and good evening.

Thank you so much for watching HealthLine on PBS Fort Wayne.

I'm Mark Evans, your host tonight a subject we haven't really tackled in a little bit of a time during HealthLine history.

It's been several months but we're talking about joint replacement surgery, the expectations for all that and we have a special guest who's back with us because he's been on a couple of times with you, Dr. Lynch.

>> I have Dr. Jonathan Lynch, an orthopedic surgeon and every time you're on we seem to get a lot of phone calls.

>> We're hoping for that tonight.

OK, and that phone number of course to give us a call and address your concerns about any type of joint surgery or if you have questions if you or a loved one or a friend has a joint replacement surgery coming up or they're considering it, this would be a perfect time for you to learn more and maybe pass on some information.

That number is on the screen.

It's 866- (969) 27 to zero and we'll be watching for your calls as they come in.

Well, Dr. Lynch, a very interesting specialty that you're in and I know that it's the process thesis thing is has been around for a long time but actually joint surgery to replace that part.

>> Can you give us a little history?

Yeah.

So you know, the first real patient centered around the hip so surgery Sir John Charlie was kind of the founder of hip replacement and I believe his first big was it was in nineteen sixty one.

So when you think of it that's relatively young.

Yes.

Relative to how far it's common you know 50 years is really pretty remarkable but you know he pioneered hip replacement surgery and certainly everything from a recovery standpoint from a surgical dissection standpoint, from an implant standpoint has changed pretty significantly in that time.

So when they used to do it we started out by doing what's called a trach osteotomy.

We're part of the bone had to be cut for exposure.

All the hips were cemented in nowadays there's there's typically no bone cuts in terms of exposure and a lot of the implants are somewhat less now which avoids loosening in the long term.

So again really come a long way in fifty years and certainly the number is growing pretty dramatically as well.

>> Yeah, I've noticed some changes as far as timelines.

Some of the information that I received today goes back to 2009 and said at that time about seven hundred and seventy three Americans had hip or knee knees replaced in that particular year but it's dramatically increased hasn't it?

>> Yes I think and today it's around about a million people in the United States get their their hip or knee replaced every year and by twenty thirty that's expected to be close to three million.

>> So it's going up pretty dramatically.

I think a lot of that's attributed to the fact that it's a fortunate, very successful surgery that as we'll delve into does have for the most part very good outcomes and patients do well with it and we also have the baby boomer population that is kind of hit the mark and with that we're seeing a dramatic increase in those numbers but well would you explain just kind of break it down?

Don't have to take us through the medical school tutorial.

Sure.

But give some idea of what actually replacement surgery is like.

>> Yes.

So I can't say hundred percent because I've gone through it and so that's what I always start by telling my patients.

But you know the first thing I always say is I do hip and knee replacements so generally I see a patient most of the time they've either seen their primary care doctor or seen an advanced practitioner had some x rays.

They generally know they have arthritis at that point and and a lot of times we're seeing them for potential surgical consults.

So you know, they've gone through a lot of times conservative measures.

>> They they they know their symptoms are consistent with arthritis, which is typically some sort of aching nagging pain in the hip and knee region that is constant nature a lot of times improves by mobilizing a little bit may have may have improved with either an entire articular steroid or an end said and by the time they've seen me generally they feel ready.

>> But I always tell them that, you know, you're going to know when the time is right for you and I can't tell you how you're going to know that because again I haven't been through it but you're going to know when it's right.

And for most people the right time is when they have bone on bone arthritis and they felt all conservative measures and they're really at a point in their life where they're feeling kind of miserable going along with their you know, their their joint that they're currently living with.

>> So the surgery itself varies a little bit between the hip and the knee.

>> The hip is generally a little easier to recover from for whatever reason.

I think a lot of it has to do a little more soft tissue around the hip whereas the knee is not protected by as much muscle.

So I think that soft tissue injury from a knee replacement a lot you know a lot more to go through but generally the first few weeks after the the joint replacement is the toughest.

>> That's the time where you know you're going to need a little more pain medications.

>> You may need opioids for a short period of time.

You're probably using a walker for two or three weeks.

>> But most people by the time they're seeing two or three week follow up or are at that point seeing the improvement and generally by six weeks people are very satisfied.

>> They have the joint they say up to three months for kind of full recovery .

But again, usually at six weeks people feel pretty well recovered and as long as the indications are appropriate, it's it's a very successful surgery and you know, I feel very honored to really be able to do it because we help people in a very significant way as well.

>> Yeah.

And as you mentioned has come a long way I would imagine and I haven't faced it yet and hopefully it won't.

But we do have in my family's history some people who have had some joints replaced from time to time especially knees.

But the pain I guess can be so excruciating and I know the last thing somebody wants is to go in and be on the surgical table and have the surgery and go through all that.

But I think the pain drives them to the point I don't care.

>> You just get rid of the pain.

Exactly.

Exactly.

And that's when you know it's time, right?

That's why you don't want to you aren't going to be like oh, you have to get this place.

And sometimes sometimes there are indications like the joint is getting deteriorated to the point that reconstruction is going to be so hard if you don't proceed now there are times where it's like hey, if you're you know, considering moving forward with this it's probably better do it now than later because it's going to make your recovery easier in my job easier too.

But that's pretty rare most of the time patients kind of knowing that time's right and when the time's right.

Oh they tell you and as long as the indications are appropriate in there, they meet the appropriate medical needs from an optimization standpoint then you should move forward with it.

>> OK, very good.

We have a call coming in right now a very interesting one.

It looks like Katie is asking to be off the air which is fine .

So she's asking as I will read the question from the teleprompter says why would someone need a special pump attached to a surgery scar that's oozing excess fluid from a hip replacement?

So if they're referring what I think they are which I do use these very often is there certain things called Ravina incision or wound vacs?

And there's these are a little newer and utilize a little more frequently now.

>> But what they do is they basically on the surgical incision.

They stimulate what's called angiogenesis or blood flow in the skin where the skin has been cut and they actually help that scar form.

>> They help decrease fluid extravasation and they actually the biggest kickback the reason we use them is because they prevent surgical site infections.

So in patients who is high risk for infection?

I'll generally use that most of the time in the revision setting when we're doing a redo surgery or going in for a second or third time.

>> Those are also indications for when I use that and that's really what the literature in the research has shown.

>> So I think it's a great tool that's being utilized a little more and you know, hopefully, you know, you get appropriate instructions discharge on what that is.

But we always try to provide that obviously.

But that's probably what they're referring to I imagine.

>> OK, now I know that whenever we talk about joint replacement surgery many people think automatically elderly people and we talked about the arthritis which develops over your lifetime and so forth.

>> But do younger people have joint replacement surgery as well?

>> They are starting to more and more now and so I think a big reason for that is again, if we look back on the history of general replacements, the initial implants one of the big problems with it was actually on especially on the hips I was what's called the polyethylene or it's the plastic liner that articulates with the ball the hip and they used to wear it a very faster rate than it does now.

>> It's now processed in a way that it doesn't wear at such a high rate but it used to wear at a higher rate and it caused a lot of bone mass around the implant.

So for young people to undergo hip replacement surgery at a young age because a lot of bone loss and problems down the road.

So if you if you replace the hip at a young age, you know, you'd be bound to come back when they're in their 50s or 60s and potentially have a pretty devastating problem to deal with in the rear vision setting.

>> Now the the plastics manufacturer, the way that it wears wears at a much lower rate almost by an order of magnitude lower and so we're doing hip replacements on patients in their 20s which is hard to believe you if we were to look back on that 10 or 15 years ago, these are again patients that need it.

>> These are patients that are walking with a horrible limp, you know, constantly living with growing pain and I've tried everything conservatively and usually I advise against it as long as possible.

But but sometimes patients who have certain conditions other than arthritis typically it's usually something called like perthes disease or other forms of congenital problems then sometimes they are being performed on young patients on the knee side a little less likely to be performed that young but on the hip side, you know, sometimes we are seeing them on younger patients.

>> What about athletes athletic or athletic injuries I should say so typically we're not seeing it on athletes, you know, especially if you're athletic.

We're usually advising against Arthur plastic surgery for that reason because if you're going to be doing load-Bearing activities or loading the joint jumping running things of that nature, we advise against joint replacement.

So we're usually not seeing hip replacement for those reasons.

But there are hip preservation surgeries that we sometimes look into depending on what the athlete may be experiencing.

>> OK, Barabas called and she's asking if there's any advice that you could provide for pain management from knee replacements.

So I appreciate your question, Barb.

And it's it's a very good one.

It's very applicable especially nowadays.

>> So I think when it comes to pain management, the big thing that comes to mind at least for me as a provider is you know, for patients who are taking narcotics more on a chronic basis so patients who see a pain management specialist that becomes something that we try and coordinate very closely so that we can control your pain after surgery appropriately when you're on opioid medications preoperatively it can make pain control after surgery extremely difficult.

The reason I generally explain to patients is because your nerves are kind of numbed at a baseline pain level by those narcotics and when you then introduce insult to the soft tissues like they become inflamed very easily because they're on this kind of baseline narcotic and so the narcotic needs go very high and no matter how you go so hard to control pain so we try and ideally get patients on a very low narcotic usage preop or off completely to allow us to control pain after surgery.

But after knee replacement surgery it's standard of care for patients to get narcotics generally for you know, a few weeks or even up to a month after the joint replacement.

We try to minimize the narcotics by using other medications including Tylenol, some sort of antiinflammatory which is usually Celebrex and a lot of times like Lyrica Pregabalin which is a nerve medication and then the anesthesiologists often we do a adductor canal nerve blocks so the block the main nerve that innervates the front of the knee to help with pain control the first 24 hours after surgery.

So there's been a lot of improvement and post-operative pain control that's kind of become a standard of care across the country really.

We've had a recent update on our guidelines and most are just not implementing that and that's kind of how we control pain after knee replacement surgery.

>> Very good.

We have Richard on line three.

>> Richard, thanks for your patience.

And what is your question for Dr. Lynch?

This is I'd like to know a couple of years back and see where they replaced all the bones in the hand.

But lately I haven't even heard anything about it.

I'd like to know it's still possible we still have an operation where you can replace all the bones with rheumatoid arthritis and other things hard can replace all the bones in the hands completely.

>> Thank you.

OK now.

My pleasure.

So I'm not a hand specialist.

I'm not quite as up to date on that.

I specialize more in hip and knee but I do know from my general training and from my colleagues do that there there are replacements for various depending on which joints are involved.

A lot of times it's the MVP or sometimes it's the hip joints to the knuckle joints and they do have generally silicone replacements I believe is the product they use certainly a little bit different material than what we use in and hip and knee.

But for for rheumatoid patients there are great options available and I certainly encourage you to consult with the hand surgeon to see see what options are potentially available.

>> Yeah, that's a whole nother world isn't it?

They did and it is a lot of nerves, a lot of bone.

It is a lot of small things to work on.

Yeah exactly.

I stayed away from that stay on the bigger things like the hips in.

>> All right.

Dave has a call coming in here and he's asking for an opinion CBD Oil for joint pain and advice for a family member with arthritis.

>> I you I certainly don't have any expertize in this I don't know of any research had been done but I have several patients that come in and say that it does tend to help.

So I think it's low hanging fruit as I referred to it.

I think it's worth trying.

I think if you have some pain around a joint I don't think you're probably going to hurt it from anything I hear from trying it.

>> OK, very good.

All right.

Well, the phone lines are still open.

It looks like some calls are coming in.

But in the meantime, let's talk about what the joint replacement is made of .

I know through the years it's been various materials.

Yeah.

So tell us about the history of that.

Yeah, good question.

So the the hip is generally made of a titanium alloy so generally again as we talked about cement lace implants now so there's actually a coating around the implant that's a porous coating if you look at like a picture bone there's small structures called microtubules are basically trabecular of bone and the porous coating is meant for that trabecular bone to actually grow into it.

So usually about by about three months after surgery there's actually a bone that grows into the poor surface on this titanium alloy and then the actual articulation is made of a ceramic head with a polyethylene liner.

Typically there's other liner's available, sometimes it's ceramic but that's basically what the materials are made of on the knee side it's a little different.

Most of the knees are made of cobalt chromium so it's a you know, a different metal and then again it's polyethylene between the two pieces of metal.

Some people who you know, it's it's debatable, you know, metal is kind of a debatable thing in our field.

But for patients who do have a high reactivity to nickel sometimes you can use a different sort of material for those patients to well how long do those replacements last?

>> Are the rest of your life ?

>> Yeah, I mean it's a good question.

I think it's hard to say for certain because obviously we hope that with the newer implants are going to last longer than they have lasted 15 years ago.

But the only way to know is to follow them out 15, 20, 30 years.

And so sure we certainly see I've seen patients that are 30 years out from a joint replacement are just now going back for some sort of revision most of time again wearing through that plastic now that that plastic wears at a lower rate, I expect these to last a lot longer.

So can you last 30, 40 years?

It is quite possible especially I think on the hip side depending on how you respect it.

I think a lot of factors go into that.

I think you know how much you're loading it, how much force it's going through it, you know, are certainly factors and joints feel for various reasons.

But the most common reasons are generally the joint either coming loose or getting bone loss around the joint secondary to somewhere of that plastic are the most common reasons.

But I expect that the implants last a lot longer now designs are improved.

>> Sure, yeah.

Do you ever do two hips at the same time or two ?

>> Good question.

I generally don't.

So if you're looking at if you're looking at the hip side I basically never do.

I think it is an option for certain surgeons and for the properly indicated patient.

I think I think it's very reasonable to do for for the right indications.

I think on the knee side we're getting newer data to suggest that doing them separate is the correct thing.

I think it's it's a lot of surgery go through bilateral knees.

A blood loss increases the difficulty getting around increased and again knee recovery knee recoveries just a little bit harder than hip recovery .

So we do do it occasionally.

I've certainly done it on the right indications but most patients that do it say that if they had to do it again they tried them separately.

I think it's the right thing.

I would think so.

In fact, I've had my doctors on the show and they have cataract surgeries for instance.

>> They only do one eye at a time you got to see, right?

Yeah.

Yeah.

That and just in case yeah.

They make sure that the the material that they're using is not going to be rejected so forth.

It's kind of a trial period once that goes they can do the other side.

It's usually a week or two .

What I can understand anyway back to your your specialty which of course is joint replacement for mainly hips and knees.

>> Um how is the recuperation process?

>> How grueling is that?

Yeah.

So again looking at between the two on the on the hip side if you got bone on bone arthritis at your hip most people come in at two weeks and are like happy like they're already at two weeks like Feehan dramatically improved because they can tell the difference right away on the knee side I really don't sugarcoat it.

>> I say the first couple of weeks are going to be asking why did I go through this?

Why you know what was the thinking and usually about that two or three more week mark patients make the turn and then by six weeks they're usually like happy and then as time progresses three months in a year out, then then they're very happy.

But I think those first two weeks I've definitely seen some patients kind of vary.

Yeah, pretty miserable as first couple of weeks.

But I think if you set that expectations appropriate people get you know, the mindset oh this is going to be tough and they usually wind up doing a lot better than they think.

>> So I think setting the expectations very important obviously see that.

>> So here's a question for you how would I know just the average person and you know, never went to medical medical school but I'm having issues with my hips or my knees.

What are some of the triggers for me to go to the doctor and have it checked out and to make sure that, you know, maybe this is something that can be fixed without a joint replacement?

>> Yeah, you know, I think it's a good question.

>> I mean I think it's you know, it's generally pain that's Agard joint and so again on the knee it's usually the inner part of the knee right at the bend of your knee is where we see it.

So if you're getting a constant aching pain there that you sometimes wake up at night, you have to get moving a few steps to make it better.

I think that's a point where you probably go to the doctor, at least get an x ray, get it checked out and see what options are available.

You're probably just going to need a shot if nothing else has been done on the hip side it's a very similar pain that you'd experienced but it's actually in the groin again, some people think that the hip is going to be the lateral or the outer part but it's really right in the groin and kind of areas where you're going to notice that pain and and if you're experiencing symptoms as well, then I think that that's where we typically recommend you come in and get an x ray.

>> All right.

So it's you as a surgeon, what are you having to do when you look at a patient?

What kind of testing what kind of questions are you asking to determine whether or not this patient actually needs this?

Yeah, I think it's yeah, it's a good question.

So I think that kind of brings up the indications the surgery that we wanted to talk about.

So I think, you know, when it comes to general placement, I think there's really three strong indications that should be first is you should have gone on bone arthritis so really you should kind of have one through the joint completely.

You should really have felt some sort of conservative measure.

So whether it be an injection therapy, you know, home exercise program, a Bray's antiinflammatory, you know, those things need to be tried first because a lot of times they can get you by for a prolonged period of time and then I think the third is being appropriately optimized and so you at the end of the day this is an elective procedure.

It doesn't have to be done done generally to save lives but it can and it does carry big risks.

And as my mentor you know that I always remember and he told me he's like, you know, we do big surgery.

We have big outcomes that are very good but you have to be ready to deal with big complications.

And so I think if you don't make sure that your patients appropriately optimize from a medical standpoint generally the main things we you know, we run into we've got to control diabetes.

We've got to make sure you know ,obesity is appropriately managed.

You know, smoking's a big problem in terms of getting the wounds to heal.

If you're on immunosuppressant medications, those can decrease.

You know, you're a lot of those medications have to be off around the time of surgery because really the biggest concern I think most surgeons have are the wound not healing and getting an infection because it can be a really a dire outcome.

And you know, every time I'm indicating or talking to patients about surgery the back of my mind I'm thinking what are the risks here?

What are their biggest risks in particular?

And that's generally what we talk about is like here's my biggest concern for you.

Here's what we need to do to get you ready for surgery.

>> And if you lay it out on the table, most people are you know, they're willing to work with you to get them there.

That's good.

That's good.

We have a call coming in.

It looks like John he prefers to be off the air and he's asking can shoulder replacement surgery today improved mobility and strength?

>> And of course we know that you mainly concentrate on hips and knees can you answer that question?

>> Yep.

I think the easy or the easy answer for me is it definitely can improve both.

>> Yeah.

I mean again I'm not a specialty and the shoulder but with modern shoulder replacements they definitely can improve mobility and strength the number one indicator for any during replacement those pain generally speaking that's the number one reason we do it.

There are other reasons when a joint is I've certainly done in the hip or the hip is so bad and doesn't move at all to the point that their backs run off and get them altogether, they're not having a lot of pain but so there's rare instances where we do joint replacement for other reasons but the one indicator should always be pain and not so much the improving mobility or strength.

>> OK, now juxtaposing your previous answer talking about who would be a prime candidate for this kind of surgery, why would a patient on the other hand be denied replacement surgery?

You know, it's a good question.

I think the the the number one reasons I can ever think of really becomes medical comorbidities.

So I think the biggest one we face and I think the hardest one that's always a discussion is is morbid obesity.

So we're talking BMI over forty and you know, it's tough because a lot of times these are these are patients that often have bad joints because they've they've carried a lot of load through the joints over the years and a lot of times the cartilage is gone bad and a lot of times they need a joint like they're miserable and it looks really bad.

But these are also the highest risk patients.

These are the patients we see get infections.

These are the patients we see sometimes lose their joint.

These are the patients we see sometimes lose their limb very rare.

And again, that's why when we're indicating patients we want to make sure everything can be addressed appropriately.

So you know, I it's always a heart to heart discussion that I have with patients in these scenarios.

I'm a huge advocate for kind of more lifestyle intervention at that point there's been a ton of research and eating a Whole Foods plant based diet.

I've really read up a lot on that lately and I've adopted that as my diet the last five years and I've loved it and I try and lead by example for my patients and I've had patients about that and they've gone on to do great.

So I mean, you know, I think again if you get a patient that that's open minded and willing to work with you, we can get them there because I know they can't move.

I know you know exercise is difficult but if we can eat them, get them to eat healthy and take an appropriate approach to to get them optimized from a medical standpoint we can often get them to the operating room and sometimes they improve to the point that they don't need the joint replacement too.

So oh that's good to be a good turn around.

>> OK, one final question.

We've got just a few more minutes Dr but Scott is asking is there an age limit on when a knee replacement can occur?

>> No, usually there's not a cover obviously I you know I look at age when they come into clinic and I get weary once they're approaching 90s when they're in their nineties.

But I've I had a lady last year I did both her she is ninety one and she we did her hip replacements.

We did them six weeks apart and she went home the day after surgery and I mean she came back her two week using a cane so I mean she proved to me that age is certainly not a ages chronological number and physiologic age is I think more important than your chronological number Most common Koplik.