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Ep. 203 - LiveWell Talk On...Advances in Joint Replacement Surgery (Dr. Omar Akhtar)

episode 203

Ep. 203 - LiveWell Talk On...Advances in Joint Replacement Surgery

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Omar Akhtarorthopedic surgeon, Physicians' Clinic of Iowa

Dr. Arnold:
This is LiveWell Talk On...advances in joint replacement surgery. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's. Joining me today on the podcast for the first time on the show is Dr. Omar Akhtar, orthopedic surgeon with Physicians Clinic of Iowa at St. Luke's Hospital. We'll talk more about the need for joint replacement surgery, new technology that's facilitating successful joint replacement surgery, as well as what to expect from post-Surgery recovery. Welcome, Dr. Akhtar.

Dr. Akhtar:
Thank you, Dr. Arnold. I'm very excited and very happy to be here on your show.

Dr. Arnold:
I'm excited about this too, because I think there's a lot going on here that, as we chatted briefly before the podcast, people don't appreciate the technology that's advancing in orthopedics. And so I want to talk about that today, but I also want to cover just some basic frequently asked questions that listeners may have about having their joint replaced. And the first is, what are the most common joints that get replaced?

Dr. Akhtar:
You know, the most common joints that are replaced, Dr. Arnold, are the hip and the knee. Just last year alone, we estimate there were over a million knee replacements that were performed in the United States alone, and about 500-600 thousand hip replacements done. And so those are the two most common and pretty big expenditure for Medicare also.

Dr. Arnold:
Right. But if it restores someone's functional capacity, all the better.

Dr. Akhtar:
The hip and knee replacement outcomes are amazing. It basically will allow a person to go from a position or a situation where they're in a wheelchair, or they have difficulty dressing, difficulty getting out of their home, to a situation where they have the potential to walk again, unlimited distances. Hike, go visit with family, go to a house of worship, to basically be independent all over again. And so it is tremendous, tremendous in terms of what it can do.

Dr. Arnold:
And over the years, I think the thing that patients appreciated the most is being able to sleep through the night. And you know, you're younger, but as you get older, you need your sleep. And you miss it when you don't get it. I think that's one of the unadvertised positive outcomes following joint replacement surgery, is that rest pain or that nocturnal pain gets better.

Dr. Akhtar:
To your point, I take those things for granted, being able to get a restful night without pain. To be able, just to get out of bed without significant pain. But yes, the majority of people will have significant improvement in their quality of sleep. So the basic functions, basic things, no question about it, are improved. Now are things perfect? No, but I would say 90% improvement.

Dr. Arnold:
Yeah, yeah. Okay. So you have the baby boomers, they're entering the Medicare age and how long does a joint replacement last?

Dr. Akhtar:
You know, Dr. Arnold, you mentioned the Medicare age, and actually we're seeing not only is it the population hitting 65 and above that are needing these joint replacements, it's even younger folks. A lot of my patients will say, "isn't this for old people, or am I too young for this?" It's really not about age, it's about quality of life. If you cannot, you know, get from your bed to your chair, or even walk more than a city block, or even go down an aisle in supermarket without panting or needing the cart, then it's something to think about, if that's what the cause is your hip or knee pain. And the other question that comes up is, well, I'm very young. I'm only 50, I'm only 45, you know, is this thing going to last more than a year or two? But the good news is modern joint replacements, hip and knee replacements, if performed appropriately in the right person, I tell my patients a well performed hip replacement there's 90% chance it'll last at least 20 years. And then if it needs to be redone, usually it's a minor little change, like changing the brake pad in a car, you change the bearing surface. And knee replacement, I can safely say 95% of knee replacements last at least 15 years, if well done, in the absence of something going wrong, like trauma. And so this is a valid concern. It's a very important question and your audience needs to know, and people need to know these things last a long time. And even when they do wear out or something happens after 15 or 20 years, let's say you have a 50 year old person. And by the time they hit 65 or 70, well, doctor, am I too old? What's going to happen, am I going be stuck in a wheelchair? Absolutely not.

Dr. Arnold:
Right.

Dr. Akhtar:
We can go and fix that problem, get them back on their feet. And then that's it, they're done. So it's nothing to really be too worried about.

Dr. Arnold:
During my internship, on internal medicine I remember I had this Dr. Packy, the guy was brilliant, but he used to say, patients die in bed, get your patient out of bed.

Dr. Akhtar:
Absolutely.

Dr. Arnold:
You know. And so he said, very few patients die in a chair, so get your patient out of bed. And I thought that was good advice. Artificial joints, do they set off metal detectors, like at the airport?

Dr. Akhtar:
This is a great question. And in general, I would say yes. Now it depends also, I think on the type of metal detector. If you're talking about a metal detector in a government building like a courthouse, those simple frames most of the time, hip and knee replacements do. But on their sensitivity, sometimes it doesn't. Certainly in an airport where you have the transportation securities administration, the TSA, the bigger scanners, they can see them. And it's very common. The next time you're at an airport, just pay attention and listen. Sometimes you'll hear a TSA agent say anyone here with a hip or knee replacement, and they'll just call out and people will wave or raise their hand. So, you know, look up from your phone, watch and observe, and they'll just make you go through the scanner. It's not a big deal. Maybe they'll wand you down or pat you down and you're done. So it's a very common thing. And as I mentioned before, there are millions of people walking around with these implants. So it's something that is very commonly encountered. And really it doesn't add any time to travel or block you away from getting into any kind of government building.

Dr. Arnold:
Well, that's good to know.

Dr. Akhtar:
Yeah.

Dr. Arnold:
Well, let's get to the new technology, which I think is exciting. And it's called the Mako system. Is that the same way you spell the sharks? M-A-K-O? Mako sharks?

Dr. Akhtar:
It is. Briefly historically, I think it was named after the Mako shark. And I think that emblem used to be a little shark fin. I don't know how that's supposed to be comforting for patients for surgery. It's supposed to be cool.

Dr. Arnold:
Yeah. So just give us an overview of how it works. I know we refer to it as robot.

Dr. Akhtar:
Yeah.

Dr. Arnold:
And, you know, I think people sometimes are fearful of robots.

Dr. Akhtar:
Yes.

Dr. Arnold:
But they don't need to be, so just give us an overview of how it works.

Dr. Akhtar:
Yep. So the Mako platform is called the Mako technique, or Mako robotic arm, or robotic assisted joint replacement. Any of those terms, those are interchangeable. And it's not a robot that's doing the operation. You know, you may think of, if you're watching a car factory where you see these modern factories, where you have these robotic arms coming in and doing the welding and moving the parts. Whereas historically, you've had people on the line building those cars. It's not like that. What the Mako technology is, it's a very smart tool. It's a smart robotic arm that enables me, or enables your surgeon to implant the joint precisely, consistently, and safely using a delicate technique. To be more specific and to use your terminology, we have to take a two dimensional picture, an x-ray for example, of someone's knee hip, and then convert that into a three dimensional joint in the operation. That's traditionally how we do it, and we do a pretty good job. But what if we can take a three dimensional picture—which is a scan of the person's joint, which is what we do before surgery—and then on the computer, on a laptop or a desktop, I can manipulate that three dimensional joint and rotate it, move it around, kind of virtually, and then I can decide how much of the arthritis to trim away, how the implant goes in. It needs to go into very specific angles and numbers. And what if I can do that before I get to the operating room, program it into this robotic arm, and then once we're in the operating room, do my normal surgical exposure and then the robotic arm comes in and as it's programmed under my guidance, I'm holding it, it helps me to mill away or trim away the arthritis and allows me to put that implant in exactly as plan every single time, the same way, or even customized to a person, depending if they have different types of anatomy. So that's all it is. It's a very smart tool, just like a tool you have in the garage. So, and it's not doing the operation, but it's doing what I told it to do under my guidance.

Dr. Arnold:
Yeah, that's precision. And we were talking about that prior to the podcast, you know, I mean, orthopedic surgeons take a 2D image and make a 3D joint.

Dr. Akhtar:
Yeah.

Dr. Arnold:
And, you know, it's harder than it looks. And I know I tease you guys, Black and Decker surgery. You know, I only jester you because I have certainly a lot of respect for you and your colleagues' skills. So what are—the precision that the Mako brings, how does that benefit the patient?

Dr. Akhtar:
That's a great question, Dr. Arnold, because a lot of people ask what's the big deal? This is just a smart tool. I mean, how is this really changing anything? In my opinion, and this is my opinion, the reason it's an exciting technology is, first, this is just the beginning. We're at the very, very early stages. And you just can, and we'll talk more about it later I hope about where this is going to go. But most importantly, because it allows us to do the operation in a more delicate, less traumatic way, it translates to better patient recovery in terms of less pain and improved faster recovery. And there is actually data to support that. I first observed that when I started using this technology a few years ago, and I thought it was my imagination, like, are my patients doing better? And then I would hear from my physical therapist, you know, your patients are doing a lot better than they used to. What changed? What did you do? And I thought, maybe that's a little anecdotal. And then papers started to come out where it is true, using this platform and this technique, it's less traumatic, more precise. And the reason that is, is we don't need to do as much dissection. I know it's a scary word, or as much exposure to the joint. It's not as traumatic. And when you're not stretching things and pulling and pushing as much, it's easier and more delicate on the patient, the tissues heal better. The person feels better. They require less pain medication and they're up walking sooner. So for the patient's standpoint, that is awesome. And it is consistently true in my opinion, from what I've seen.

Dr. Arnold:
Interesting. I've been in practice for 25 years. And back in the day when I saw patients and would do pre-ops for orthopedic surgery, I would always tell them, I'd say, look, the surgery's kind of the easy part. It's you participating in physical therapy afterwards, which will determine your success. And I think sometimes patients underestimate that.

Dr. Akhtar:
Yes.

Dr. Arnold:
So I always try to prep them and say, you know, you're going to do fine through the surgery and you'll get home. But if you don't participate in physical therapy, it's all for not, because that is so important.

Dr. Akhtar:
There's no question about it. You put your finger right on it. The surgery really is the easiest part. In fact, it is the, I wouldn't say the safest, but it is the smoothest part of the whole process.

Dr. Arnold:
Yeah, absolutely.

Dr. Akhtar:
The visit, surgery, and then the post-op. And I tell everyone of my patients, Dr. Arnold, that I have the easiest job. I just do the operation and my patients have to do the hard, heavy lifting.

Dr. Arnold:
Yeah.

Dr. Akhtar:
And despite this technology, one still has to go through therapy. You still have to make your appointments. You still have to put your effort in to get the good outcome. It's not where, oh, you just lie down there and someone's peeling grapes for you. You have to do the work.

Dr. Arnold:
No, it's so true. What's your line of sight on the horizon for technology and orthopedic surgery? What are you thinking?

Dr. Akhtar:
Yeah. So just imagine, so right now we have this tool. It's this big robotic arm in the operating room. We have a three dimensional scan on a screen in the operating room, but just imagine you have something called augmented reality. You're starting to see that now with some of these smartphones where you can project an image of a person's joint onto your visor. Imagine wearing some smart glasses or a smart visor in the operating room. And not that you have x-ray vision, but you can overlay the person's joint on your visor as you're looking at the person's knee or the hip. And not only that, you can start to see the angles and where the tools should go to trim away the arthritis or the diseased parts of the joint and how the new part should go in. And not only that, what if you have sensors you can attach to the patient's body while you're operating, and you can see in real time the amount of trauma or stress you're applying and adjust your surgical technique to really optimize and make a person come out of it more comfortable, with less inflammation, less trauma. So this is just the beginning. I think the possibilities, Dr. Arnold, are endless. There are people far smarter than me that are coming up with cool things down the line. And I think it's just going to be exciting.

Dr. Arnold:
Yeah. Just in my career, the things that I've seen change is a lot.

Dr. Akhtar:
Yeah.

Dr. Arnold:
And, you know, young surgeons like yourself are going to see it even more. Well, every guest on the show, almost every guest, gets to answer the question: why did you choose to be whatever special you are? And for you, how you chose to be an orthopedic surgeon, tell us how you got there. Why did you choose orthopedics?

Dr. Akhtar:
Well, you know, Dr. Arnold, it was a long path. I won't get into it, but I have a couple of engineering degrees and I was actually an engineer before I started my medical career.

Dr. Arnold:
So you drove trains?

Dr. Akhtar:
Yes, exactly. The Amtrak train from LA to San Francisco, right?

Dr. Arnold:
Yeah, okay. I'm impressed.

Dr. Akhtar:
The punchline is, I enjoy helping people, being able to recover their independence and quality of life. To go from being in constant pain or in a wheelchair, or like you said, can't sleep at night because of this joint that's waking you up. To be able to get up and walk, take care of your family, go to work, if you're retired, enjoy your retirement. That is such a joyful thing to do to see. And to be able to do that again and again, it's rewarding and it's addicting. So that is the reason, is to be able to really make a concrete, tangible difference pretty quickly.

Dr. Arnold:
Yeah. I think, you know the internal medicine specialties, we don't get to see our work unless it doesn't turn out as it should. You know, so if I manage your cholesterol appropriately and you don't have a heart attack, it's not appreciated that if I didn't do a good job and you had a heart attack, we'd see that. So I think the specialties like yours and other surgical specialties, where you actually make someone better is really rewarding. I'm jealous of that sometimes.

Dr. Akhtar:
Well, at the same time, you know, the nice thing about where you are or where my internal medicine friends are, is you get to develop these long-term relationship.

Dr. Arnold:
That's true. You're right.

Dr. Akhtar:
That's extremely rewarding as well.

Dr. Arnold:
Yes.

Dr. Akhtar:
So it's, you know, you sort of pick, but everything is enjoyable.

Dr. Arnold:
Yeah, you're absolutely right. Those are relationships that are truly, truly a gift. An opportunity, a blessing.

Dr. Akhtar:
Yes.

Dr. Arnold:
Well, Dr. Akhtar, thank you for joining us today. This was really interesting. This is great information. We're going to have you back when this technology continues to grow, to have you keep us up to date on it. Once again, this is Dr. Omar Akhtar, orthopedic surgeon with Physicians Clinic of Iowa - St. Luke's Hospital. For more information about joint replacement surgery, visit UnityPoint.org. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers, about our podcast. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.