Hip and knee orthopedic surgeon, Elizabeth Gausden, M.D.

0:07 Hi, it's Doctor Robert Seikard with Episode #26 of the Doctor Podcast Show. Thanks for tuning in and we hope you'll subscribe and also press on the like and repost button. And we always appreciate your comments as well. Today we have a great guest. If you have any knee or hip problems, you'll definitely want to watch this segment because we have Doctor Elizabeth Golston here today. Doctor Golston is a orthopedic surgeon who specializes in surgery of the hip and the knee. She's an attending surgeon at HSS, which is the hospital for Special surgery here in New York City, which is considered by everyone to be the best orthopedics hospital in the USA and probably in the world.

0:52 She's also an assistant professor of orthopedics at the Weill Cornell Medical Center, also here in New York City and also one of the top medical centers in the USA. Thanks very much for coming today. Elizabeth. I really appreciate you taking the time to talk with us about important topics. I know you specialize in in knee and hip surgery. How did you become interested in that specifically? And tell us about your unique training in that area. Sure. Well, first of all, thank you so much for having me.

1:24 My pleasure. Excited to be here. So I originally got interested in orthopedics like a lot of people do from playing sports growing up and then it carried through Med school. I really liked the being involved in the surgeries with a medical student, dabbled in some other things and it always had that pull back towards orthopaedics. So that's the the original interest and then during my residency training which I I did at HSS as well, I always thought I was going to be a sports surgeon some more Arthroscopy shoulders but I really fell in love with trauma as a as a young resident and and that's an exciting field.

2:03 Every day is different and I was planning on a career in trauma and then later in my residency some of the attending surgeons at HSS approached me and said hey you know you really like joint replacement too. You should combine the two and and come back on staff. So that's kind of my roundabout way of doing exactly the niche that I do. So I did a did a five year residency at HSS and Orthopaedics. I did a trauma fellowship at University of Texas in Houston. So it's a very busy level 1 trauma center, a lot of blunt trauma.

2:36 And then I did an arthroplasty fellowship, so hip and knee replacement specialty at the Mayo Clinic in Rochester, MN. And then I came back to New York. Wow. So only seven years of training after four years of medical. School. Yeah. Talk to my husband. I'm sure went by really quickly. I only did five years of training, so seven years is is a major accomplishment. So that unique training allows you to do special types of surgery by combining all those skills that you learned during two fellowships.

3:09 Tell us about that. Yeah, for sure. I'm in a unique situation at HSS because we are so high volume. We have a we do a lot of hip and knee replacements. How many do you do? Just just to give us an idea. Yeah. So every year in the United States, there's about 800,000 knee replacements done, 800,000 and 450,000 about hip replacements and HSS total does about 13,000 hip and knee replacements a year. So we're a very high volume center. And so because of that a few of us have special niches and my niche is fixing fractures that occur around hip or knee replacement.

3:45 So I do a lot of, you know, primary or first time hip and knee replacements, but I also specialize in those rare complications where somebody breaks around their hip or knee replacement and I I fix it or revise it. So in other words, they've had previous hip or knee replacement and then somehow through an injury or some other they they get a fracture surrounding that and then that must be very difficult to fix because there's a lot of scar tissue and the anatomy is not. Normal. There is scar tissue and and really it's the the joint replacement itself.

4:18 The prosthesis can make it challenging, The bio mechanics around it can make it challenging to get the bone to heal. In some cases it makes sense to fix that bone, and in some cases it makes sense to just take out the prosthesis and put in a bigger one depending on the fracture, and those are called peri prosthetic fractures and fractures around hip or knee replacements. Right. And HSS or a hospital for special Surgery is known for doing very complicated surgeries and have experts in the field like you.

4:48 How? How did HSS become the top orthopaedics hospital in the country? And and tell us about the other people you work there with? Yeah, it's got a really long, rich history in New York City. It was originally called the Hospital for Ruptured and Crippled and it changed its name, yeah, several decades ago, but that's still on our our paychecks. This hospital for Ruptured and Crippled. Is that right? And it became, it was originally you know did some other types of surgery and it just over the decades focused more and more on orthopedics.

5:19 And I think that's what makes it so great is that it is so laser focused on musculoskeletal problems and so we do orthopedic rheumatology for the most part. It's grown obviously over the years and now it's a major center and I think you know a couple of things that make it so special is the volume that we do. I think patients can expect that they'll get a certain level of care because we're so used to taking care of these problems. I like to say that they're on an assembly line, but in a good way.

5:49 It's, you know, nobody's first time doing anything. But because of that, we also do, like you said, a lot of the very complex things that a lot of other centers may not see a whole lot of, we see quite a bit of. Right. So most of my patients are from the New York City metropolitan area. And if sometimes they'll ask me for a referral, I usually refer to orthopaedics at NYU or I'm on staff or sometimes I'll actually refer to people at HSS because a few of my patients have had surgery there by some of the surgeons and I know they've gotten great results.

6:29 So patients in New York City have a choice. But how do people who live outside of the major urban areas like New York City or Chicago or LA? How do they find a good orthopaedic surgeon if if they have a serious problem that needs somebody with your expertise to fix? Yeah. It's such a good question and I think that's something that you know, we all struggle with family members, with other specialties. How do you find that quality, quality doctors to take care of these issues? And I think as a as a patient, one of the more important questions to ask is not only of the surgeon or whoever's doing the procedures, how many of these do you do a year, but also how many get done at your center because it's so much of it is is the team.

7:14 I'm sure you you experienced the same thing you're you're the captain of the team. But it really comes down to how how frequently does this team perform this operation. All the players involved are so comfortable doing it. So that's those are the things that I would, I would ask. So volume is is very important I think the amount of experience somebody has in doing a particular type of surgery. And then I think there is something to be said for for word of mouth and going with you know the the comfort of you know I've had fair number of referrals.

7:46 It happens very early in practice where somebody has a good result and they tell their friends and that's that's generally how we we seek care. It's maybe not the the most scientific way of doing it, but it's certainly is very common. And I wanted to ask you about hip surgery. So in in the old days, years ago, my patients who had hip surgery, I take care of a lot of senior citizen patients, right. And they, they've had all sorts of surgeries, but many of them have had hip surgeries in the past. After they had that, they'd be out of Commission for weeks or months and in rehab.

8:22 And it took them a long time to recover, and they still had pain. But in recent years, some of my patients tell me they have this anterior approach to hip surgery, anterior meaning in front of the hip, whereas in the old days they used to do posterior hip surgery. And it looks to me that anterior hip surgery is a quicker recovery and patients are having less pain and discomfort. Can you tell us the difference between this anterior and posterior approach to hip surgery? Sure. This is one of the hottest topics in arthroplasty.

8:56 So you hit it early, which is a a great question. And at every single major Orthopedia conference, there's great debate amongst the leaders in arthroplasty about this topic. So the bottom line is they're both good approaches, they're both standard of care approaches. The anterior approach is not necessarily a new approach, but it's gaining popularity over the past few years. So. So the two two approaches are posterior which which it really is more of like an oblique incision and it does split the gluteus maximus muscle.

9:28 Which is a muscle in the back of the hip. It's a big muscle. It's a big muscle, but either way you have to to dissect through muscle to do the replacement. So the anterior approach does not split that gluteus maximus, it goes in an interval, but there still are releases of muscles. So when we say that it's a completely muscle sparing approach, that's a little disingenuous. Each approach has to has to get involved with some of the muscles. Because there are muscles surrounding the hip joint, you can't avoid them, correct?

9:58 The anterior approach which I do, most of my surgeries now, about 90% of my primary surgeries are anterior. So I am a proponent of this approach. I like it. And I think the main benefit of the approach, if you look at large databases and this could be debated on the on the podium, but at large databases is that it's a slightly lower risk of dislocation or the hip coming out of the socket after the surgery. For that reason, we usually don't put people on hip precautions. So after the surgery, they can cross their legs, they can bend at the waist versus the posterior approach traditionally was a higher risk of dislocation.

10:34 So we would make people follow those precautions. They couldn't sit in the low chair, they couldn't cross their legs. Now that's changing, but that's one of the differences. The other difference that people talk about, like you alluded to is a slightly faster recovery time, right. So the Mayo Clinic did, did one of the best randomized controlled trials comparing those two approaches, randomized 2 groups and they did see that it was a faster recovery, but not on the order of magnitude that I think a lot of people think.

11:02 So it was about two to five days faster off of a cane or Walker in that study. So when I counsel patients about the approach, I say in my mind the biggest benefit is not having to follow precautions and a lower risk of dislocation with a slight added benefit of that slightly faster recovery time. So, so that's the breakdown. And of course, I'm sure in the comments section, this is definitely going to be argued back and forth and you can certainly find smaller studies to to show each way. But it's definitely something that patients are coming in asking for more and more is the anterior approach.

11:36 Yeah. Interestingly, I have patients who've had both approaches, like they had one hip down a few years ago, the posterior, and then they have the other one down the anterior and they all love the anterior much better so. Yeah that's true. I've I've certainly had that too and I think at the end of the day what I what I tell patients though is is they both are really good approaches they they're the you want to find a surgeon and that you trust and and say what what approach is best for me because there are certain patients that I think an anterior approach but you may not get that that great benefit.

12:10 So one of the risks is if you have somebody that's morbidly obese and their pannus or their belly lays over the incision, that can be a real risk factor for for problems with the incision with an anterior. Approach infections. Infection or wound? Wound problems, yeah. A lot of it also, I guess, depends on the surgeon's experience. They've done a few 1000 posterior approaches and they're really good at it and they get great results. Why? Switch, that's a big thing too. I mean, and there's certain surgeons, there's friends of mine say, hey, I've done my last thousand posterior cases.

12:41 I haven't had AI, haven't had a dislocation, so why should I switch? And that's a great argument, you know. Can't argue with success. Can't argue with success, yeah. How long does it take you to do a hip replacement surgery? It's a it's on average somewhere between an hour and an hour and a half for a primary hip replacement depending on a few factors. And there certainly are people that are a little bit faster, a little bit slower than than that, but that's that's about the average. And is that done under general anesthesia, the the?

13:09 That's a that's a great question. We've really gone more and more to spinal anesthesia or regional anesthesia. So what I explained to patients is it's not general. So there's no breathing tube, but you're asleep. If you're not awake during the procedure, you just don't have a breathing tube. Right. So you're kind of in the sleep twilight state, right? But you're breathing on your own, and the hip and the area you're operating on is totally numb, so they don't feel any pain or discomfort. Exactly is is the anterior approach quicker surgery than the posterior?

13:43 Or it depends on the surgeon's experience? Depends on experience, but on average it actually is slightly longer compared to a poster approach. I think more and more fellows coming out of fellowship are are trained in the anterior approach, so there's less of that learning curve. But as it was gaining popularity, a lot of surgeons in practice were starting it in practice and and going through that learning curve during their actual practice rather than fellowship. So we're seeing that it's the times are are evening out now I see.

14:14 And what is the artificial hip made out of? What is the material that you use? So about 99.9% of hips done in the US are the same combination winning combination. So the stem itself usually titanium, The head is typically ceramic. It used to be cobalt chromium. We're using a lot more ceramic heads now. The liner that acts like your new cartilage is, is polyethylene and we can talk about that 'cause that there was a big change in that in the 2000s that became highly cross-linked. So that's no longer the limiting factor of of wear in these.

14:49 And then the cup itself is titanium as well. There were, I think 10 or 20 years ago, weren't there, some recalls of of some hip materials? Yeah, so it was probably, yeah, around that time metal on metal became popular and the idea of that was you know pre mid 2000s when it was conventional polyethylene before they started doing this highly cross-linked polyethylene, the Poly or the plastic would wear. So one of the proposed solutions to that was let's eliminate the the plastic and do just a metal articulation on a metal metal head, large metal head on a metal cup.

15:29 It seemed like a great idea because the wear characters were great. The problem is there was a lot of metallosis or leeching of metal ions. So that caused both systemic issues as well as some local inflammatory tissue reactions and so, so several of those were recalled and a lot of patients had had big problems with that. So the materials now have a long track record and they're not causing these problems. Yeah, especially after the mid 2000s they started this highly cross-linked polyethylene and the wear characteristics of that are just excellent.

16:03 So the articulation is highly cross-linked polyethylene with ceramic ceramic head and that's really what I would say and many of us would say is the winning combination. So how long does a hip replacement last? That's a great question. There's not one great answer for that. Different in different people. I generally say it's about a 1% failure rate per year over time and that's all reasons. So infection, fracture or dislocation, you know instability, aseptic loosening or loosening of the implant from the bone, all those things.

16:35 What what I generally tell patients is it's usually not the implants now that fail, it's another reason your infection or your you fracture around it. But that's on on average the database studies, it's about 1% failure rate per year over time. It's pretty low. Pretty low. And honestly, we're probably better than what I just quoted. That's probably a conservative quote. That's the general accepted number. Yeah, so most people that are 60 or plus, I say, hey, my goal is for this to last you the rest of your life.

17:04 Right. And what can you do with a hip replacement? Can you play tennis? Can you run? Can you play basketball? Yeah. So traditionally we would really limit what people would get back to. Most of it was concerned about fracture or you know, implant failure, the the wear of the polyethylene. And now we're really becoming much more aggressive about what we're letting people get back to in general. I tell basins, hey, did you run before? And a lot of times they say no, I haven't run in, I haven't run in 30 years.

17:37 So like, no, you probably shouldn't pick that up. But if you're a runner, it's something that gives you joy and it's your passion. Is it the best exercise on a hip replacement? Probably not, but I'm OK with you getting back to it in smaller doses. I generally ask them to wait about six months until that implant's grown in and their muscles have fully recovered. But yeah, I don't have big limitations on what people can do after surgery within the reason of I want them to, you know, experience a full recovery before getting back to those things.

18:05 So you can go back to pickleball, she's saying. Is that right? Yeah, don't do like 90 minutes on your post op day three, but we'll we'll talk once you're recovered. You can certainly get back to it all. Right. Now what about knee replacements? Tell us what that's about and are there different materials, different types of knee? Replacements, Yeah. So knee replacement is. It's actually more common. It's about almost twice as common in the US now than than hip replacement. And I always counsel patients that that knees are harder than hips.

18:34 So a lot of times with the hip, you have your hip replaced and you forget about it. Once you're recovered, you really don't think about it on a day-to-day basis. Knees are a little bit different. It's harder to totally forget. So you generally want to wait until you're really kind of suffering from knee print problems before you pull the trigger on a knee replacement. And there are a few variations in knee replacements for the most part, the tibial component and again a polyethylene or that plastic liner and a femoral component.

19:05 There's a few variations on that, whether we retain or sacrifice the the PCL or the posterior cruciate ligament. And then there's also now robotically assisted robotic assisted knee replacement and manual knee replacement, all variations on how we perform it. And studies will show that there's not great variation in outcomes based on those. But I think there's a lot yet to be demonstrated, especially in the robotic area. That's interesting. Theoretically, I would have thought the hip joint is is more complicated because there's more areas of movement and then that would be more problematic long term.

19:46 But as you said, my patients who've had knee replacement complain. They complain more. Yeah, yeah, it's a tougher. It's a tougher swollen. Oh, big time When? I see them in the summertime. They're wearing shorts. I see their knees are still swollen. It's hard. It's really hard. And the hip, the hip, believe it or not it's really it's a more simple joint to replace because it's ball and socket. So the mechanics of it are are more simple and the knee is really quite complex. We think of it like a hinge, but it's more complicated than that.

20:14 There's some translation, there's some medial pivot and all these things were were really hyper focused on replicating the native joint with our prosthesis and we're getting there. But I still tell patients it's not this is not a normal knee, this is metal and plastic and there's certain limitations of it. So, so there's a reason why you don't see professional athletes in the mid career getting knee replacements. It doesn't function quite as well as any of me yet. Right. So they wouldn't be able to resume running and.

20:45 That's basketball. Now there are there are outliers that do get back to high intensity sports like running. Again, I would say it really depends on where a patient starts. So it's pretty unusual for somebody who is an active runner to, you know, pull the trigger and and do a knee replacement, but certainly have people going back to tennis, skiing and activities that in the past we weren't seeing. Right, Amazing joints. My my most my favorite joint is the ankle. I think that's the most incredible joint in the body, 'cause it's so tiny and it supports the rest.

21:18 Of the body I'll have to give you Mum. My good friends. Elizabeth Cody's a foot and ankle surgeon, so you have to get her. I'll get her next to talk to talk about the ankle. Now, I've heard some of my patients have partial hip replacements or partial knee replacement. What's the difference between a full and a? Partial Yeah. So in the hip side, if you're doing it electively, it's a total hip. In the fracture setting, sometimes if somebody doesn't walk a whole lot and they're not a high demand patient, we'll do what's called a hemi arthroplaster, hemi arthroplasty, where we won't resurface the cup.

21:51 But if you're doing it electively, you'll do a total hip. The knee side there is partial versus total and there's three compartments of the knee, the medial, the lateral and then the anterior compartment of the knee. And in most cases, the arthritis effects, usually all three compartments. But there are cases where somebody just presents with medial arthritis or lateral arthritis or anterior arthritis and then we can do a partial knee replacement. So that's just replacing that specific compartment and I do a fair amount of those and we do a fair amount at HSS.

22:24 The majority of us use robotics now to do partial knee replacements. There are some studies. Again, this will be controversial in the comments, but there are some studies showing there's benefit with using robotics to get the alignment right with partial, particularly unicondyl or irregular lateral knee replacements. I was just about to ask about robotics, but then it occurred to me, one one of the things that amazes me is why do people get these problems with their knees and hips so that they need the surgery and there's a few 100,000 done?

22:58 Yeah. Then other people have no issues or problems at all. Is, is it genetic? Is it environmental? Is it? I think it's all of the above. I think a huge percentage of that reason for needing something, you know reason for developing it is genetic, you know, and a lot of patients come in wanting to know that the more what can I do if I have bone on bone in my hip, can I prevent it in my knee. The best thing that we can control is our weight. That's the one factor that we have really clear evidence that the heavier, heavier you are, the more rapid the progression of your arthritis and the worse your symptoms.

23:36 So particularly on the knee side, if you can lose weight as a patient, if you're on that bubble of potentially needing a knee replacement, there's fair amount of examples of people that lose 30 lbs. They say, hey, my knee feels a lot better. So that is that because there's less bone to bone rubbing. I think it's the force through the knee. So you're not reversing the bone to bone rubbing, but the the the pressure that you're putting through the knee is less. So yeah, everything is amplified. So I think they say one 1 LB of body weight if it equates to to four, four times that amount on your joint.

24:11 It's interesting you say that because I thinking back, most of my patients who've had knee or hip replacements tend to be on the overweight side. I rarely see somebody who's thin. You do see it. You do see it. And that those cases are probably more dramatic than anything. And sometimes it's an old injury. Post traumatic arthritis can happen. If somebody had an old labral tear that they never, never knew about or that can that can cause or even an old fracture and then around the knee that can predispose somebody to it.

24:40 And then the other thing in the hip side that really predisposes is actually congenital hip dysplasia or being born without full coverage, the ACETAB over the thermal head. And we see that a fair amount. So if somebody's in their 40s or 50s getting a hip replacement, that could be a that could be a contributing factor. Any association with diet? I know we're talking about decades of diet, but. Yeah. Is there potentially some, some, you know, evidence and inflammatory? It's an inflammatory disease, so limiting the inflammatory components of your diet.

25:14 But I I still would argue that, you know, for the most part, it's a it's a genetic and A and a weight issue. Right. And what about some people tell me they don't want to run because it's bad for their knees and and bad for their hips. But I've seen recent literature that says that actually running may be protective for your knees and hips. What? What's the bottom line on that? Yeah, I mean, I ran a marathon myself, so I can't tell people not to do it, but I think if it's your passion, you should definitely go for it.

25:48 But yeah, there's probably some some safer sports for for our joints compared to long distance running. But I think running a few miles here or there to stay in shape is probably much better than the alternative of not exercising if that's a passion of a patient. So there's no evidence that running actually damages the knee or hip joints, is that? I think running in moderation, I think yeah, we could we could potentially link longer distance running, but I think in moderation and again the weight plays into it, a bigger person who's doing running at maybe more problematic compared to a lighter person.

26:28 Right. What about osteoporosis that seems to be increasing in incidence or maybe we're just diagnosing it more because we have special imaging that that diagnosis that do women who have an increased risk of osteoporosis have more knee and hip replacements? Good question. A lot of patients ask that too. No they're they're not necessarily linked. I think we are diagnosing it more. I think it's still actually under diagnosed in the population. I do a lot of my my patients about my my patient population about 70% female and so I see it a lot where somebody.

27:06 So it does seem to be more common in in women. Is that osteoporosis? It definitely is more common in women. So osteopenia or osteoporosis is common and I think it's commonly untreated in women and I think there's a lot of concern and I can, I can, I can understand why. When you when you read about some of the medications that are being used, patients you know understandably come in and they say I've read the side effects and they sound horrible. As a trauma trained surgeon and somebody that fixes fractures, I would argue you don't see.

27:38 What you don't see is the other side of this. You know if you break your hip that's a life changing event. And so yes these side effects are real but they're very, very rare. So if your doctor or your primary care doctor or your OBGYN recommends that you start on a medication to improve your bone quality, I would seriously consider doing it because it's much better than the alternative of having one of these life altering fractures. Right. So the risk of the medications is much lower than the potential risks of a fracture and then needing surgery and and so on.

28:12 That's good advice because I I have patients who tell me they have osteoporosis, they've had fractures, but they're afraid to take those medications which. Right. And we still know, I mean I think we have good surgeries for hip, hip fractures, but we still look at the data and you know it's a, it's a really morbid event if you break your hip and you know a lot of these, a lot of these patients that it happens to, they never fully gain their independence back. So it's it can be really serious. So the repair of a fracture, the surgery for that is more complicated and difficult and the recovery is longer than if you're just doing it for somebody who has bad osteoarthritis and pain.

28:52 Yeah, I do. A lot of somebody has a native hip fracture. They, it can either occur in the femoral neck or a little bit higher up in the femur or it can occur in the intertrochenteric region. So if depending on where it occurs, it's a femoral neck fracture, we can treat that with an arthroplasty. We just remove that bone and replace it if it occurs a little bit lower down, an intertrochenteric fracture, usually we fix those fractures with a nail. So two different types of types of fractures, yeah.

29:22 And I do warn patients when they are having a hip replacement in the setting of a fracture. It's not usually planned. It's usually emergent. Generally say hey don't compare yourself to your friend that's coming in for this total hip electively your tissues are traumatized. You're generally starting off with a little bit worse protoplasm. So we do know that your recovery takes a little bit longer and the risk of risk of complications is slightly higher. So namely the risk of dislocation we know is a little bit higher if you coming in for for a fracture.

29:54 So dislocation means the hip prosthesis separates from the patient's bone. So right that the head of the prosthesis dislocates from the socket of the prosthesis. And usually so A lot of times patients will be like, well, how I know if that happens, you'll know there will be no mystery. You you won't be able to walk, you'll be in excruciating pain. You'll you'll need usually to call an ambulance to to bring you in, and then the emergency room can generally reduce those under sedation. Right. And because of your extra training, your unique training of doing those dual fellowships, you do a lot of those complicated cases where you have fractures and then fractures on old hip surgeries.

30:38 Yeah. Yeah. That's a big part of my practice now is fixing those, fixing those fractures. And I assume that's a much longer operation. Generally is, yeah. Generally. Generally is a little trickier, takes a little longer and and the risks are higher for patients, but. And that's probably under general anesthesia or? It depends. It depends on what we're doing and how long it'll take and how, how, how the patient is, what their comorbidities are. You mentioned earlier about robotic surgery. Can you tell us some more about that?

31:09 Sure. Yeah. Robotics has gained a lot of traction in the past few years. One one thing that we haven't shown yet is that outcomes are superior, Clinical outcomes are superior. We're we're working on that. But we do know that a robot when added to a surgery does add precision. So it helps us place the components of, whether that's hip or a knee replacement. It places those components with a little more precision compared to manual instrumentation. Now, how do you control the robot? Is it? Is it like a little joystick like on a video game or or how do you do that?

31:41 So it's a little different compared to the general surgery robot where you might be sitting in another corner of the room and orthopaedics, the robot is usually with you. So you're doing the approach, you're doing all the soft tissue dissection and you're retracting everything out of the way. The hip side, the robot can help as the reamer basically helps mill the bone of the acetabulum and it helps position the final cup or implant and we can position that with greater accuracy in terms of angles relative to your pelvis.

32:09 You can also help us get the leg length more precise, right? That's, you know, when we do a hip replacement, we can either shorten or lengthen the leg and so the robot adds precision there. On the knee side. It helps with both soft tissue balancing and makes the cuts or the saw cuts slightly more precise. So the robot is actually attached to a saw blade in many of these examples. But again, you're the surgeon doing the approach. It's not like you're in another corner of the room, it's just adding that extra precision.

32:40 So it's it's precision, but the data is not. Certain yet I think we're still early days. So we haven't necessarily shown a large scale that improves patient outcomes, but we have shown precision. Is that the da Vinci robot also, or is that a different company? Different, different. And there's four major orthopedic companies and there's multiple robots on the market right now. See any of them better than the other or the date is not in. Yet in Full disclosure, I am a consultant for a while. Whatever the company can edit that output.

33:11 Yeah, so there's there's there's these, there's multiple robots. There's one robot in particular that's from Stryker that's based on three-dimensional planning. So you get ACT scan ahead of time. So in for me, I prefer that robot because I think it's the most precise versus some of the other robots are based on just you're you're templating ahead of you're you're using a probe to to tell the robot where the landmarks are when you do ACT scan and then you register the bone and I think that's the most precise way of doing it and that's what Striker's Mako robot does.

33:46 I see. Very interesting. You also, I know are interested in computer guided surgery. Is that different than robotic surgery and how is it different? Yeah, slightly different. There's you know the robot is an actual physical robot in the room with you. And it's it's kind of computer navigation. Plus computer navigation on its own is just without a robot, but it's helping you make the cut. So for instance, one of those devices, an accelerometer, it's just a handheld device in the knee and you can use a few landmarks and it registers.

34:20 Your cuts are, you know, perfect to the mechanical axis. It's just that it's not the robot itself. Rather than a handheld device, I. See So. Both technology, you know, enabling technology to help make your surgery more more precise. Right. Are you combining the computer and the robot? Usually not because the the robot. In my case I use a lot of three-dimensional planning robotics or striker robot, Striker, Mako robotics. So I'm getting all the benefits of what I would get with the, you know, handheld computer NAV systems with the robot.

34:57 You see a time in the future where AI plus a robot plus a computer will do the whole operation. I I think, yeah, the Sky's the limit and it's it's moving really quickly. There's even VR and AR systems that are added into it where a surgeon can wear, you know, wear the goggles and see the CT scan superimposed on the patient. I mean there's there's a lot going on right now and I think you know where we are right now, end of 2023. I'm excited to see what what it looks like 5 years from now because I'm sure it will look different.

35:31 Right. Do you do any research and teaching? Yeah, part of part of my job at HSSI do a fair amount of research and most of my research is focused on that niche of peri prosthetic fractures, fractures around hip and knee replacements and outcomes of those. And I teach, I teach fellows, residents and medical students and that's, you know, really fun. A big passion of mine. Wow. That's a lot of time that you spend devoted to your career. That's great. So in in my experience when I was training and in years past, orthopedics was basically a male dominated specialty, but now I'm seeing more and more female orthopedists and orthopedic surgeons like yourself.

36:15 How's that changed over the years at HSS and and all over the country? Yeah, it's a good, it's a good question. I'd still argue that we're a male dominated specialty. If you look at the numbers, there's still many more men that go into it compared to women. We've come a really long way compared to to, you know, 30 years ago. And then within orthopedics, there's still certain subspecialties that are more male dominated than others. Arthroplasty hip and knee replacement tends to be one that's a little more male dominated.

36:46 I think the last I saw was that it was only like 3% of the field is women really. So yeah, I think we've made a lot of efforts HSS and other major academic institutions we're we're really making an effort to to get more women involved and interested. And I I think that's important because you know, I I think there's a misconception that it's really requires a ton of strength to do this, this career. And yeah, it's a physical job, no doubt. But I think all surgery is is a physical job and I don't think, I don't think anybody's size should limit them if it's something they're interested in.

37:27 And with robotics and and things like that, it really almost neutralizes that. Right. Enabling tech, there's certain things that are really coming, coming to the forefront. There's certain impactors that a few of the major companies are designing. So you know, they they studied how many times you actually mallet or use a hammer to hit something in during a hip or knee replacement and it's like a crazy amount of times. And so they're designing things that automate that, you know, a certain amount of force.

37:58 Not only is it making it better on the surgeon, I think those things are making it better for the patient because it's a little more controlled, systematic, measured. So I think it's good all around. So it's it's becoming more and more precise, more precision surgery and therefore more reproducible and with time that are results. That's the name of the game. Especially in primary hip and knee replacement you you want to get to the point where you do something the same way every time and get reproducible results.

38:28 Right. As the population ages, do you think you're going to have more and more surgeries or are we eventually going to figure out how to prevent these basically chronic diseases of aging? Yeah, I think if you look at projections, both knee and hip replacement are going to be increasing in incidence over the next decade. It's interesting when you look at the the rise of what was that thinking some of the other drugs for weight loss, there's potentially some some sense that potentially if the if the weight loss can be mitigated that it may mitigate the risk of especially knee replacement.

39:10 Right. I had a doctor a few weeks ago that we spoke about weight and Ozempic and Govi and those drugs and a lot of my patients are on that and lost 5060 lbs. And I think, I think it's really promising, but I don't actually, I think I'll have a job for a while because I think, I think if anything it's going to bring patients that were too heavy and too too much at risk for a complication. You know, there's a certain cut off where somebody's very, very heavy. We tell them to lose weight before their surgery, but I think that those drugs will really help those patients.

39:47 But I don't foresee it completely diminishing the need for for hipper knee replacements. Unfortunately, I think we're probably a little further away from that. Well, if it does, you'll just do a few more fellowships. Yeah, just go back, right? Now some of these patients have medical problems that you're operating on and HSS is primarily an orthopedic hospital. How do you make sure that the patients stay healthy during and after the surgery? We have a great, a great medical team. So anybody that's having surgery at HSS will get a clearance from one of our medical doctors.

40:24 So they're hospitalists that that run the service too. So they'll get cleared by a Doctor Who specializes in internal medicine. Make sure that you know that they don't have any medical problems that need to be tuned up before surgery. Any specialists, for instance, if somebody sees their cardiologist, they'll the cardiologist will have to sign off on them too. And then while they're in the hospital, we have a great system where there's a hospitalist that also manages their medical care while they're admitted to the hospital.

40:56 So you're making sure you're staying healthy during and after the surgery. Exactly. How do you deal with patients who are on blood thinners like Coumadin, aspirins, Relto, Eliquis, a lot of my patients are on that. With eye surgery. It's different. They can actually stay on those medications almost always. With hip surgery, I would think There's a lot of bleeding and you're cutting through muscles. How do you? Deal with that. We would prefer them to come off of it for their hip or knee replacement, especially 'cause that's elective surgery.

41:28 So generally, if they if they can come off of it, we recommend they do. And it depends on the drug. You know how long they have to be off of it in the fracture setting. If they've if they have a fracture emergently, I will tend to operate through Coumadin or one of the other blood thinners. I think it's more important to get this the case done in a timely manner and take the risk of of extra bleeding so. Where do you see orthopedics headed in the next 5 or 10 years? You you mentioned that things will will change.

42:02 How about a forecast for beyond that, maybe 10 years from now? Yeah, I think it's an exciting time. I think the, the addition of robotics has has made it so that it's very easy to collect data like in in a large scale. So collecting additional data from each case is to, you know, soft tissue balancing and component positioning and then add that in with post operative data. There's more wearables that people are using after surgery. So their watch is collecting data, their phone might be collecting data, they may have sensors around their knee or their hip that's collecting data.

42:39 And I think all of that's going to be really exciting to see if those things can help us do a better job of their hip or knee replacement. I think we've, we've come really far. They're both very good operations. I think the things that we're looking at are just minimizing the risk of complications. It's already low, but we want it to get even lower and optimizing the outcome in the recovery, that's.

43:03 Pretty amazing. Looking forward to all that. Thanks very much for coming today. This has been very educational. I'm sure everybody out there has has enjoyed it and learned a lot. We really appreciate your taking the time to come and speak with us today. Well, thank you so much. This was this was fun and thanks again for having me. My pleasure. Thank you.