Robotic Hip Replacement Surgery - Ghassan Boghosian, DO, Eisenhower Desert Orthopedic Center
(gentle music) - Hi, I'm Brett Klein with Eisenhower Health here in Rancho Mirage. Welcome come to our Zoom lecture series and I will turn it over to the doctor. He'll introduce himself and then we'll get started. - Right. Hello everybody. Thank you for joining me today.
It's an honor to have you all with me. This is a talk about robotic surgery, particularly for the hip replacement and some of it applies to knee replacements as well. So let's dive right in.
So the title of the talk is robotic assisted hip replacement surgery. Hip replacement surgeries have been performed for a very, very long time. They started back in in the '60s. And as you could imagine, hip replacements have gone really well.
They're actually one of the most successful operations in the world being performed today. But nonetheless, still sometimes report dissatisfactions with their hip replacements. And I'm happy to tell you that that no longer has to be the case. There was a lot of changes today with how we do a hip replacement surgery that hopefully will minimize those very, very small outlier of patients who aren't necessarily happy with their outcomes. "So innovation creates tomorrow and tomorrow is here today." And that's true when it comes to robotic hip replacement and robotic surgery in general.
Obviously, a lot has changed in the last decade or two with regards to technology, and we're going to dive a little bit into that today. But before I do, I'd like to talk a little bit about what arthritis actually is, and maybe even talk about some of the non-surgical treatment. One of the big questions that comes up around hip replacement surgery is the approach.
So we'll talk about that. And then of course, before you understand what robotic surgery is you need to really understand what non-robotic surgery is. So I'll talk a little bit about that as well.
And then lastly, we'll get into a little discussion about what makes it different and why robotics is the way it is. All right. So what is hip osteoarthritis? Well, first it's important to understand that arthritis is the loss of something. Most people think that arthritis is the presence of something, and they say, "Hey Doc, can you just go in and scrape away the arthritis from my hip or my knee or my shoulder?" And really, you can't do that because arthritis is the loss of the normal cartilage that was once present in that hip joint or knee joint or shoulder joint. So when we were all created, we were given a thick layer of cartilage.
You see that here in the photograph, on the white, that white substance that's on the end of the bones and that white substance is cartilage. That cartilage is a very thick layer that becomes a very soft and very smooth surface onto which the opposing surfaces can glide. And when those surfaces glide against each other the coefficient of friction which is what we call, the surface tension between two substances is such that it is incredibly smooth. Further that, the cartilage layers do not have any sensors within them, any nerve endings and therefore whatever happens in that cartilage generally isn't felt by the patient. So in the early stages of arthritis when that cartilage starts to dissipate away patients don't really feel it because there's really no nerve endings.
It's not until that cartilage is completely gone. And when it's gone, you start to feel the underlying surface of bone rubbing against the underlying surface of bone on the opposing side. And that causes a variety of problems including pain, inflammation, and significant discomfort along with limitation in motion. Let's see if I can, there it is. Okay. So here's an x-ray of what a normal hip
should look like. You can see here on the left and the right hip, this person has a normal appearing hip replacements, excuse me, normal appearing hips. And you can see the ball and the socket here.
It doesn't look like I have use of my pointer. Brett, can you see it by any chance if I move my pointer around? - [Brett] No. - Okay. I don't either. So I'm just gonna have to visually talk through it.
So you could see here, the ball and the socket and you can visualize the space between them. And that generally, that space is the cartilage space. Contrary, this x-ray is a person with severe osteoarthritis of their hip. And you could see here now that they have bone on bone disease with complete obliteration of that space that was once present between the ball and the socket.
There is bone spurs that have formed around the side of the hip, especially the ball. And there are cystic changes. These are cysts within the bones that have formed within the bones themselves.
And the combination of all of these things cause pain, they cause inflammation, and they certainly cause loss of range of motion within that particular joint. So speaking of which, pain is often felt in the groin can sometimes radiate to the side of the hip. And on very small occasions can be felt in the buttock area in the back of the hip. But most often, location for arthritis of the hip is that within the groin. It's kind of that crease of your pants when you sit down right where this patient's thumb is and then it radiates to underneath his palm. Often what we find with patients who come to see me in the office, they can have location of pain kind of spread around the hip all the way to the buttock back in the back of the hip which is often caused by sacroiliac joint tissues.
It can be caused by bursitis, which is directly on the side of the hip. It can be caused by meralgia paresthetica which is an injury to a nerve that comes over the side of the hip. It can be caused by piriformis syndrome.
It can be caused by referred pain from the back. So as you can see here, just because someone has pain around the hip it doesn't mean that they have hip arthritis. Again, there are a multitude of reasons why people can get hip pain and these are just to name a few. So one of the most identifying factors for people who have arthritis of the hip is loss of motion within that joint.
So people who have advanced osteoarthritis, like you saw in that earlier x-ray will lose rotational motion around their hip joints. So they'll complain of things like, "Hey Doc, I can't get to my toes when I cut my toenails," or "I can't put on my shoes or my socks." Or, "Getting in and out of my car has become exceptionally difficult." Those are all common signs of patients who have arthritis of the hip and less so for patients who have say bursitis or back pain. They don't typically complain of loss of motion. So they'll see it when they're golfing.
And then they'll also see it when they're getting in and out of a car and other activities as such. All right. So let's talk about some of the non-surgical treatment options. Those include things like activity modification. Obviously, if it hurts, you wanna do less of that activity to try to minimize some of the pain that causes that activity. You wanna talk about weight loss.
Certainly, excess weight can be a big source of pain around the hip or any joint for that matter. And it's been fairly well studied, and we know that there's a seven to one ratio. So for every excess pound that a person carries around, there's about an extra seven pounds of stress that they put on that joint. So weight loss is a critical factor.
Exercise is important. I mentioned earlier that with activity modification people tend to give up certain activities and that caused them pain. But movement is key not only to your joint, but to life. And so, we wanna make sure that patients keep active as much as possible.
And there are a variety of things that we can do to change the impact on the joint. So instead of doing, say, for example, running we could do like an elliptical or a stationary bike, which would be less stressful to that particular hip or knee. Another good example would be using pool exercises which can be great because of the buoyancy. And then of course, there's medications. So there's, non-pharmaceutical medications like glucosamine and chondroitin. There's also turmeric.
So there's a lot of things over-the-counter that can help minimize the pain. And then there's over-the-counter medications. Like now we're talking about Advil, ibuprofens, all of these anti-inflammatory medications that are available at the stores, Tylenol and so on. But of course, you know, all of these medications carry a particular risk profile. So we're very careful about what we prescribe for who and certainly talk to your doctor if you decide to use one of these medications before you start them.
And then there's prescription medications. We've all heard of Celebrex, Meloxicam or Mobic, Tramadol ultram all these medications can be used to alleviate some of the pain. And then lastly, injections. Injections come in the form of anti-inflammatory medication, such as corticosteroids. Steroids like prednisone, Depo-Medrol, Kenalog. All these medications can be injected into the hip, in this case.
And what they do is they decrease the inflammation caused by the arthritis, thereby minimizing the pain. They're not getting rid of the arthritis. The arthritis is still there, but because arthritis causes inflammation, and inflammation can be very painful, it can reverse that inflammation, thereby allowing better function. And typically, I use cortisone injections and people who say you know, "Hey, look, I know I have bone on bone disease, I know I need a hip replacement but my daughter's getting married in three months or two months. And boy, I'd really like to be there and have a good time at the wedding and not worry about the significant pain." So a cortisone injection would work well for that patient providing him temporary relief.
And then they come back and either talk about repeating a shot or proceeding with surgery to fix the problem. Often, patients come into the office and the question comes up, "What approach is being used for their hip replacement?" Well, this is a big topic of conversation when it comes up. And typically, is very time-consuming. So I thought I'd spend just a couple of minutes talking about it today because I'm sure it's gonna come up as well in the question and answer session at the end, which I look forward to. So understand that with hip replacement surgery, the hip itself that we have to access is very deep within the center of the body. And we have to get to it one way or the other whether we go in through the front, we go in through the back, we go in through the side.
We have to make an incision on the skin and then we have to push and pull some of these muscles out of the way to get to the structures that we need to get to. There's a lot of work that has to be done and we need good visualization. We've got to see what we're doing and we need good access so that we can put these components and where we want them to be in.
And jeopardizing that visualization can sometimes lead to improper placement of the components. So we have to make sure that we can see things properly in order to give a patient what should be a 20, 30, 40-year hip replacement, if all goes well. So when it comes to approaches there are a lot of approaches. And the ones that are more commonly used are listed here.
They are the anterior approach. They are also the modified Watson-Jones which is also called an anterior lateral approach. And then there is a traditional posterior approach which is, the traditional posterior that's kind of what they started out with back in the day. And that's a bigger incision.
And then there is the mini posterior. So when we talk about approaches today, the modern approach is when we talk about muscle sparing and quick recovery, and patients who are up and walking right away after the surgery go home the same day or the next day. And they have very little consequences from the surgical operation itself. These are the patients that are typically undergoing one of these more advanced approaches.
And that would be either the anterior approach or the mini posterior approach. And the anterior approach has a good rap and a good reputation because it's been used now since 2010, I think with good success. It has good results, good outcomes.
And the mini posterior approach has also been used now since 2010 and 2012. These are modern approaches that got developed together at the same time. There are smaller incision approaches that are about equal in the length, and they're about equal with regards to their recovery. So the issue that comes up, of course is people often miss or drop the word mini from the posterior when they're talking about it. And they refer to this other posterior approach which is, of course, a much longer recovery. And it's an approach where muscles are cut in order to get into the hip.
And that's really not performed anymore. I mean, it's reserved for the incredibly unusual scenario where something is very odd in an operation that would otherwise take five times as long. But today's workhorses if you will, for surgeries are the mini posterior and the direct anterior. On to conventional hip replacement surgery.
So let's talk a little bit about what is a standard hip replacement? And what are the surgical goals that we're looking for as physicians when we're performing these operations? What are our outcomes? And what are we trying to achieve? Well, in order to understand that, first, you have to understand some of the basics and where we're trying to put these components. So what I've done here is I've included a little bit of a visual of a, obviously a graphic of a patient lying on the table. A skin incision is made after the patient has been prepped and draped, sterilized, and then the surgeon moves the femur out of the way. And then we see the socket, otherwise called the acetabulum. And that acetabulum, you can see here, all the red which is the inflammation, the erosion of the cartilage within that socket, all of that has to be taken away. There are bone spurs around there that you'll see here in a minute.
And we achieve that task by using the circular reamer. That circular reamer is attached to, frankly, a drill on the other side. And that drill spins around and spins this circular reamer, removes all that bad bone, and then we insert this cup. The cup is the artificial socket. It gets implanted up into and against the native bone of the patient's pelvis and then a plastic liner gets impacted right into the inside of it.
That liner now becomes the new articulation. That's where the ball inserts. And you see on the back of the cup it has this roughened kind of metallic surface. And that surface is called a grit blast. And it's a titanium surface that the bone grows into.
Now, the femoral side. We remove the head by performing those cuts and we implant that femoral stem. And on top of that, we implant the femoral head.
The new head enters that plastic liner that you saw earlier. And the two of those become the new hip replacement. So that's a conventional hip replacement, how it's performed. Now, what's important to note here is there's no magic to doing this particular surgery.
Conventionally speaking, the surgeon makes an incision, moves the femur out of the way, holds the handheld reamer in my hand. And I ream the acetabulum or the socket based on what I see and how far deep I got to ream the socket. What level, what size, all those parameters are just made by frankly my expertise and my experience or the surgeon's experience and performing that particular operation. And so, a lot of it while we get good at doing these things because we do them over and over and over again, some of it is left to the surgeon's distraught, if you will, as to how he feels these particular components need to be placed. So this is what it looks like. This is our surgery goal.
We're looking to place a socket inside the pelvis. We're looking to place a ball on top of a stem. The stem sits securely inside the femur.
So what I've done, next is I've shown you a couple of x-rays and these are varying x-rays. Some of which I grabbed on the internet, some of which are my own patients. And we're looking to see what are the surgical goals and what we're really looking to do during the operation.
The first of which is the cup size. And what we're looking to do here with the cup size is to make sure that that cup fits perfectly within the patient's socket. That it is not too large.
It is not too small, and it is well attached to the bone, there's no black line between the white metal and the patient's gray bone, that black line would otherwise indicate a component that is maybe a little undersized. So we don't see that here. It's a good-looking cup and it's a good fit.
Next, we look at cup position. And in cup position we're looking at the angle of the cup relative to the patient's pelvis. So what I'll do here is I'll draw a line across the bottom of the pelvis, and then we draw a line tangential to the position of the cup. And you see here, I've wrote 43 degrees. It's measured at 43.
And our goal during surgery is to place that cup at about somewhere between 42 to 44 degrees, 40 to 45 degrees is even acceptable. And in this case, it is 43. So anything in that early 40 range is great.
A cup that is too shallow, i.e. 30 degrees of abduction or 30 degrees of position can impinge where the femur hits the cup, when the person moves their leg outward and anything that's too high, say a cup placed at 60, 65 degrees is in a position where the ball can now dislocate out of the cup. And obviously, that's a complication we don't want for our patients. So optimally positioning the cup at 43 or 42 degrees is great. Let's move on to cup version.
Cup version is the position of the cup relative to rotation of the forward axis of the body. And that typically we aim for about 20 degrees. Again, if it's too forward, anteverted say 30 degrees, then the patient will impinge and the femur will touch the cup and cause pain.
And if it's too retroverted, i.e. five degrees instead of 20 then the patient can dislocate their hip. And again, that's complication we're trying to avoid. So those are two cup-related positions that we're trying to optimize. And the surgeon can typically do that based on his or her experience and/or as we'll see in robotic surgery. So let's talk about the stem.
Again, here you see the stem is perfectly seated and perfectly sized for this patient's anatomy. It's a nice fit. It doesn't look undersized or oversized. We're looking at the stem position.
It's straight down the pipe, if you will, of the femur. It's going right down the tube of the femur. We don't want it angling in either direction. And then lastly, what we're looking to achieve here is leg lengths. Leg lengths can sometimes be a little difficult to understand for patients when I talk about this with them in the office.
So I'll go through a little demo with you here. What we do to achieve the measurement of the leg length is to draw a line across the bottom of the pelvis like we did previously. And then we measure the length of that line or the position of that line relative to the right and the left femur. You could see here that in this x-ray, it's the patient's left hip that is severely degenerated. On your screen, it is on the right but that would be the patient's left hip. So if we measure the distance from that line to what we call the lesser trochanter on the right hip you can now measure the distance relative to the right hip and relative to the left hip.
And when we compare the distance of those two lines, you can see that the right hip is, excuse me, the left hip is higher, meaning the left leg is shorter. The other way to measure it is to simply translate that line north up to the lesser trochanter. And we can appreciate that the lesser trochanter on the left hip, again, the damaged hip is sitting higher than the right suggesting that that left leg is shorter. All right. And we'll come back and answer any questions if you have any on this here, as we get towards the end. So here's that patient's hip replacement.
And what we see here is a correction of that leg length. So what we see now is that this patient's lesser trochanter on the right and the left fall directly in the middle of that line. And therefore, the leg lengths are perfectly matched. I'm including some scenarios in which that doesn't happen. So these are varying x-rays that I've grabbed at random places.
And these are depicting situations or scenarios where there's a slight discrepancy between the person's right and left leg. Now, I'll tell you the truth. Some of these patients come in and they have a little bit of a discrepancy between the right and the left. And frankly, they can't tell the difference.
And as you know, we're all born with a little bit of a difference between our right and left hips anyway. And so, most patients may not even notice it but in a couple of the latter examples here the differences are pretty great and patients do notice it. So in this case, as you can see here the left and the right hips are no longer equal. The line is transecting the left side right in the middle of the lesser trochanter and on the right hip, which is on the left of your screen.
The lesser trochanter is a little bit below suggesting that the right leg is a little bit longer. All right. Here's another example. So a line drawn through the center of the pelvis. You could see that on the right hip, it is going right through the center of the lesser trochanter and on the left hip, the replaced hip, the lesser trochanter is slightly below, therefore, the left leg is a little longer.
All right, one last example. I included this because it is an egregious change between the left and the right side. Not only can you appreciate that the left leg, which is of course, on the left of your, excuse me, the left leg which is on the right of your screen, has a significant leg length discrepancy where the left leg is significantly lower than the right, but there's also an offset discrepancy. That means how far out or to the side the hip is relative to the other side. So the distance between the center of the body and the hip is much less on the non-operated side and the distance between the center of the body to the new artificial hip is much greater on the operated side. So that's definitely something that should be avoided at all costs.
Okay. Enough of that, let's talk about robotics. This is exciting stuff, and we've come a long way, as you could imagine in the evolution of many things in life, especially surgical interventions. And this is of no exception. Today, we live in a world where we have smart watches. Swatches can take an EKG right off the back of our wrist. We live in a world where we have smartphones and at the slightest of requests, we can ask our smartphones to look up data for us and provide us information that we couldn't have done just five or six years ago.
And we live in a world where we have smart cars that have the capability of driving autonomously without our particular input, if you will. And so this is, you know, this is a new era in technology and this is a day in life where technology has changed radically and it will continue to change, of course, not only in surgery, but in every part of our life. And it touches us in every which way, whether we'd like it to or not. So come robotic surgery.
This is the Stryker MAKO platform. And what you see here are three robots. The one on the far-left of the screen is a robot used for partial knee replacements. The one on the far-right of the screen is a robot used for knee replacement surgery.
Total knee replacements. And the one in the middle is used for hip replacement surgery. But this is what they look like.
And it is a robotic machine that comes on the base that has, you could see there with the Stryker logo on it. And it has this pivoting arm, if you will, an elbow right in the center, and it will move to positions to achieve certain actions during the operation that allow it really infinite number of positions. So MAKO robotic surgery was initially founded and invented in Florida in 2004.
It was developed initially for partial knee replacements. And then it was acquired by the company Stryker, a very well-known and very big orthopedic company in 2013 for $1.65 billion, rightfully so, it's done very well for them. So if I can get this video to play, this video did a great job of describing it.
- [Narrator] More than 100 years joint replacements. - [Ghassan] Okay. So rather than having them narrate I'd rather do the narrating myself. So again, hip replacement surgery conventionally has been performed for a very long time.
And the objective of robotics is to make things a bit more accurate, a bit more precise in performing the operation. So what you see here are the computers on the far-right and far-left that help us achieve the outcome. And in the center here, you see the MAKO robot by Stryker. And what it has on it is that drill reamer on the right side. And then it has the reamer handle on the left.
So we start by first taking a CAT scan of the patient's body or pelvis and we build a three-dimensional model of the patient's hip. Once we have that three-dimensional model, we can now import that data in a 3D form onto the screen and take all the appropriate measurements that we need. We can take all the appropriate views and view in a 3D form that particular patient's anatomy. And what that allows us to do is it allows us to measure incredibly accurately the patient's pre-surgical position of the hip-leg length offset, everything that we need to reconstitute. And so, when we put the patient on the operating room table we now have to register the patient's anatomy, i.e.
telling the robot where things are in space. And we do that by this verification and registration process which takes about 15 to maybe 30 minutes. And once we complete that registration process now, the robot knows exactly where the patient's anatomy is. So what we do is we introduce this reamer and you could see here the reamer's attached to the robot handle, and we introduce it into the field and we put it exactly where we want the reaming to commence.
And once we turn on the robot, the robot will actually adjust the patient's, excuse me the robotic arm and the reamer to the exact position into which we want to make all the railings of the acetabulum. So once the reaming has been completed, we remove the reamer and we put in the cup. And the cup again, as directed by the robot at that exact 43, if that's what we've decided, and that exact 20 degrees that we talked about earlier so that the position of the cup is optimized not only for what we planned, but will actually be executed in exactly the fashion that we hoped. And there are several processes for checks and balances throughout the surgery that allow us to make sure that that indeed has happened and that our outcomes are exactly what we hoped for them to be. Okay. Quick case example that I'd like to show you.
So here's a patient. I thought this was an interesting patient. This is a relatively young individual who presented to my office with severe right hip pain. She was born with a congenital deformity. And as you could see, the left hip, which of course is on the right of your screen, x-rays are always backwards. The left hip looks normal, the right hip looks very deformed relative to the other side.
And you could see that the ball is of a different shape. The femur significantly higher. There is a big leg length discrepancy of 23 millimeters. There's 25 millimeters and an inch. So this is almost a full inch difference between her right and her left side.
This poor gal, she was struggling, she was in a lot of pain, couldn't walk, couldn't do simple things like even getting out of a car, couldn't put on her shoes, couldn't tie her shoelaces. And was on terrible pain medications that were altering quality of life. And so we've decided to proceed with a hip replacement for her. All right. This is not actually hers.
I couldn't find her exact screenshots for everything that I intended to show you. So I grabbed this from a different case, but wanted to just show you what is capable of performing during the operation. And in this particular screenshot, I'll go back and forth between her actual screenshots and not hers. And I'll tell you which is which. So in this particular case, what I'm showing you here is the position of the stem and how we intend on positioning perfectly-sized to this particular patient's anatomy, not only for size, but also what we call varus or valgus the position of the stem relative to the canal of the femur.
And then in the next x-ray, you see the same for the cup. So again, in a 2D, and of course a 3D fashion a three-dimensional fashion, we can place the cup exactly where we intend, not only with regards to the 40-20 that we talked about earlier but also relative to the size of the patient's anatomy. You could see in this particular example this patient has a 58-millimeter cup. And of course, these components these aren't one size fits all, they come in numerous sizes so we can choose the one that fits perfect for that particular person. This is back to her screenshot from the robot computer.
And what I'm showing here is, as you could see it's as planned. And in planned view that means that was my intent. I was thinking of lengthening her by 16 of the 23 millimeters and leaving her about seven millimeters short. I didn't think that I can get the whole 23 back and I wasn't sure if I wanted to for a variety of medical reasons.
So I was thinking before I did the surgery, this is right before I made an incision that I would try to lengthen her by 16 and see where we go during the operation. And of course, you can make intraoperative changes. So just because I've planned for 16 doesn't mean I'm stuck with 16, I can throw out the whole operation, I can make finite little changes, I can make changes down in a one millimeters of difference between leg length and offset. All right. So next, now we start with the surgery.
Again, everything you've seen so far has been pre-surgical, it's either done in my office or it's done in the operating room before I've made incision. In surgery, the first thing we do is we insert this thing. It's called an array and it goes in the pelvis with two pins and those pins are attached to the pelvis so that the array these little black circles that you see have little disks the other side of them, and the little disks are visualized by the camera on the robot. So any changes, any minute movement changes that happen to the patient during the surgery, the robot knows that, "Hey, this patient's changed in position where I think I'm going to have an action. That person is no longer there for me to have that action."
And therefore the robot needs to make adjustments in its position and angle and so on and so on. So the arrays are the communicated device that communicates with the robot. So the robot can follow and track the patient as the patient moves in space. And of course, the patient may move themselves because sometimes a patient as they're breathing they might cough or something like that. And they might move.
Or if I'm maneuvering the leg myself, of course the pelvis and the leg changes in position and space and the robot has to accommodate that motion. All right. So this is post-surgical.
Once I've registered, I've now done the hip replacement, and I have put in the parts. I was actually able to not only increase the leg length by 16, I was able to increase the leg length as you see in the bottom-right of the screen, a full 23 millimeters relative to her other side. I was able to correct her leg length discrepancy previously 23 millimeters, all the way back to neutral. You see the two columns it gives me.
This is reduced versus preop. I lengthened by 23 compared to the opposite side zero millimeters of difference between her left and right hip. So that's our surgical goal.
That's really what we're aiming to achieve. All right. I have one patient testimonial.
This is a different patient, not the one that you just saw. I included him because I liked something that he did. At the end I thought it was kind of cute. So I'm gonna show this particular one. I didn't wanna bore you with 10 of these 'cause frankly, they're all about the same. So this is a patient who came in.
He had previously had his right hip replaced somewhere else. When he presented to me, he had severe left hip arthritis. It was quite severe bone on bone disease, osteophytes and bone spurs as you could see in the upper right-hand side of the screen, where the ball is his femoral head was what we call an up and out deformity. So it was up out of the socket and out of the socket. All of these things caused significant pain making it very difficult for patients to walk.
The other thing that does is cause a lot of instability where patients feel like they can't stand on their hip or their leg and feel like it's going to give out on them. And you can see here, the leg length discrepancy between the right and left side, there's a huge shortening on the left compared to the right hip. - There you go. - [Ghassan] As you could see, that's a very painful gate.
My heart goes out to him when I saw him. And I just, I couldn't see him walk that way. It looks very, very uncomfortable. He has a cane with him and his daily life basically consisted of waking up, walking to the living room, spending the day pretty much on the couch, going back to bed at the end of the day and not really good quality of life, so to speak.
So needless to say, we fixed him. So this is his x-ray. Now you could appreciate that the leg lengths are even, the cup is in a perfect position, the offset is perfectly matched the other side, the stem is well-sized and well fit to the size of his femur. The cup is well-sized and well fit to the size of his acetabulum or pelvis.
And this is him after. Okay. Donald. Welcome back. When was your surgery? How many days ago? - Two weeks and four days. - [Ghassan] Perfect. All right, come on up for me. There you go.
Take a walk. - Now I can dance. - [Ghassan] There you go. He's ready to dance.
- We're gonna do good. - [Ghassan] You guys are cute, I love it. Thank you. - We're celebrating 75 years next week. - [Ghassan] Congratulations. What a blessing? You got to love that.
I mean, you know, it's things like this that really make you smile in a day and really keep you going. And there's just so much badness going on in the world today that people like that exist and people like that can truly change your life. And me as an orthopedic surgeon, when I see this it just reminds me of why I've chosen this career and why we're here to help these people. And this is, it's amazing to see him and the quality of life that he now has with his loving wife.
So it's very cool for me to see someone do that well and only two and a half weeks after surgery. All right. So enough of the talking head doctor let's take some questions. - [Mike] Hey, this is Mike Runner. - Hello, Mike. - [Mike] Yeah, I'm actually a patient of your clinic.
And I'm talking to Seyed Tau about my hip and I'm talking to him Thursday. He gave me an injection of steroids about a week ago. I got bone on bone on my right hip. And I was just wondering if I could talk to you about seeing you or getting an opinion from you. - Yeah, absolutely. I'm happy to see you.
Seyed Tau is Dr. Schnauser's physician assistant. The good news is you're already in good hands. Dr. Schnauser does robotic surgery identically to the way that I do it.
And so, in either case, I think that you've made a good decision. So you're down the right path already. Obviously, if you'd like to get a second opinion from me I'm happy to see you, but you're already off to the right start.
- [Mike] Okay, great. That sounded great. So I can just talk about this procedure a little bit further and it did help my hip, but it's like, it's not, it's like a bandaid, it seems like. - Right. And typically what we'll do is we'll offer people the cortisone injection really for the purpose of diagnostic and hopefully a therapeutic outcome.
And basically what that means is sometimes when we talk about hip arthritis, there's so much that happens around the hip that sometimes the source of the pain can be the arthritis. Sometimes the source of the pain could be bursitis. Sometimes it could be tendinitis or piriformis tendonitis. It could be the back. So you're kind of left wondering and scratching your head.
"Hey, is the arthritis really the source of his pain?" 'Cause the last thing in the world we wanna do is go in and replace someone's hip, then to find out three months later that the hip pain that they presented with three months previous is still there. So sometimes what we do is we bathe the hip where the arthritis sometimes lives with lidocaine and cortisone and see if the pain goes away. And if it goes away, then from a diagnostic standpoint then we can confirm to ourselves that that indeed was the source of his pain.
Now the x-rays that I've shown you throughout the course of this talk, these are all patients who have very severe bone on bone. It's clear as day. There's no doubt that those patients ever had any other source of pain and their hip arthritis is really the source of what's brought them in. But sometimes patients come in and they have very slight amount of arthritis with a lot of pain. And then we're left wondering how much of that is from arthritis and how much of their pain is from something else. So cortisone shot is definitely a great way.
- [Mike] Okay. I'll talk to him that thank you so much. - Absolutely. Thanks for coming on today. All right. Well, you guys have been amazing if you don't have any other questions, I'd like to wrap up and just say thank you for joining us tonight and I'll turn it over to Brett. - [Brett] I think we have one more.
Robert. - [Robert] I do have a question. You hear me, doctor? - Yes, I can.
- [Robert] Okay. This is Robert Crowell. I was wondering if you could elaborate on in any way without seeing the say personally about how far or what is the difference between treatment that's available non-surgical compared to having to go to surgical solutions? Can you elaborate on that? - Yeah, that's a good question. So talking a little bit about non-surgical versus surgical and when do we kind of make the jump from one category to the next.
Really, that's a very multifactorial decision. The decision has a lot to do with it with regards to age. So obviously if someone's got advanced arthritis at the age of 40, we're gonna exhaust every absolute option and make sure they've had every possible treatment under the sun before we consider hip replacement surgery. Because these hip replacements aren't intended for the 40-year-old.
Of course, we do them on younger patients, but again, after we've exhausted every absolute option. And when a patient is in their 60s, certainly in their 70s, or in their early 80s, then there's not really a big advantage to waiting, 'cause all we're doing is we're kicking the ball down a road. You might as well just do it and get it over with and let the patient return to their quality of life. Now, the tricky situation becomes when a person is 58 or 62 and what do you do in those situations? Because while they can certainly have a hip replacement wouldn't be a bad thing to wait a couple of years. So, we exhaust all those options that we talked about earlier as well, you know conservative management and injections and medications.
And then of course, prior to surgery, we always obtain some sort of a medical optimization or medical clearance from the patient's medical doctor or their cardiologist, if necessary, to make sure that we've optimized that patient for surgery so that when they go in they're medically as prepared as possible. And there's not anything about them that we can make better. And by that, I mean, things like their hemoglobin A1C if they're diabetics, their hemoglobin and hematocrit if they're anemic, and so on and things like that that can otherwise be usually improved. - [Brett] All right. Any last, last comments from anyone? Otherwise, we'll bring it to a close. So doctor, thank you again very much for a very informative lecture as always.
And thank you everybody for participating. - Thank you, Brett. And thanks to Eisenhower for helping to set this up. - [Brett] Have a good night, everyone. - Thank you. (gentle music)