08/30/2022
I have over 30 years of orthopedic surgery clinical practice. I studied chemical, biochemical, and biomedical engineering and medicine at the University of Pennsylvania. I have performed many thousands of surgeries, thousands of joint replacements.
A good long lasting result with joint replacement surgery requires both good surgeon technique and good choices of implants.
Surgeon factors include location of incision with approach to the joint, handling of tissues and closure technique, speed of surgery, use of anesthetics, after surgery treatment including blood thinners to reduce chances of blood clots, wound care, therapy, etc. Long operative times can increase the risk of bleeding, anesthesia complications and risk of infection with the joint being open and exposed for longer periods of time. In the case of total hip replacement, the anterior approach, for example, is associated with a very high incidence of nerve injury. The lateral femoral cutaneous nerve is injured in most anterior approach cases causing numbness on the side of the thigh. Although this is generally well tolerated, a few people develop painful neuromas which are extremely troublesome and very difficult to treat. I have also seen patients with fractures that have occurred when other surgeons have done this approach, which is also an increased risk with that technique.
Most of my surgeries take less than one hour. I use Zipline closure technique where there are no staples or sutures penetrating the skin. The purpose of this is that not only are there no sutures or staples that need to be removed, but it can lower the risk of scarring, reduce pain, and lower the risk of skin inflammation and infection.
Implants:
Hip replacements:
Smaller prosthetic femoral heads have excellent wear properties but increased rates of hip dislocation. Larger prosthetic femoral heads have lower dislocation rates but can put more stress on the hip socket components and also on the trunion, which is the neck of the femoral implant. This can increase the risk of complications including metal debris, inflammation, pain etc. I use dual mobility total hip replacements which have the ideal 28 mm size prosthetic femoral head, made of ceramic, which locks inside a larger highly cross-linked polyethylene femoral head which gives the benefits of both small and large heads without the higher complication risks of either small or large femoral heads used individually. This technology has been used in Europe for over 20 years. It became available in the US later and I have been using it with excellent results for 12 years.
Knee replacements:
Many hundreds of thousands of knee replacements are done every year in the United States. Fewer than 10% are partial knee replacements. However, it is estimated that over 40% of knee replacements could have been candidates for partial knee replacement which is a much lower risk procedure with easier recovery. These procedures are not being done as often as they could be due to lack of surgeon knowledge, experience, and training with these techniques. The Oxford partial knee replacement has the most congruent components of any knee replacement in the world. It was developed in the United Kingdom and has been used for over 40 years with excellent results. It has also been improved upon with upgrades in the components and the technique of implantation over the years. Many people have isolated severe arthritis in one of the three compartments in the knee and therefore it is not necessary for many of these people to undergo total knee replacement. It is better in many cases to just replace the one compartment with the severe arthritis. This preserves more normal knee function without removing ligaments. In most cases the patient has the surgery in the morning and is back in their home for lunch the same day. There is much less pain and blood loss, and much lower risk of infection and blood clots. The components are much more congruent, designed in that fashion to minimize the risk of wear. There are specific criteria which make a patient a candidate for a partial knee replacement including medical conditions and findings on standard and special x-rays. I have been performing Oxford partial knee replacements for over 12 years in patients in young adulthood and in every decade of life up to age 95. For those who are not candidates for the Oxford partial knee replacement, there are several excellent total knee replacement options based on the condition of the knee. Most people are treated with 3D printed components which have outstanding bone integration rates without the use of cement. Some patients are better treated with more constrained components depending on the condition of their ligaments so that I always have posteriorly stabilized and total stabilized options available to give the patient the best results. Instability is one of the most common problems causing dissatisfaction with total knee replacement and this can be directly related to the surgeon’s skill and technique as well as the choice of implants used. Of course, it can also be related to patient factors present before and after the surgery and unrelated to the operation. Just like all automobiles are not equivalent, all joint implants are not.
