New Advances in Orthopedic Surgery and Total Joint Replacement

Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Welcome to the show. I'm Deborah Howell, and today we'll be talking about the advances in total joint replacement surgery. Our guest today is Dr. Anatol Podolsky, an orthopedic surgeon specializing in hip, knee, and shoulder replacement surgery at the MemorialCare Joint Replacement Center at Orange Coast Medical Center. Welcome, Dr. Podolsky.

Anatol Podolsky, MD: Hi, how are you today?

Deborah Howell (Host): Very fine, thank you. Joint replacement strategies and surgeries can be extremely effective in eliminating pain and improving mobility for those who suffer from joint-related pain. We're here today to talk about the types of joint replacement surgeries available, ways to reduce the risk for revision surgery in the years following surgery, and recent advances in joint replacement surgery. So that's kind of a mouthful, but let's start at the beginning. Dr. Podolsky, what types of procedures are performed at the MemorialCare Joint Replacement Center at Orange Coast Medical Center?

Anatol Podolsky, MD: Well, as you mentioned earlier, the total shoulders, total knees, total hips are the common procedures for joint replacement. There are other smaller joints sometimes replaced, but these are the most common. Just to give you the statistics, approximately half a million of total hip procedures are done in the United States every year. Three quarters of a million for total knee replacement, and a much smaller number for shoulder replacement.

Deborah Howell (Host): Okay. And why are some of the reasons that someone might need a joint surgery?

Anatol Podolsky, MD: When the joint wears out, most commonly with a degenerative process, it means the cartilage has degenerated to the bone. It becomes painful to walk, the joint is harder to move because the low friction is gone, and function and pain are the main indicators for doing the procedure. It actually may improve the overall health of the patient because mild exercise or some exercise is better than none. And they cannot do it due to pain in the hip or knee or the shoulder.

Deborah Howell (Host): Absolutely. Are we talking mild pain or pretty severe pain?

Anatol Podolsky, MD: Well, it's the pain that failed conservative treatment. First you try to use some medications like anti-inflammatories or even plain Tylenol, injections into the knee including cortisone injections with local anesthetic, or injections of lubricants like Supartz or Synvisc may improve the patient's condition. But if the pain continues to increase, then they may be candidates for replacing the joint.

Deborah Howell (Host): Understandably. Let's talk a little bit about total hip replacement. Could you discuss what the current research and findings show?

Anatol Podolsky, MD: We had a wonderful conference this year in San Diego, it was in March, and we had a whole bunch of new information. One of the interesting things was that there was a multicenter study in academic centers that analyzed different hip approaches, anterior, posterior, and lateral approach. And what they found, surprisingly, despite claims of earlier recovery and improved outcomes with a direct anterior approach, our findings indicate, they said, that the approach may confer a greater risk of early femoral failure. In other words, at five years, a lot of people with anterior hip approach had loosening of the femoral stem. So that was a surprising discovery. And another study came out in the same subject. The Mayo Clinic compared their top expert in anterior hip and top expert in mini-posterior hip, and the mini-posterior hips actually had better return to walking and physical activity.

Deborah Howell (Host): Oh, that is interesting. That's why we have conferences, I guess, huh?

Anatol Podolsky, MD: Right.

Deborah Howell (Host): So what questions should patients ask when determining the best approach for them?

Anatol Podolsky, MD: Well, you should discuss with your surgeon what approach he is comfortable with and what he feels the advantages are for this specific patient. Anterior approach is not thrown out. You know, some people prefer it, and some patients are better candidates for it. Somebody who is skinny or somebody who doesn't have a big muscle mass, you know, so a woman that is relatively thin would be a good candidate for anterior hip. The advantages, of course, were claimed but never substantiated. For example, they discuss that they don't cut any muscles. But if you look at some instructional videos even from the Academy of Orthopaedic Surgeons, they said, well, if you can't get the femur out of the wound to install the femoral component, just cut this muscle and then this muscle. So one of the presenters at the Academy said that a lot of beginning surgeons are doing anterior approach, but they are performing actually posterior hip arthroplasty through the anterior approach.

Deborah Howell (Host): Interesting. How often are revision surgeries required for joint replacement?

Anatol Podolsky, MD: Very good news for everybody. This overall rate of revisions at 10 years after total hip has decreased now to 6%. It used to be over 10.

Deborah Howell (Host): That is incredible.

Anatol Podolsky, MD: Yes. And this is mostly due to reduction in dislocation. For example, posterior hip is the most common approach in the US, and more and more surgeons are learning now to repair the posterior capsule after surgery. And it reduced dislocation rate from 5% down to about 1%. Comparable to other approaches. But still, interestingly, the most complication-free approach for dislocation purposes is the lateral approach that they still use at Mayo in some cases.

Deborah Howell (Host): Alright. And what are some of the ways in which risks for revision surgery can be reduced?

Anatol Podolsky, MD: Well, as I mentioned right now, repairing the capsule is very important. Making sure that you reviewed the x-rays and do a good planning before the surgery. In other words, a leg length discrepancy could be quite irritating to people if the leg is not the same length. So you need to discuss it with the patient and prepare, make sure that your prosthesis is fit to correct the patient's deformity. So the other ways to prevent complications is to go to a hospital that has a program. We have a program that patients attend first a lecture before they schedule their surgery, and they discuss all the different ways to prevent problems like infections, dislocations, what kind of therapy to expect, what activity return timeframe is, and when to come back to driving, for example. So all this educational activity prior to surgery is very, very helpful and improves outcomes.

Deborah Howell (Host): I would imagine so. Now, what are some of the recent advances in preventing complications and reducing revision surgery when having joint replacement surgery?

Anatol Podolsky, MD: Okay, so maybe four or five years ago a study from Chicago came out and they stated that irrigating the total joint during the procedure with betadine solution prevented infections. And they had very good statistics to prove it. The other program that was very popular in reduction of the infections was to do preoperative pre-wash, or we call it chlorhexidine bath. The patients are given a bottle of this chemical, the surgical scrub, and with a plain washcloth they do the 10-minute bath twice a day for three days before surgery.

Deborah Howell (Host): Ah.

Anatol Podolsky, MD: So that helps to reduce infection rates. In one of the recent years at Orange Coast, we had zero infections due to these changes.

Deborah Howell (Host): That makes total sense to bathe the area before the surgery. That's interesting. Now what traits should they look for when selecting a surgeon to perform joint replacement surgery?

Anatol Podolsky, MD: Well, the basic principle of division of labor, if you know what I mean, is very important. If somebody is interested in this field of surgery and does a fair amount of surgeries per year, or does more complicated surgeries like addressing complications of his own or other surgeons, that would be somebody I would choose for my surgeon.

Deborah Howell (Host): There are so many elements, but you do want to have some kind of rapport with your surgeon.

Anatol Podolsky, MD: Yes, it's important to have explanation to your questions. And I talk to patients extensively before they decide on a procedure. So we review the pros and cons of approach, we review the preoperative optimization of the patient, which is a whole new area of medical activity to avoid problems. So for example, if a patient has diabetes or heart problems or kidney disease, these are all reflective of the complications that you may expect. So prevention, of course, is the best treatment.

Deborah Howell (Host): Absolutely. I have one final question for you, Doctor. With the new advances in joint replacement surgery, what should an individual expect as far as recovery time?

Anatol Podolsky, MD: Well, I'll give you my statistics. Most of my patients stay in the hospital one or two days after total joint replacement. We do new pain management program with local anesthetic blocks that improves the recovery and allows the patients to go home soon. So after surgery, which takes about 40 minutes, you get up the same evening or the next morning and you do physical therapy. On day one or two, you're ready to go home.

Deborah Howell (Host): It's phenomenal. Back in the day, it used to take weeks, even months.

Anatol Podolsky, MD: I remember when I was in training in the 90s at Mayo Clinic, we had patients stay for 10 days after total hip.

Deborah Howell (Host): Yeah, crazy. Well, thank you so much, Dr. Podolsky, for your time today. It sounds like a much better time to be a patient for these kind of circumstances. And we really do appreciate your time today.

Anatol Podolsky, MD: Well, thank you. It's my pleasure.

Deborah Howell (Host): For more info or to listen to a podcast of this show, please visit memorialcare.org/podcasts. That's memorialcare.org/podcasts. That's all for this time. I'm Deborah Howell, have yourself a terrific day.