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Orthopedic Community Lecture Series
Living Without Hip Pain:
Your Guide to Hip Replacement Surgery
Presented by: Kenneth H. Jahng, MD, Orthopedic Surgeon
Lecture presented on: Tuesday, October 10, 2023 • 6 - 7:15PM
For those with chronic hip pain from osteoarthritis and aging, hip replacement surgery can restore mobility and quality of life. Join Dr. Kenneth Jahng as he discusses the stages in hip deterioration and the latest techniques for total hip joint replacement, most of which are now done on an outpatient basis. This includes the newer “anterior approach” which can lead to less pain and faster recovery times for patients, getting you back on your feet in no time.
It’s Your Move:
Learn About Knee Arthritis and Knee Replacement
Presented by: Jesus Fajardo, MD, Orthopedic Surgeon
Lecture presented on: Tuesday, October 24, 2023 • 6 - 7:15PM
The world of knee replacement surgery is continually advancing. Now, almost 100% of knee joint replacement patients go home the same day and many wonder why they waited so long. Join us to learn about current treatment options for knee arthritis, including knee replacement.
Dr. Fajardo's Biography.Dr. Fajardo's Lecture Replay from October 24, 2023
Speaker A: Megan Gutierrez
Hi. Good evening, everyone. My name is Megan Gutierrez, and I'm our community health manager here at San Antonio Regional Hospital. So I have the great pleasure of, helping to coordinate programs in our community outreach and educational events such as this. We have a fantastic speaker tonight. And, again, if you need any refreshments, please feel free to grab those. And if you need the restrooms, those are out, these doors into the right. So first, I'd like to bring up our our director of program development here at the hospital, Ron Nowosad.
Speaker A: Megan Gutierrez
He'll talk about some of our orthopedic services here as well. So please welcome Ron.
Speaker B: Ron Nowosad
Thank you, Megan. And, Megan does an outstanding job. There's Brenda Nuno Gutierrez in the back. She's also with our hospital, and she does a lot of work with orthopedic, a lot of very interesting people, some outstanding surgeons and wonderful clinical staff. And those are the things that make the hospital's joint replacement center as popular as it is. And so now we're at a point where we're doing over 600 joint replacements a year, which is, pretty phenomenal and perhaps one of the fastest growing and largest joint replacement centers in the area. So I'm not gonna take too much time. I'll let you know that the, joint replacement center is actually advanced certified by the joint commission for 3 years in a row.
Speaker B: Ron Nowosad
In fact, we're gonna be, certified for the 4th time, hopefully, when joint commission comes back sometime in March. So that said, what I'm gonna do now is introduce you to Janet Block. She's a registered nurse. She's an orthopedic nurse navigator here. And she's the one that touches every patient, not only before they have their surgery, but after they have their surgery and during their surgery. And she's an excellent resource, a wonderful nurse. In fact, she's been a nurse for 37 years. And also, she, has been in our organization for 35 years.
Speaker B: Ron Nowosad
So that said, we'll turn it over to Janet.
Speaker C: Janet Block
Thank you, Ron. That was cute. I don't actually touch every single patient here, but most of them most of them I do. So, please welcome me in or help welcome doctor Fajardo. He is an orthopedic surgeon with fellowship training in adult hip and knee reconstruction. He specializes in nonsurgical and surgical management of hip and knee arthritis, including robotic hip and knee replacement. Doctor Fajardo is a native of the Inland Empire and a graduate of Harvard Medical School. He is fluent in both English and Spanish.
Speaker C: Janet Block
Doctor Fajardo's clinical interests include nonoperative management of hip and knee including anti inflammatory medications, platelet rich plasma injections, corticosteroid injections, and non opioid nerve blocks. Doctor Fajardo performs minimally invasive procedures surgeries, including the anterior based muscle sparing, total hip replacement, which has been shown to have lower rates of dislocation and improved likelihood of return to previous activities. He utilizes a multimodal pain control method to minimize postoperative pain while performing elective joint replacements as outpatients here at our facility. Doctor Fajardo is trained in and performs robotic assisted partial knee, total knee, total hip replacement for optimal accuracy, and he'll speak more about that in his presentation. Please join us in welcoming doctor Fajardo to our orthopedic community lecture series here at San Antonio Regional Hospital.
Speaker D: Dr. Fajardo
Hi. Good evening. Thank you for coming. So as as I was introduced, I grew up here in the Inland Empire in Riverside, went to school in San Bernardino, and then Harvard Medical School and came back here to practice medicine. I don't have any financial disclosures with any of the products that I'm presenting, and, all the information that I'm presenting is evidence based. We all try to practice evidence based medicine, but we have our own preferences and philosophies. But I I put those all aside, and I'm giving you information that's from the American Academy of Orthopedic Surgeons and that has been reviewed. The AAOS website, OrthoInfo is a good website to look for, information on multiple, medical conditions.
Speaker D: Dr. Fajardo
So the agenda for today is, the lecture is on knee replacement and that's ultimately what we'll talk about. But first, we're gonna cover what is the knee, what is arthritis, what causes arthritis, what things can be done other than a knee replacement for the treatment of arthritis. And then when it comes down to an a knee replacement, giving you all the details and it's actually a lot more complicated than it looks on the surface. So the knee is the biggest joint in the body. It is where the femur, the biggest bone in the body, meets the tibia, which is the 2nd biggest bone in the body. And the surfaces of the bones are covered with cartilage. We have a meniscus on each side which acts as a shock absorber, and then we have ligaments on the outside of the knee, the inside of the knee, which prevent the knee from moving side to side, and then the cruciate ligaments ACL and PCL, which prevent the tibia from shifting out from under the femur. And the knee is moved by all the muscles, specifically the quad muscles, which are 4 muscles in the front of the thigh, and they connect to the quadriceps tendon, connect to the kneecap, which is the patella, that connects to the patellar tendon, and that connects to the tibia.
Speaker D: Dr. Fajardo
And that's the connection that allows you to straighten out your knee and, more importantly, keep your knee straight when you're walking so it doesn't buckle under you. And then not pictured here, there's the hamstring muscles in the back of the thigh, which attach to the back of the knee and help you flex the knee. And what is arthritis? So arthritis comes from the Greek word, a combination of arthron, which means a joint, and it is, which means inflammation. Just like tendinitis, otitis, anyitis is inflammation of, the previous word. And the most common type of knee arthritis is osteoarthritis, and that's the regular wear and tear arthritis in which the cartilage that covers the femur and the tibia wears away over time. And that can happen to a combination of activity level, previous injuries, as well as genetics. There can also be a a composition of post traumatic arthritis. Many times in sporting activities or motor vehicle accidents, people can have fractures.
Speaker D: Dr. Fajardo
And if that fracture occurs within a joint, it can injure the cartilage and we can do a really great job of putting the bones back together in good alignment. But on the surface of these pieces of bone is the cartilage, and cartilage does not have very good blood supply, has very poor healing potential. So a lot in a lot of these situations, people develop arthritis over time earlier than they would have if they had never injured the knee. And this these injuries don't have to be something dramatic like this. It could be something like an ACL tear, because in this example, there's a torn ACL, but at the same time, there's a torn meniscus, which can either be repaired or debrided. But either way, the the shock absorber to the knee is injured, so then the cartilage is gonna take more shock over time. And then as you can see in these, on the left side of the image, there's bruising in the bone. And so the cartilage also took a took a shock during that injury.
Speaker D: Dr. Fajardo
And, over time, it can accumulate to, cartilage wearing away faster than it would have otherwise.
Speaker D: Dr. Fajardo
that too. Alright. we'll continue. And then there's inflammatory arthritis, which can be autoimmune, and then there's other types that we will go over. So for inflammatory arthritis, it means that there's inflammation within the knee knee joints, and that causes, activation of macrophages and other cells in the knee. And that inflammation ultimately eats away the cartilage sooner than it would have otherwise. And these things can include diseases like rheumatoid arthritis, psoriatic arthritis, lupus, even inflammatory bowel disease, which mostly affects the, the bowels and the intestines, can also have a contribution of inflammation within the joints as well as sarcoidosis, which usually affects the lungs but can also go to the joints. And then there's a handful of other inflammatory diseases, which can also cause accelerated wear of the cartilage.
Speaker D: Dr. Fajardo
These include gout and pseudo gout. Gout is a disease where the level of mono sodium urate is high in the blood. Once it reaches a level, that is high enough, they actually start to crystallize just like sugar in water. Once it gets to a high enough concentration, it solidifies. And the the gout crystals are the ones there on the left, the needle shaped crystals. And that can cause severe pain, swelling, and over time can wear away the cartilage. There's another disease called pseudogout, which is similar. It's also a disease where crystals get deposited within the joints and it's called, calcium pyrophosphate dehydrate deposition disease.
Speaker D: Dr. Fajardo
Fortunately, for gout, there are medications that can help with that and prevent the attacks. But for pseudo gout, there's no known treatment other than treating the inflammation as it comes. Septic arthritis means infection within the joints, and that can either be due to bacteria breaching the skin, going into the knee, or sometimes it spreads through the bloodstream from a distant site. And the infection can eat the cartilage away within a matter of days, 2 weeks. And then not so common here, but more common in the East Coast, Lyme arthritis. That's, Lyme disease comes from a tick if it's carrying a specific bacteria, and it causes that notable rash in the shape of a target. And over time, if it's not treated, it can actually cause various problems throughout the body, including, chronic joint pain, neuropathy with a facial droop, and even cardiac issues. The symptoms of arthritis, regardless of the the cause, are usually inflammation, pain, swelling, stiffness.
Speaker D: Dr. Fajardo
And when it gets to the point where the cartilage is uneven and rough, it can cause a sensation of locking, catching, clicking, cracking, and grinding when you bend and straighten out the knee. The pain can cause the knee to buckle. And usually, the natural history of arthritis is that at the beginning of life, people start out without pain. And then as time goes by, there's little flare ups which are either exacerbated by just turning the knee the wrong way or doing, excess activity, going to Disneyland, walking more than normal. And over time, these flare ups add up and add up, and the baseline pain continues to increase, as shown in this graph. This shows over 10 years, but everybody is different depending on what the type of arthritis is and genetics as well. So how do we diagnose and evaluate the need for arthritis? Starts with a medical evaluation, getting a history. When did the pain start? Was it initiated by an activity or an injury? Doing a physical exam, seeing what the range of the motion is in the knee, seeing whether there's grinding, popping, clicking, and then getting x rays.
Speaker D: Dr. Fajardo
We usually start with, weight bearing x rays. And those are avail very valuable because they give us a picture of the knee in action when you're standing on it. It shows how much joint space is left and also what the alignment is. In some situations, if x rays do not show an obvious problem, then we can get MRIs, CT scans to see if there's injury, to the meniscus, whether most of the cartilage is okay and there's only a tiny spot that is injured. Cartilage defects or even cracks in the cartilage that can't be seen on x-ray. Small cartilage defects or even cracks in the cartilage that can't be seen on x-ray, and we see those on the MRI. Laboratory tests that we get when we think there's something else going on other than regular osteoarthritis. We can get blood tests to see if there's evidence of increased uric acid when we're looking for gout, to see if there's increased white blood cell count when we're looking for infection.
Speaker D: Dr. Fajardo
And lupus and rheumatoid arthritis can also be diagnosed by blood tests. Sometimes we even get fluid from the knee. If we suspect that there's gout or pseudo gout, we can take out the fluid and look for those crystals or in the case of septic arthritis to see if there's bacteria in there and what kind. And there are actually a lot of treatment options before knee replacement, and we'll go over those briefly. Most of the information that I'm going over is from the American Academy of Orthopedic Surgeons from their most recent, evidence based recommendations on the nonsurgical and surgical treatment of knee arthritis. So the easiest thing to do is activity modification, avoiding things that make your the knee hurt. Sounds pretty simple. So the things that people with arthritis should avoid are things that involve impact because usually what's going on is the cartilage is is thin or it's wearing out, and the cartilage is what takes the shock when you're jumping, running, walking.
Speaker D: Dr. Fajardo
And usually with cartilage wear, it also goes meniscus tears and meniscal wear. So avoiding running, jumping, things that are good, swimming, cycling, those keep the joint moving to prevent stiffness and their low impact. Weight loss helps tremendously. The more weight we carry, the more pressure on the knees. And in certain situations, like going up and down stairs or even getting up from a chair, because of the, the way that the the weight is transmitted. The weight in the knee can be up to 7 times higher, the pressure than your actual body weight. And the way I explain it to patients is if you hold a gallon of milk next to your chest versus way out here, it's all depends on on the torque and how far away the the mass is from the from the joints. So losing weight can help reduce the pressure and the pain.
Speaker D: Dr. Fajardo
And if, for example, if you lose 10 pounds, your knees feel 70 pounds less pressure, so it makes a lot of difference. And it also makes a difference when we're thinking about knee replacements. It's known that obese patients have longer surgical times, higher risk of infection, and higher risk of the parts getting loose. So it's definitely good all around. Using a cane or a walker, that has, moderate recommendations. When you do use a cane, you would use it on the opposite side. So if it's for a left knee, use it on the right hand. If it's for a right knee, use it on the left hand.
Speaker D: Dr. Fajardo
And then medications, including topical medications. These are over the counters. They used to be prescriptions. Diclofenac gel is the generic. Voltaren is the, the brand name. And there is strong recommendation that it can help, reduce pain, and the risks are very low. Knee braces can also help. Sometimes just a simple compressive brace can keep the knee warm and provide some, compression and sense of security.
Speaker D: Dr. Fajardo
But we also do have other types of braces that have hinges that try to offload the side of the knee that is worn out and put more pressure on the other side of the knee. And some people note relief with that. Physical therapy can also help. Even though physical therapy cartilage grow back or the meniscus, heal, improving the range of motion and strengthening can help stabilize the knee, and there's strong recommendations that, that can be beneficial. And there's basically no no downside to it. Heat and ice can help as well. Usually, I tell people heat in the morning to loosen up the joints and ice at the end of the day, to calm down the inflammation. But in reality, if you like heat or you like ice at both times, it's probably okay.
Speaker D: Dr. Fajardo
And then oral medications, we try to stick to non narcotics such as, acetaminophen and other NSAIDs like Ibuprofen. There's strong evidence that those can help. There's strong evidence that using narcotics is not a good idea to control knee arthritis. It causes significant adverse events both before and after surgery. And then after that, there's injections. There's a few different types of injections that we'll go over. The first one is hyaluronic acid, which are the gel injections or the rooster comb injections. And everybody has a small amount of fluid within our joints.
Speaker D: Dr. Fajardo
It's made of hyaluronic acid and it lubricates our joints. So the thought is that we add some extra hyaluronic acid into the joint to lubricate it, like adding w d 40. But the evidence shows that it doesn't it's not as effective as as we once thought. And at least in this edition, there's moderates evidence recommending that it's not used for the for the treatment of arthritis on a regular basis. And, because of this, many insurances are starting not to cover this treatment either. Corticosteroid injections are the main type of injections that we get. There's moderate evidence evidence that they provide short term relief. They can help anywhere from 2 weeks to about a year.
Speaker D: Dr. Fajardo
It really depends on the patient, and the level of arthritis. But the the one thing that that is true about these injections is that as time goes by, the arthritis gets worse, the injections become less effective. The duration of the of the relief is less. So they provide short term relief. It's not it's not a cure. It's a management. But it's a perfectly good option. PRP injections is something that's starting to be advertised on TV and the radio, and it's starting to gain popularity.
Speaker D: Dr. Fajardo
There have been more studies recently that have looked into this. At this time, the evidence is limited. But the studies have shown that they're, that they do help reduce pain and improve function. Most of the studies that I've seen show that they work better than hyaluronic acid and about the same as a steroid injection, but they can last a little bit longer. And then lastly, stem cells. So stem cells are cells that are multipotent. They can turn into many different things. They could turn into cardiac cells, neurons, and even cartilage cells.
Speaker D: Dr. Fajardo
And there's been a a lot of interest in using stem cells for the treatment of knee arthritis. And there's 2 ways that it can be used. 1 is to decrease inflammation and not necessarily cure the arthritis, and then the other way is to try to regrow the cartilage. But in reality, re-growing the cartilage doesn't work unless it's a very small defect, because when people have advanced arthritis, the surfaces are irregular, and rough. And then if you put stem cells in there, I pretty much equate it to putting the cells in a mortar and pestle and just grinding them up. But certain types of stem cells can decrease inflammation, so they would be used in the same way as PRP or corticosteroid injections, not as, not as a cure, but rather as a treatment to help with pain for a certain duration of time. Nerve ablation is another option in which using either heat or ice, we freeze the nerves that go into the knee and that can help decrease pain. Usually, we tend to reserve that for people who cannot have surgery because of medical issues or people who are having surgery and we want to decrease their pain postoperatively.
Speaker D: Dr. Fajardo
But they're they're not a magic solution, and the nerves do regrow back over time so they only last a few months. And the evidence for them at this point is limited. And then also controlling the inflammation, if it's due to lupus or rheumatoid or Lyme disease, treating the underlying cause. A long time ago, there was no treatment for lupus or rheumatoid arthritis, and people used to end up with terrible deformities and really bad joints and required complex reconstructions. But, at this time, there's so many biologic medications and, disease modifying drugs that, there's no reason that we shouldn't be controlling this. And in many people, it can prevent the progression to severe deformity and arthritis. Supplements. So this is from the AAOS patient guide.
Speaker D: Dr. Fajardo
Glucosamine and chondroitin sulfates, they're molecules that are found in normal cartilage. And the thought is, well, if we take supplements, can we help the cartilage grow back? They've done studies, and the studies show that even though some people report relief, overall, that's not a prevalent effect, and it does not stop or reverse the progression of arthritis. So it's not something that we routinely recommend. But if you were to want to try that, there's not much downside to it other than making sure you buy it from a reputable source. Supplements are not regulated by the FDA, so they they don't analyze the ingredients or the dosing or anything. So it's a good idea to buy it from a from a good store and a good brand to make sure that, at at least you're getting good clean ingredients. And then we got a surgical treatment of knee arthritis. Cartilage grafting is when somebody has a very small area of cartilage damage and they're young, usually less than 45.
Speaker D: Dr. Fajardo
And what we can do is we can take cartilage from another part of the knee and put it in the defect. Osteotomy is another option that used to be common, but it's not that common over the last 20 years. And it's basically somebody has arthritis in one part of the knee, we cut the tibia and we realign it to put weight on the other side and wait until that wears out and then you get a knee replacement. Now with the with the implants being long lasting and the good results, it's very rare to have to do, this type of operation. Arthroscopy or a cleanup. Usually, that's reserved when somebody has a meniscal tear and just a little bit of arthritis and most of their cartilage is still in relatively good condition. Because in that situation, most of their pain is probably coming from the meniscus tear and a little bit from the arthritis. But if somebody has severe arthritis or even moderate arthritis on the MRI, then at that point, the major source of their pain may be the arthritis and not the meniscus tear.
Speaker D: Dr. Fajardo
And in those situations, the studies have actually shown that debriding the meniscus versus doing a sham surgery end up with the same results. So that would be on a case by case basis looking at specifically at at your x rays and images. And then the main topic of today's talk is arthroplasty. There's partial and total knee replacement. Partial knee replacement is when only 1 of the 3 compartments of the knee is worn out. And in that situation, we only replace that one part. The downside of that is that over time, you can develop arthritis in the other parts of the knee. So one of the things that we do is, either through X rays or an MRI, really scrutinize the other parts of the knee that we're not replacing to make sure there's no arthritis and that we're not setting you up for failure.
Speaker D: Dr. Fajardo
Usually, people who have a partial knee replacement on one side and a total knee on the other one that really know the ins and outs of both of them, The range of motion is a little bit better in the partial knee. It's not a sig significant difference. But, the other difference is that when you do a partial knee replacement, you get to keep your ACL, which is important in people who do pivoting sports. And the benefit of doing a total knee replacement, it's a slightly bigger operation, but it replaces the whole knee. And you can't really develop arthritis because there's no cartilage left. And depending also on what the deformity is, if the leg is really bow legged, or knock kneed and depending how much range of motion is, total knee replacement might be the only option. And we're gonna go over the procedure. I'm not gonna show any bloody pictures.
Speaker D: Dr. Fajardo
They're all, animations. So the incision is made in the front of the knee, usually a few centimeters, proximal or to the towards the head from the kneecap and a little bit down. And how long is the skin incision? Usually, my skin incision is about 3 fingers underneath the kneecap, two fingers over. So and then the kneecap is usually about 3 centimeters. So that adds up somewhere to around 8 to 10 centimeters. But, realistically, the knee the incision is as big as it needs to be in order to get the job done and put the parts in a good alignment. Because the the the incisions, they all heal well. And if a knee is not put in a good alignment, that can have detrimental effects.
Speaker D: Dr. Fajardo
Once we get through the skin, then this is what we see. We see the quad muscles up top and then the patella in the middle. And basically, there's a few different ways of opening up the capsule to see the inside of the knee. On the very left in red is the medial parapatellar approach in which we split the quad tendon in line with its fibers. We go around the kneecap, and then we go straight down right next to the patellar tendon. The other 2 types of, ways of opening up the capsule to the knee, the bottom part is still the same. We go next to the patellar tendon and around the patella. But in the middle one, we go at an angle and we split the vastus medialis muscle.
Speaker D: Dr. Fajardo
And then on the very right one, we go under the vastus medialis muscle. The peripatellar approach is probably the most common. The other ones are the ones that are advertised as, minimally invasive. And the studies have shown that with these other approaches, maybe for the 1st or 2nd week, there is better, better strength. But after about 2 to 3 weeks, it's all equal. But with these less minimally invasive approaches, it's harder to see, the knee joint. So there's a higher rate of putting the parts in not an ideal location. So it's a it's a give and take situation.
Speaker D: Dr. Fajardo
But, the most common one is the medial parapatellar approach. Once we get to the actual knee, this is the femur. And the white is the cartilage, and then the red under is the cartilage that's worn out and the underlying bone is exposed. And we basically make a cut in the bone in several directions until it looks like the middle picture. And then we put the femoral components, on the femur, which is on the very right. Then we get to the tibia. We remove the surface cartilage and the meniscus until it looks like the middle picture. And then we put a metal base plate and a plastic liner until we get to the very resurface the kneecap all the times, some never, some sometimes.
Speaker D: Dr. Fajardo
And the studies have shown that there's really no difference whether you replace the kneecap or not. But most surgeons do take into consideration the amount of cartilage wear. If the kneecap looks perfect, we're more tempted to to leave it be. Because one of the things that can happen when you resurface the patella is you cut the surface off, make it thinner, and put the plastic button. And that puts it at higher risk of fracturing, which is devastating. I'd rather have somebody break their femur or their tibia than the kneecap. But if the cartilage wear is significant and the patella is of enough thickness that it can tolerate a resurfacing and not put you at high risk of fracture, then we can resurface it and put a little plastic button on there. So it depends on on a case by case basis how how bad the arthritis is underneath the kneecap because there's definitely pros and cons of each one.
Speaker D: Dr. Fajardo
During the surgery, we do take out both of the meniscus and all the bone spurs, so you don't have to worry about that. And the parts, they come in many different sizes. The tibial baseplate comes in about 10 to 12 different sizes. The femur comes in about 10 to 12 sizes, and the plastic liners all come in about 10 to 12 sizes as well. So it's very customized to your knee. And then once we put the trials in, determine what the best size plastic liner is, what the best size tibia and femur are, then we put the the parts in. In terms of the, tibia and the femoral component, even the patella component, there's 2 ways that they can be put in. The gold standard traditional way is with cement, which is shown on the right.
Speaker D: Dr. Fajardo
And then recently, there has been increasing interest in using cement-less or press fit in plants like the ones on the left. The studies have shown that at this point, there is no difference cemented parts are the cement is the strongest the day that it dries. And then after that, it's it's only downhill. It's just like cement on your sidewalk. It looks the prettiest the day that it dries, and then after that, it can crack. And over time, knee replacements can't loose can loosen. The cement can crack and the parts can get loose, and that could require repeat operation. The thought behind cemen-less parts is that they have a surface where your body grows into it.
Speaker D: Dr. Fajardo
So over time, the bond between your body and the implant actually grows stronger. But the studies have not yet shown a difference. Maybe we need longer term studies of 20 years or longer to actually see the difference. And then finally, the closure. Most of us close the skin with dissolvable sutures and skin glue, both for cosmesis, but staples are still an acceptable way to close the knee. And then we talk about alignment, getting the knee straight. A long time ago, when people first started doing knee replacements, we try to make everybody's knee perfectly straight. But it turns out that for most people, their knees aren't actually perfectly straight.
Speaker D: Dr. Fajardo
I saw a recent study where 33% of healthy 22 to 25 year olds with no arthritis at all. They did not have knees that fell within 3 degrees of of normal. And then only about 66% or 2 thirds of people had knees that were within 3 degrees bow legged or knock kneed. And a very small percentage actually had perfectly straight knees. So at some point, we started thinking, when we do hip replacements, people are usually very happy. People sometimes even forget that they have a hip replacement. But for a knee replacement, people are happy. It's less pain than they had before, but it never feels natural.
Speaker D: Dr. Fajardo
So one of the things we started thinking about is maybe part of the problem is we're taking people's knees and making them perfectly straight when they were not naturally straight, and that's why it doesn't feel normal. So from that was born the theory of kinematic alignment, which means trying to resurface the knee and leaving it in the alignment that it was before within reason. If someone has a severely bowed leg, we're not gonna leave it severely bowed, but we're not gonna try to make it perfectly straight either. And they've actually done many good studies on this where people have both knees replaced at the same time. And on one side, they make it perfectly straight. On the other side, they do kinematic alignment. And it turns out that it doesn't really make a difference. And then once we get to the parts, there's a lot of different companies over 10 companies that make knee replacements.
Speaker D: Dr. Fajardo
But the four biggest manufacturers that you might hear about are Smith and Nephew, Depew, which is a Johnson and Johnson company, Stryker, and Zimmer. Other ones, MicroPord, Conformis, DJO have a lower market share. They're all pretty good brands. There have been recalls, and I'm pretty sure each of these companies, they have all had a recall at one point or another. I don't necessarily think one company is better than than another. It's more of a preference than what you trained with. And then getting into more details about the actual parts themselves. So the tibial place base plates, it's usually made of a titanium alloy.
Speaker D: Dr. Fajardo
Titanium is a good material for orthopedic parts because it's it's not as rigid. It does bend a little bit, and it resembles the elasticity of bone. Sometimes, however, the Tiburon plant can be can be made of a cobalt chrome, alloy. And then the Tibial liner, the plastic liner, that's also, an area where there's a lot of diversity, a lot of products, a lot of marketing. And a lot of it depends on what the shape is, whether they have a post, and whether you keep the PCL or not. In all cases, we remove the ACL to put do a knee replacement. On the very left is a CR, which stands for cruciate retaining, meaning that we keep the PCL and we take out the ACL. Not shown here, there's medial congruent where it looks just like the CR.
Speaker D: Dr. Fajardo
But on one side, the, the socket is deeper and that helps stabilize the knee in cases where he had where we had to take out the PCL. There's ultra-congruent where both parts of the plastic liners, there's deep sockets and that helps stabilize the knee. And then we have PS, which is the 2nd picture in which we cut out the PCL. And basically, this post on the plastic liner replaces the function of the PCL. And those are the main types of plastic liners that we use in standard knee replacements. The other types, highly constrained CCK hinge, that's when somebody is having a redo knee or maybe in their 1st knee, but there's severe damage and the important ligaments, the LCL and the MCL, are gone. They need to be replaced. The study show that whether you use CR, PS, medial congruent, ultra-congruent, there's really no difference in the outcomes.
Speaker D: Dr. Fajardo
What I think contributes the most in making sure that the knee is actually balanced, that the the laxity and the tightness is the same on the inner side, the outside that the range's motion is good. If the knee doesn't bend all the way, it doesn't straighten out all the way, it doesn't matter what kind of plastic you put in there. Patients are not gonna be happy. And then the femoral components, that one is usually made also of a cobalt chrome alloy and can sometimes contain nickel. But there are certain companies that make nickel free implants, for people with nickel allergy. That's another area of controversy within orthopedics. We wonder and we think whether sometimes people have painful knee replacements because of nickel allergy. But it turns out that nickel allergy on the skin does not necessarily correlate to nickel allergy within the knee joints.
Speaker D: Dr. Fajardo
But regardless if somebody has a nickel allergy and, you know, there's nickel free options, so might as well use them. And there's a few companies that make that make those options. And then the femoral component has to have a cutout, to match the post on the plastic liner, if if the liner that is being used has a post. So so far we've covered cemented versus cement-less materials, plastic liners, and then we covered the the alignments. And now we get into the technology, which is probably, the biggest, thing that's being marketed. There's many different ways for doing a knee replacement. The basic way is manual instrumentation, which is the most common way that a knee replacement is done in the United States. And we'll go over that.
Speaker D: Dr. Fajardo
After that, there's other options, patient specific instrumentation, navigation, and then we get to robotics. So manual instrumentation is where we use guides that go in the femur and inside or outside the tibia. And we basically align them to the tibia, make sure that it's straight up and down. And when we look at it from the side, that the slope is representing the slope in your knee. And then we cut through the slots. Then there's patient specific instrumentation. In this scenario, we take a CT scan or an MRI, and then we basically plan the surgery on the MRI or CT scan, and we decide how much bone do we want to cut at what angle. And then the company makes these custom printed plastic, components that once we open up the knee, they sit on your bone perfectly and only fit on your bone.
Speaker D: Dr. Fajardo
And it has the slots that'll allow us to cut the bone to the predetermined, parameters. And that can help with sizing, determining before the surgery what size parts we need to have instead of having all of them. And also alignment. These guides that we use in the femur and the tibia, they're based on averages and not everybody's leg is average. So these are just a little bit more accurate because they take into account the bow that you may have in the shaft of your femur or your tibia. And then we get to navigation. It's the next step up in technology. And in that situation, what we do is that there's a computer with sensors, and we have a probe.
Speaker D: Dr. Fajardo
And we scan the surface of your bone, and the computer gets an idea of what the structure of your knee is. And then we move around the hip. We put the probe on the ankle so we get a sense of the alignment over of the of the bones, and that helps us cut the femur and the tibia with increased accuracy in terms of alignment. And sometimes it can also help us with tension because some people's ligaments are tighter than other people's ligaments. Ligaments. So some navigation systems allow us to bend the knee one way and the other and get an idea of how tight ligaments are. If somebody has loose ligaments, we cut less bone. If somebody has really tight ligaments, we cut more bone so that the parts can fit and you can end up with full range motion.
Speaker D: Dr. Fajardo
And then the last step is robotics, and that can help us with sizing, alignment, soft tissue tension, and some robots even with accuracy. This is an example of the Mako robot that we have here at San Antonio. And the way that works is that a CT scan is done before surgery, and then we can plan the surgery before we even make an incision. We determine the size. We determine, what angles we want to cut the bone at, how much bone we want to take out. And then once we get to the actual surgery part, the robot has the handle attached to it with the saw. And that helps us cut the bone in the exact place that we planned within half a millimeter millimeter of accuracy and within one degree of of accuracy, which is not something that's achievable, by the human hand or eye. And there's many different robotic systems.
Speaker D: Dr. Fajardo
The Mako is the most popular one and the most high-tech, but there's ROSA, other ones. Each company has their own robot that only works with their system. But what does the data actually say about this? The data says that there's actually no difference in outcomes, function, or pain between navigation and manual knee replacements and that there's no difference in function outcomes or complications, between robotic and conventional knee replacements. Obviously, this doesn't take a lot of other factors into consideration. If somebody does a robotic knee replacement but does not balance the knee, it's not gonna end up well. And if somebody does a manual knee but they really know how to balance the knee, then it's gonna be an excellent outcome. But this other studies that I have seen show that the that the robotics, systems do increase the risk of outliers, which means that most of the X rays that we get after, the parts are within, the parameters that we want them to be. With manual asymmetration, there can be more outliers where the parts are maybe not as good as we wanted them to be.
Speaker D: Dr. Fajardo
But it turns out at the end, it doesn't make a significant difference. And then where is the surgery done? Before COVID, most people used to get knee replacements, hip replacement, and stay for a few days and maybe even go to rehab. After COVID, that changed dramatically. Now 80, 90 more percentage of surgeries are done as same day surgery, either at a hospital or a surgery center, if the surgery center is properly equipped. And people start walking within one to 2 hours after the surgery. Physical therapist works with you. They have you walk around the hallway, go up and down stairs that they have so that you can practice for when you go home. Outpatient physical therapy is extremely important.
Speaker D: Dr. Fajardo
We can do a perfect knee and when you're still under anesthesia, have perfect range of motion. But without physical therapy and really moving the knee, it can get full of scar tissue, and that's called arthrofibrosis. And people can end up with a knee that doesn't bend very much. So the surgery is only half of of the whole process, and then physical therapy is the second half. Return to work is is on a case by case basis depending on what you want to do, what you do for work, what your duties are, what your progress is in a recovery, and then patient specific situations. By about 3 months, most people feel good enough that they go back to work if they worked before. And it really takes a year for the need to get as good as it's going to get in terms of the inflammation going away, achieving maximum range of motion, achieving maximum strength, and having the pain go away. And it's actually beneficial to go home.
Speaker D: Dr. Fajardo
The studies have shown that going home as opposed to rehab is associated with less complications. What I tell patients is that when you come into the hospital or the surgery center, you're coming in because you're getting, a new need. You're not coming in because you're sick, and you don't want to be around people who have infections and other things, which can compromise your success. So it's better to go home. You rest more. People don't wake you up to take your blood pressure and take blood every 4 hours. And the results are the same, if not better. Before surgery, it's really important to have a thorough medical evaluation.
Speaker D: Dr. Fajardo
I tell patients nobody dies of knee arthritis. It is painful, but nobody dies of knee arthritis. But people can die if we do a surgery without doing a good medical evaluation and identifying issues or, optimizing known issues. So we usually get chest X-ray, EKG, blood tests, have your primary care doctor see you, and have any specialists like a cardiologist or pulmonologist give the green light saying you are in the best condition, to have an elective surgery so that you can have the best outcome. The one of the biggest issues with knee replacement is pain control. It can be very painful for the 1st few weeks, but we've made a lot of progress over the last few years. We start with preoperative medications, which are getting in the preoperative area trying to modulate the transmission of pain in the body before it even starts. And then we do a lot of things during surgery.
Speaker D: Dr. Fajardo
Regional anesthesia, we try to do these surgeries under a spinal anesthetic. That decreases sensation in the legs, requires less general anesthesia so that when people wake up, they have less nausea, they're less groggy, and they're able to start and get up and walk within an hour or 2. It also decreases blood pressure during the surgery and reduces blood loss. During the surgery, we inject a combination of medications into the knee and around the knee to decrease pain. And most of the time, we also have the anesthesiologist do a nerve block before you wake up, and what they do is using ultrasound, they block one of the nerves that goes into the knee, and that can help decrease the pain for the 1st few days. And then postoperative medications, usually a combination of anti inflammatories, Tylenol, and narcotics if needed, but we try to keep the narcotic ease to a minimum as that has shown to also be a a negative predictor of success after knee replacement. And perarticular injections and peripheral nerve block are highly recommended by all the evidence, so that's something that we routinely do. And then we get to the complications.
Speaker D: Dr. Fajardo
99% or more of people do just fine. But there are situations where complications can happen, can happen 10, 20 years later if infection spreads from another part of the body. I've seen situations in where which people have urinary tract infections stubbed toes that got infected, other things, and the infection spread through the bloodstream into the knee. So it's really important that once you have a knee replacement, if you have infection somewhere else in your body, make sure you get it addressed in a timely basis, really take care of yourself. Stiffness is another complication. So that's why physical therapy is so so important. But some people are also predisposed to having increased, scar formation. So if you have had other surgeries or have cuts in your body and you notice they form a lot of scar tissue, that's something to be mindful of and maybe, keep a closer eye on the progression and maybe requires more physical therapy.
Speaker D: Dr. Fajardo
Instability. So when we do a knee replacement, we replace the surfaces of the bone. But what holds your knee together is your medial collateral ligament, your lateral collateral ligament, your PCL, if we leave it, and the capsule. But those things can stretch out over time, and the knee can become unstable. The parts can be perfectly well fixed to the bone, but they can be unstable relative to each other. If that happens and it becomes symptomatic, that could be require surgery to redo the knee. And then we get to loosening, the parts can get loose from the bone over time. And if they're painful enough and they're causing bone damage, it could require a redo surgery.
Speaker D: Dr. Fajardo
And then fracture, can fall. They could break their femur, their tibia next to the implants, and many times, it has to be fixed. But like I said before, the worst fracture that can happen is the patella. Such a small bone, but it's extremely difficult to fix and extremely important. And then there's always a chance of people having persistent pain. That's why one of the important parts of a physical exam in history is, seeing what other things may be going on. Hip pain can often refer down to the knee. I've seen people that come see me for knee pain.
Speaker D: Dr. Fajardo
X-ray and they had bone on bone arthritis. And then we did a hip replacement, and they didn't have hip pain before, just hip stiffness. And their hip got better and their knee pain went away. Sometimes people gonna have pinched nerves in their lumbar spine. The l three and l four nerve go directly in the skin over the knee. So if you have a pinched nerve nerve there, you can have pain in the knee even though there's nothing wrong with the knee. And unfortunately, sometimes people have a combination of 2 or 3 of those at the same time. And in those situations, sometimes it's helpful to do a knee injection to determine how much pain is actually from the knee versus other places.
Speaker D: Dr. Fajardo
Because the worst situation is I do a surgery and somebody goes through the extensive rehabilitation process and they don't get better. So it's really important to know everything that's going on and make a a discussion taking all that into account. Like I said before, knee replacement is an elective surgery, so we want you to be as healthy as you can be so that you can have the best outcome. And there are certain things that we know contribute to negative outcomes, but that we can't really change. One of them is age. When people get 80 years or older, we a little bit more. But that is not necessarily a cutoff. It has to do more with that when people get over 80, they tend to have more medical issues than when they're under 80.
Speaker D: Dr. Fajardo
And I've done hip knee replacements in people who are 90 years 90 years old and look like they're easily going to live another 20 years and they play tennis every day. And in that case, if they have no medical conditions or only small medical conditions, they're a good candidate. On the other hand, I've seen 60 year olds that have had 3 heart attacks and uncontrolled diabetes, and they're actually at more risk of complications than the 90 year old. So age is is important, but to a certain extent, it's just a number. And also the type of arthritis, the best outcomes are for people with regular wear and tear arthritis. If you have other types of arthritis or it's high risk of complications, for example, autoimmune disease, if somebody has lupus or rheumatoid, they're probably taking medications to suppress their immune system to control their main disease, and that can put you at risk of getting an infection after the replacements. And we do give extra antibiotics and take extra steps to try to decrease that risk, but we can't completely eliminate it. If somebody has arthritis because they had an infection in the past, they're they're at higher risk of the infection coming back.
Speaker D: Dr. Fajardo
There's people that have a knee infection. They're fine for 10, 15 years, and then the infection comes back. And for a long time, we couldn't figure out why. And it's not until about 2019, there was a study in Nature that showed that in somebody who has a knee infection and then 10 to 15 years later, they had a 2nd surgery for unrelated issues. They had a part a piece of their bone taken out and the scientists looked at it under the microscope and it showed that the bacteria were actually still there in a dormant or sleeping state within the bone cells. And they're just waiting for the right opportunity to come back and cause a mess. So, you know, in those situations, we just have to be aware of it, be vigilant. And then there's other risk factors that we can address.
Speaker D: Dr. Fajardo
Obesity, BMI over 40, like I said, is associated with with a higher risk of infection. And, actually, the risk of infection starts to increase at BMI 35, but at 40, it really skyrockets. That's why in a lot of hospitals and surgery centers, we have cutoffs where above 40, we try to lose some weight before we do the surgery. Smoking has shown to cause wound healing issues and infection. And if people stop smoking at least 6 weeks before, that can decrease the chance of complications. But it's better to have never smoked at all, making sure diabetes is under control. Nutrition is important. Making sure you have enough protein to heal the incision, heal the tissue.
Speaker D: Dr. Fajardo
Anemia, if people are anemic, there's a higher rate rate of infection, higher rates of needing transfusion, which then also puts a risk of infection. And if people have depression or anxiety, it can cause issues with participating in rehabilitation. And then also people who are on chronic narcotics, can have decreased outcomes. So we try to decrease the amount of narcotics before surgery. Things that I tell everybody that are important to know and that are normal. Clicking can happen if you move your knee in a certain direction. All of our knees have a little bit of laxity, but because we have cartilage and meniscus, we don't hear any clicking or feel it. But in a replace knee, it's metal and plastic.
Speaker D: Dr. Fajardo
So if you bend it and then move it to the side a little bit, there might be a little click and that's normal. For many people, it goes away over time. And people just also learn to ignore it, but that can be normal. Numbness on the lateral side of the incision, so all the nerves go from the inner aspect of the knee to the outer aspect of the knee. A 100% of people develop numbness on the outside part of the knee. I do think the nerves recover to a certain extent, but people also just get used to it, and they recover some sensation. But if you touch one side of the scar and the other one, it's usually never the same, but it's one of the known side effects of this. And then kneeling, I personally have no restriction on patients kneeling.
Speaker D: Dr. Fajardo
But even with that, only half of people or less actually do it. Because when you kneel, you usually put pressure on the incision and it can it can feel weird and cause anxiety. So half of the people prefer just not to do it at all. Common questions that I hear from patients that are thinking about a knee replacement is how long will it last? They actually last for surprisingly long time. This is one of the studies that I saw recently in patients with at least 15 years of follow-up, and it showed that at least 82% of knee replacements lasted 25 years. So 8 out of 10 people at 25 years are doing just fine. The people that have tend to have lower outcomes are younger people less than 55. And that's usually because their activity level.
Speaker D: Dr. Fajardo
They wear out the parts or they cause the parts to get loose. And then people who are overweight put more stress on the parts and they can get loose. But, overall, there's pretty good success, with the parts that we have available these days. Running, that's also a controversial issue. Astra Surgeon. When people ask me if they can run, I say, run for your life if you have to. Otherwise, try not to. Because at the end of the day, it's metal and plastic.
Speaker D: Dr. Fajardo
There's no give. There's no cushion. And one of the main reasons that knee replacement fell these days before it used to be the plastic, it would last by 10 years and would need to be replaced. Now the plastic with the studies that they're doing, easily 20, 30 years, I think. The problems now are infection and loosening. And for example, in in the cemented knee, if somebody runs and jumps, the parts are taking the impact. That impact is affecting the cement. Walking, cycling, golfing, dancing, swimming, all those you can do with walking, cycling, golfing, dancing, swimming.
Speaker D: Dr. Fajardo
All those you can do without any limitations, but I would try to avoid running if possible. And then when can I drive? It depends on the knee you're having and whether you have an automatic or a manual transmission. Most people drive an automatic car. So for a right leg, a right knee, it takes a little bit longer. You have to make sure that your knee bends enough, to move from 1 pedal car, step on the brakes without thinking twice or stopping because of pain in the case of a need for immediate braking. For most people, that's somewhere between 4 to 6 weeks. For a left knee, it can be a little bit shorter as long as you're off narcotics and can get in and out of the car, and use your right foot for driving. It can be a little bit shorter, than that time.
Speaker D: Dr. Fajardo
In that time. When making this presentations, I went through all the things that I would ask my surgeon if I was having a knee replacement. So I hope I covered most of your questions. But if there's any additional questions, I'm happy to take them. Yes. Now there's
Speaker E: Question from the audience
some reason that I have bone spurs Mhmm.
Speaker D: Dr. Fajardo
Which is my goal is to start my brace. Mhmm. Could they be connected? Well, if you fall directly onto the knee, you can you can bruise your bone, and that does get better. It takes takes a few weeks. But sometimes people can have underlying arthritis and it's not symptomatic, and then something happens like this where it starts the inflammatory process within the knee, and then the inflammation just never goes down because there's arthritis and other issues. So they could be connected. It could be the inciting event, to the the line that starts going up. But, you know, the treatment would depend on how bad the arthritis is.
Speaker D: Dr. Fajardo
An MRI could be helpful if the X rays don't show enough information. But, yeah, definitely, that could be an exciting event to pain from the arthritis.
Speaker E: Question from the audience
What causes a burst and sec behind the knee?
Speaker D: Dr. Fajardo
Okay. So one of the common things that can happen when people have inflammation in the knee is a Baker's cyst or or a popliteal cyst. That's a fluid collection in the back of the knee. There are cases in young people where they have a Baker cyst for no good reason. And in those situations, we can drain them and take them out. For most people, what a Baker's cyst is when there's inflammation in the knee because meniscus tear, ligament injury, arthritis, and the inflammation causes excess fluid to build up within the knee. And if there's too much fluid in the knee, some of it will track to the back of the knee, go between the hamstring tendons and form a little fluid pocket in the back of the knee called the Baker's cyst. And in that case, the Baker's cyst is not an initial problem.
Speaker D: Dr. Fajardo
It's not a primary problem. It's a secondary problem. And what we have to address is what's causing all that fluid. And once we address that, then the bigger cyst should go away. And for people who have bad arthritis, often it's a knee replacement. Yeah. So it's it's it depends a lot. So when people turn 60 and older, people can start having degenerative meniscal tears, which are meniscus tears that are not from an acute injury, a twist, or a fall, but rather just from wear and tear.
Speaker D: Dr. Fajardo
And the way you could think about that is that the regular meniscus is like like flat carpet, and then over time, the fibers can start coming out and it could start fraying, and that's a degenerative meniscal tear. And and a lot of people 60 years and older that have no symptoms, if you get an MRI, you might see a degenerative meniscal tear that is not symptomatic. So just because there's a meniscus tear doesn't mean it needs surgery. It depends how what kind of tear is it. Is it a degenerative tear, or is it, a different type of tear that we can see on MRI, whether it's a horizontal tear or vertical tear? Did the meniscus tear happen from an acute injury? And how much cartilage is left in the femur and the tibia. If somebody has better arthritis and then they tear their meniscus, in that situation, doing surgery for the meniscus will probably do nothing for the pain. So it it depends. It it depends on what the tear looks like, what the rest of the knee looks like, whether it's causing mechanical symptoms.
Speaker D: Dr. Fajardo
Sometimes the meniscus tear can cause the knee to lock up. And we put that all together to determine whether this can be treated non operatively, whether it needs surgery, and whether if it needs surgery, whether a clean up arthroscopy to shave the meniscus tears needed, or whether a replacement may be more appropriate. So it's, it's very multifactorial.
Speaker E: Question form the audience
Since the, knee replacement is made of metal Mhmm. I was wondering if extreme weather might be very hot and very cold would affect, your joint.
Speaker D: Dr. Fajardo
Yeah. So that that is a common complaint of people who have knee arthritis and have a knee replacement. And I've actually seen it in other parts of the body, like the ankle. You know, sometimes people have fractures in their ankle, and then sometimes we do surgery, and they complain about pain with cold weather. And, you know, we theorize it could be due to the metal. But then people who don't have surgery also have the same issues. And people with knee arthritis, who don't have any metal in them, often cite cold weather as as an aggravating factor. And that continues until after, the knee replacement, and some people continue having that.
Speaker D: Dr. Fajardo
So I don't think the knee replacement parts necessarily cause more pain in the cold weather. I think it has more to do with, with the nerves, the sensory nerves. When there's trauma, whether it's treated surgically or non-surgically, the nerves become very sensitive. And things that usually don't cause pain can start causing pain such as cold weather. And there are some people that have injuries that break their wrist or other things, don't have any surgery. And the nerves get so sensitive that they develop something called chronic regional pain syndrome, where even touching the skin with a feather is extremely painful. So it has more to do with the nerves becoming sensitive. And something that can help with that is desensitization therapy after the surgery, which includes touching the area around the incision once it has healed with something cold, something warm, fabrics that that are soft, rougher, just so that the nerves that are re-growing, and they don't know what's normal what what's normal to be felt, so that the nerves get used to being touched and stimulated.
Speaker D: Dr. Fajardo
And they realize it's normal to be touched. It's normal for it to be cold and it becomes less sensitive.
Speaker E: Question from the audience
Everything's perfect. Uh-huh. Is the a range of I mean, if you do everything
Speaker D: Dr. Fajardo
Yeah.
Speaker E: Question from the audience
What what do what range of motion do you end up with?
Speaker D: Dr. Fajardo
Yeah. So our goal is to make you be able to fully extend the leg to 0 degrees and to be able to bend it to at least a 115 degrees. The studies have shown that people who have 10 degrees or more of a flexion contracture or that they can't fully straighten out their leg by more than 10 degrees, they have issues walking and going up and down stairs. And they've also shown that a minimum of about a 110 degrees is needed for going up and down stairs, bending the knee enough to clear the step, getting in and out of a car. There is a balance between stability and range of motion. During the surgery, we take out the ACL. So the parts are designed in a way that they replace the ACL, they account for that, and they make your knee more stable. But that stability comes at the expense of range of motion.
Speaker D: Dr. Fajardo
So things that I tell people that, they shouldn't expect to be able to do is squat all the way down to the ground. Because the main goal of a knee replacement surgery is to help with pain. It is to help with range of motion, but not to be able to bend the knee to a 120, a 130 degrees. It's to help with pain and give you a range of motion so that you could do most of your activities of daily living. If somebody starts out with a stiff knee and can only bend their knee to 90 degrees, it's a little bit harder for them to get to that a 115. Most of the time, we're able to increase the range of motion, and people end up with more motion than they did before surgery. But it's really hard if somebody is only able to bend their knee to 90 degrees to make them have the same outcome as someone who had, perfect motion before the surgery. So there has to be realistic expectations and that's something that we go over before the surgery.
Speaker D: Dr. Fajardo
Oh, you mean if you have a knee replacement and you fall?
Speaker E: Question from the audience
Yeah.
Speaker D: Dr. Fajardo
Well, it's yeah. It's it's always important if you have a knee replacement and you fall or you feel that something is wrong to get it checked out, because problems can always be addressed sooner rather than later. It's relatively rare for people to fall and break their femur or their tibia or their kneecap. It's it's not a common common occurrence, but it does happen. But most of the time, when people have simple falls, they're they're usually okay. But I always advise people to get it checked out and make sure, that it's not something small that could turn into something big. Alright.
Speaker A: Megan Gutierrez
Thank you so much, Dr. Fajardo. Can we have one more round of applause for our speaker? Thank you so much for an excellent lecture. So with that, we'll go ahead and close out tonight's program. So thank you all again for coming tonight. We love being able to host in this space. A couple of things before you leave. 1st, on your seats when you enter, there's an event feedback survey. So we'd love to hear from you all.
Speaker A: Megan Gutierrez
Please fill that out. And if you turn that in on your way out and see Brenda or Ari at the check-in table, in exchange, we will give you a nice, SAR branded stress ball for for your troubles this evening. And feel free to grab a cookie or something on your way out as well. Please let us know if you have any questions. We're here here to chat for a few more minutes. But other than that, please get home safely and have a lovely evening.
Speaker B: Ron Nowosad
Yeah. Sorry. There there just one I wanna say. I truly hope that you found this session as informative as I did covering so many of the basis of knee replacement surgery and nonsurgical approaches, etcetera. So we are all very fortunate to have someone like doctor Fajardo here in our community taking care, our patients. So thank you very much doctor Fajardo.
Don’t Shoulder The Pain:
Innovative Surgical Treatment for Shoulder Pain
Presented by: Connor R. LaRose, MD, Orthopedic Surgeon
Lecture presented on: Thursday, Novemberber 9, 2023 • 6 - 7:15PM
If you’re sidelined by shoulder pain while carrying out daily activities, it may be time to consider orthopedic treatment. Join Dr. LaRose as he explains common conditions and causes of shoulder pain and when surgery should be considered. Learn about new techniques in shoulder replacements like the “reverse approach” and rotator cuff surgeries, which are commonly performed now as outpatient procedures.
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