What patients are often surprised by is that you're full weight bearing right after a knee replacement. So as soon as you're off the table and awake from anesthesia within an hour, we like physical therapy to get you up walking. Now, it feels a little unique. Your knee is now kind of realigned, it feels a little different.

And so as a consequence, we have you walk with a walker at first. So patients are usually on a walker, at least for the first several days after surgery, if not a couple of weeks. And then beyond that, they start to wean to a cane and then they wean off all gait devices. So what I would say in terms of the first week, there's some pain involved, there's swelling, you're up right away.

I always tell patients, let your physical therapist guide you. The physical therapists are very good at what they do, and they do a lot of knee replacement post-op management, right? So the first week it's all about getting yourself mobilized taking deep breaths, just starting to move your knee.

I think mobilization and bending actually is helpful to reduce pain. If you're apprehensive of moving and you become stiff and that in and of itself becomes painful. Right.

Dr. Eric Chehab:
My sense is that a lot of patients fear total knee replacement because of the pain. And you mentioned earlier that we've taken a lot of steps, preoperatively, inter-operatively during the surgery, and then post-operatively, can you outline some of those advances that have been made? Because certainly it seems that patients now have many more options to keep them comfortable. Surgeons have more options now to keep patients comfortable postoperatively. So I think it's worth explaining this a little bit, because I think people's current fear about knee replacement is because of the fear that someone had knee replacement five or 10 years ago. And aren't aware of some of the evolution that's undergone for pain management.

Dr. Jeff Goldstein:
So just as we said that the principles of the technical aspect of the knee replacement has not changed so much, the way we manage everything surrounding the knee replacement, such as pain management has evolved considerably.

So, and as I stated before, it starts before surgery. So it starts with multiple different pain medications. There was a time where everyone was just loaded up with narcotic pain medication. What we've realized is that that can actually be counterproductive. And it's not that there's no role for opiates and narcotics for early post-op management. Of course there is, but there's other pain pathways in the body. And so while we give narcotic pain medication, we also realize that anti-inflammatories are helpful. Some of these pain medications that help with neuropathic or nerve pain are helpful.

Tylenol actually can be very helpful. Those are all preoperatively. We usually have our anesthesiologists give a type of nerve block, which is very effective at reducing pain, but it also doesn't create what's called a motor blockade, like some of the old nerve blocks. In other words, patients come out with reduced pain, but they don't have weakness associated, which allows them to mobilize quicker. In surgery itself, we now give these periarticular injections. So we inject and infiltrate all the tissue in and around the knee, which has been proven to be helpful with post-op pain. And then on the postoperative side, it's a combination of multiple types of pain medications. Elevation, ice, swelling management, and mobilization, and all of those things help with post-op pain management.

Dr. Eric Chehab:
That's terrific. That's a great summary. I think it's really important that patients understand that things have evolved considerably for pain management and you put it so well that the techniques have been pretty stable over time, yet everything around knee replacement in terms of the rehabilitation, the pain management have evolved considerably.

So let's move on. A few weeks down the road we've gotten past the first week. We're now about a month out from surgery. What's happened in that timeframe.

Dr. Jeff Goldstein:
The way I like to phrase this, I tell patients that 90% of your recovery is going to be within the first 12 weeks or three months. And within that period of time, there's considerable variability.

So you have to be careful of talking to too many friends or neighbors about what their experience has been after new replacements, because it really can be all over the map. You're doing this for long-term purposes, not short-term gratification. In other words, you're trying to have a long-term durable bearing construct that's going to get rid of your arthritic knee pain, going to allow you to do the activities you like to do for ideally the rest of your life. Within that period of time, everybody turns a corner at a certain period of time within that early six to 12 week period.

So there is pain and the pain usually gets better and better, and it happens incrementally. One of the things I always tell patients is I see you at points along the continuum. You see yourself every day, so you don't necessarily appreciate those incremental improvements, but they're happening. The first month, there's pain, there's swelling. Sometimes patients have difficulty sleeping as a combination of pain and also just having a difficult time getting in a comfortable position.

Sometimes patients have changes in their diet. Sometimes they are eating more than normal. Sometimes they have no appetite and I don't have a timeframe to tell patients when these things improve. The one thing I could guarantee them is at some time, your diet will normalize your sleeping habits will normalize. You'll be okay.

Dr. Eric Chehab:
So, sometimes when patients are asking me about knee replacement, I'll say, well, look for the first week, you'll probably wonder why the heck you did it. By about a month, you're going to start feeling some of the benefit of the procedure. And by about six months, you're going to be ecstatic that you did it. So, like you said, there's a gradual continuum of improvement. There's not a one size fits all for everybody, but the expectation is you will turn the corner. You will start feeling better. The remainder of your life will begin to renormalize, around the knee replacement. I think it's fair to say that physical therapy plays a critical role in knee replacement, probably more so than hip replacement to some degree.

Dr. Jeff Goldstein:
I would agree with that. So with knee replacements, so much of this is getting your range of motion back. And so early on, when you have pain and swelling, it's difficult to move. Patients are stiff in the immediate aftermath of knee replacement. So on the O.R. Table, I always get patients moving.

So there's no mechanical blockage to patients moving, but when you have pain, when you're awoken and your knee fills with blood and you start healing and scar tissue, you might have stiffness early on, that would be a normal expectation. And then physical therapy is what gets you over that hump. And so I'm a big believer in post-op physical therapy after total knee replacements, much more so than total hip replacements.

Relearning how to walk is difficult to do without a little assistance. If you've been walking for years with your knee bent at a certain angle, and all of a sudden it's straight, that's very difficult from a coordination and balance standpoint to get used to.

And so it's very helpful to have someone to guide you because it's not just your knee. You need to work on your glute muscles and your quad muscles, and your hamstring and your low back. And so all of that goes in to having a successful rehabilitation outcome after knee replacement. And I would trust the expertise of a physical therapy to lead you there.

Dr. Eric Chehab:
I'm sure you get this question all the time. Patients come in and they're ready for a knee replacement. Hey doc, how long does this thing lasts?

Dr. Jeff Goldstein:
There was an era where they used to tell patients that they lasted 10 years. We answer that question a little bit differently now. And part of that reason is number one, the materials are of much higher quality.

We are at a different generation of metal and plastics than they were in the 1980s and 1990s. The way I respond to that question though, is to not tell patients how long they're going to last, but to flip it around and say, The risk of revision, the risk of a redo is 1% per year. And therefore, if you take all commerce of knee replacements at 10 years, we expect 90% of them to be going strong.

At 20 years, we expect 80% to be going strong. At 30 years, we expect 70% and then you're getting pretty old at that point. Right? And so there's no warranty on the box, but generally speaking, our goal in general is for your knee replacement to outlast you. And we expect you to be around for a long time.

Dr. Eric Chehab:
And then some trends in knee replacement, we're seeing more knee replacement being done in the outpatient setting. Speak to that a little bit.

Dr. Jeff Goldstein:
As we've gotten better at blood management, so the need for blood transfusions is so much less, using spinal anesthesia or even lighter general anesthesia, patients are feeling better and they're able to get up with physical therapy quicker than they used to. In terms of post-op pain, and as I told you before, they, the worst day is not the day of surgery and it's not even the day after surgery. And so whether you're doing it as an inpatient in a hospital setting, or as an outpatient at a hospital or an ambulatory surgery center, the worst day is not the first or second day.

And because we've done well with home health and home physical therapy, we're able to adequately take care of patients and they do a great job of this at their home, in an outpatient setting. What we've seen, and this has been going on for about the last five years is there's been an exponential increase in knee replacement surgeries being done in an outpatient setting.

It has now been proven in the literature with data that for the right patient, it is safe and effective. And patients actually really enjoy the experience because for patients that are healthy enough, that are motivated, that have good support at home, they prefer to sleep in their own bed than to sleep in a hospital bed.

They're less likely to get infected in their house than they are in a hospital. And so patients are much more open to it. And then with COVID, that further changed the paradigm. So even patients who might've been reluctant a year ago now are saying, you know what, I'd rather just get my surgery done.

I'll rehab at home. I trust the nurses that are coming. I trust the physical therapist, the pain medication that you're giving me at home is the same as you'd be giving in the hospital anyways. And so, because it's safe and effective, we're seeing those numbers go up and up. Now, not every patient is a good candidate.

Dr. Eric Chehab:
Right? You mentioned for the right patient.

Dr. Jeff Goldstein:
Yeah. So if you're a patient who has multiple medical comorbidities, uh, cardiac history, diabetes, obesity, anemia, those are probably safer to be done in a hospital setting, where you're managed by either a hospitalist or an internist, you have cardiology available, but for a healthy motivated patient, I think that outpatient total knee replacement has proven now to be a great procedure and patients seem to like the experience.

Dr. Eric Chehab:
And then another trend in total knee replacement, which is different from when I was in training, is, the postoperative need for a skilled nursing facility, the majority overwhelming majority of patients are now going home as opposed to a skilled nursing facility.

Dr. Jeff Goldstein:
And this has also been backed up in the literature and that is that patients generally speaking can go home, should go home and should want to go home. Because number one, the outcomes have been shown to be improved. A lot of times patients say to me, but you don't get physical therapy twice a day if you go home versus going to a rehab center and while that's true, the real gains that you make with physical therapy in terms of range of motion and strengthening really don't happen the first two weeks after surgery, it's really week two to week six. I think there is no cleaner environment than your own home. You're not surrounded by other patients. I think that patients, so that infection risk is really the infection risk is lower, but then there's another, there's a psychologic component as well.

And that is that in order to rehab and improve quickly, it's good to reacclimate to your home environment. So it's good to sleep in your bed. It's good to shower in your own shower. A lot of times patients say, but I have stairs and I say, you know what? You're going to go up your stairs to get your bedroom, no hospital beds on the first floor.

You're not going to shower on the main level. I want you to push yourself. It's not that I think it's easy. I think it's hard, but I think it's in your interest and it's those patients that reacclimate to their home environment quickly that have better outcomes and quicker outcomes.

Dr. Eric Chehab:
So let's move to some of the potential complications and pitfalls of knee replacement surgery, and they are related first of all, to the knee itself, but also some other medical conditions. So would you mind taking a moment to speak about some of the most common complications of knee replacement?

Dr. Jeff Goldstein:
Yeah, I think it's actually a really important conversation. It's an important topic that is often overlooked in the dialogue between a physician and a patient. And one thing I've learned before I even go into the specifics is that patients, generally speaking, do not get angry if they have a complication, but they do get angry if they have a complication and we're unaware and uneducated of the potential risk of the complication. And so it's so important to have that conversation. So what I tell patients is that there's a risk of wound complications and infections.

Infections are rare, in that they're infrequent. When they happen, they're a big deal, but they happen in less than 1% of the cases. There's risk of stiffness. So we talked about how I get you moving on the operating room table. Your job is to stay motivated with physical therapy. There are patients, a very small percent of them that just genetically scar with higher frequency than other patients, right.

There's risk of blood clots. The risk of blood clot is pretty low if you mobilize quickly. And so nowadays, whereas in the past, we used to use heavy duty blood thinners for most low risk and normal risk patients, we're giving aspirin twice a day as your blood thinner. There's also other risks of anesthesia.

So that would be cardiopulmonary type of risks and those again, they're very infrequent. So when patients have complications, of course, it doesn't matter if the risk was 1%, it happens 100% of the time to you when you've already had it. But the risks are low in that they're infrequent, but we're very careful and we do a lot to mitigate these risks.

Dr. Eric Chehab:
And then again, in terms of other complications down the road, what is the most common mode of, let's say, failure of a total knee replacement?

Dr. Jeff Goldstein:
The most common causes of revisions or reduce would be infection, instability, which is a consequence of the soft tissues being imbalanced. Now that can happen after your surgery, but that can also happen down the road from attritional stretching out of some of the soft tissues.

Occasionally we see what's called a aseptic loosening. So the prosthesis actually de-bonds from the bone, not because of an infection, just because the cement mantle kind of wears away from the bone.

Dr. Eric Chehab:
I've had that described as like the tiles in the shower that jostle loose after years.

Dr. Jeff Goldstein:
Exactly. And then, you know, listen, any trauma can change the conversation. If you have a fracture that can of course loosen or damage and implant. But what I will tell you is that plastic wear and wearing out the actual materials, which in the past was probably the number one cause of problems, is what we believe now to be much less of an issue in this generation.

Dr. Eric Chehab:
So the outcomes for knee replacement are excellent. I'll sometimes describe knee replacement as a home run of a surgery, not a grand slam, not everything's perfect, but a home run of a surgery, it's an unbelievably good hit. Patients can walk better. Their pain is significantly improved, but some patients will report some symptoms. I think they're termed nuisance symptoms, correct? I call them nuisance. They may have a name to them, but, but go through some of those.

Dr. Jeff Goldstein:
So in terms of expectations, the goal of a knee replacement is not to turn your knee back into what it was when you were 20 years old. It's a machined knee, it feels a bit mechanical, if you will. Sometimes you hear clicking because metal touches plastic. Sometimes it feels a little unnatural now. You're still happy because it's gotten rid of your pain. It's made you much more functional. You're able to do pretty much every activity you'd like to do. Some of the anecdotal complaints that patients have had, and these are not necessarily complications.

They're just part and parcel of having a knee replacement. Patients, number one, it can be difficult to kneel because it's difficult to put pressure on a scar. It's not that the prosthesis is at risk. I allow my patients to kneel after knee replacements. It just sometimes feels uncomfortable. Sometimes patients get a numb patch on the outside of their knee, and that actually happens in the majority of cases.

There's a very small nerve. You can't even see it, but it gets cut in every single knee replacement that's ever been performed. To some degree that area of numbness shrinks over time. Some people are irritated by it. It has no functional consequences. It doesn't make you lack strength or mobility, but I always tell patients to expect it because if you tell patients to expect it, then when it happens, their anxiety level goes down because they know it's normal. Sometimes patients can be a little stiff, uh, and I don't mean stiff pathologically stiff–

Dr. Eric Chehab:
Stiffer sitting for a while.

Dr. Jeff Goldstein:
Yeah, where they just feel a little bit stiff because we like to say that your range of motion after surgery will be plus or minus 10 degrees of your pre-op range of motion. In other words, it's not a guarantee that you'll have better range of motion after a knee replacement.

You might, that certainly would be a goal, but sometimes you even have a little less range of motion. Now that's a small price to pay. If you get rid of all your pain and you're back on the golf course and playing tennis, but sometimes patients do experience a little bit of stiffness. Sometimes a little soft tissue irritation can happen as well.

Dr. Eric Chehab:
Patients who ask me about the knee replacement and I'll say exactly what you say. You're not going to get a, uh, the knee had when you were 20. And you might feel a little bit of stiffness. If you're sitting for a long time, you might have a little soreness going up and down stairs.

You might have some discomfort if you kneel on it. But when you're asked, you know, how does it feel when I'm walking around? Oh my God. It's like night and day. I think I've seen, that seems to be the typical response.

We've covered an awful lot of ground regarding total knee replacement, and I can't tell you how much I appreciate your time with this. Is there anything else that you would like our audience to know about total knee replacement?

Dr. Jeff Goldstein:
What I would tell you is that knee replacement surgery is a very common surgery and it has very good outcomes.
The patient satisfaction scores are very high. There's a lot of marketing in what you'll read about sort of new advancements and we don't need to go through the data on each of these advancements. The one thing I would tell patients is that when you're looking for a physician, you're really trying to get from A to B.

And there's a lot of different pathways to get you there. And so I tell patients, choose a technician, not a technique. You want to have that good relationship, someone that you trust that you think will do a good job for you. Someone that has a reputable background and reputation, education, et cetera.

And so I would say, beware of jumping on a bandwagon too early. You also don't want to jump on a bandwagon too late. Uh, but there's a lot of quality physicians, a lot of quality knee replacement surgeons, certainly within our organization, I can think of many. And I think we have a lot of good physicians that get great outcomes. And I think the nice thing about living in the Chicagoland area is you have a lot of great options. And our patient population is very fortunate for that.

Dr. Eric Chehab:
Dr. Jeffrey Goldstein, I want to thank you for taking your time to be here on Ortho Inform. This has been a great journey through total knee replacement from some of the early iterations, and then what we're doing now to help patients recover more quickly and help them move better, live better. If you want to learn more information about Dr. Goldstein, please visit ibji.com. And once again, thank you for your time.

Dr. Jeff Goldstein:
Thank you for having me.

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