Joey Romero, MD, Orthopedic Surgeon with St. David’s Center for Hip and Knee Replacement presents on advancements in the treatment of hip & knee arthritis and robotic assisted surgery.
we're gonna start by giving a little bit of my background. You could get a little a little bit more about me and our practice here. We're gonna discuss different types of arthritis and some of the non operative treatment options for arthritis. We're gonna go over some of the surgical advancements we've made in joint replacement over the years, and more recently. And then we're gonna focus on 2020 updates and robotic Arthur plastic surgery, and then we'll close with a few questions. So this is my family. My wife, Brigitte. My two sons were five and three. Carter and Coulson. This was a photo we took in New York when I was finishing my fellowship. Um, I'm a native Texan, grew up in South Texas, did my undergrad at UT Austin Medical School at UT Houston, residency at UT Southwestern in Dallas and Parkland, and did my fellowship and joint replacement at Hospital for Special Surgery in New York, which is, uh, primarily an orthopedic and rheumatology hospital. Okay, so I work for the center for hip and knee replacement at ST David's. There's three Orthopedic, a joint replacement surgeons here, my senior partner, Shelby Carter, on the left or the partner Jake Manual on the ride in r two p. A s. Alison on Alex. We also have a clinical team of 11 members, which kind of keep everything running smoothly. Here, Um, so a little bit about about what I dio My practice and primary joint replacement is really focused on minimally invasive hip and knee replacements, including anterior muscle sparing approaches, partial joint replacement for the right candidates and robotic assisted surgery. I also do revision joint replacement for joints that have really just worn out over time, failed for one reason or another or whether there's been an infection or fracture. There's no joint that's too complex for us to manage here. We sort of run the gamut of all things that are related to joint replacement in hip and knee care. So different types of arthritis we're gonna talk about it can really be broken down into two main categories. This primary osteoarthritis, which is seen with our typical wear and tear and aging common for patients over the age of 60. Um, and then we have secondary osteoarthritis, which, if you're seeing patients under the age of 55 they have significant arthritis. You have Thio start thinking about other factors that may be at play here, including bme genetics, previous injury potential auto immune inflammatory diseases, a vascular necrosis and hip dysplasia. Uh, we're gonna focus on three of the most common types of inflammatory arthritis. Just thio, give some pearls for diagnosis, treatment and work up. Um, but this is gonna be rheumatoid arthritis, psoriatic arthritis and ankle losing spinal itis. There were briefly going to touch on arthritis Secondary date vaster necrosis. I know most of you know this, but just a brief rundown, the femur and tibia, they have a cartilaginous surface that is allows for smooth, painless gliding of the joint. Some in this cartilage surface is protected by the meniscus in the knee, which act as shock absorbers to prevent further damage and injury. But if you have damage to the meniscus or the cartilage over time, you will see that this hard village can wear away to expose the some conjugal bone in the femur and the tibia. And this exposure of the subcultural bone will lead Thio painful, debilitating types of arthritis that inhibit motion function quality of life. Um, some typical findings that you can see in osteoarthritis or going to include things like loss of joint space, osteo fort osteo fight formation and sub control sclerosis. Which is really this dense whitening of the bone near the articular surface where you have increased a joint surface stress forces. Kell, Grin, Lawrence classifications used gravies, grade one and two are really the more doubtful and mild joint space narrowing. This is early arthritis, where you may see a little bit of osteo fight, formation and lift. And also, if I lipping but the mawr moderate and grade three and grade for arthritis, you're going to see more significant loss of joint spaces. You see here on the right, you can have complete obliteration of the joint space and and primary osteoarthritis. It could be more concentrated on one side versus the other. And an example of what you may see clinically and an X rays here is is ah, progressive deformities and primary osteoarthritis can can focus more on wearing the inside versus the outside of the joint. On the left side. Here, uh, the screen we see a patient has a large bow leg deformity, also known as the various deformity with a really worn out Maura, the medial aspect of their knee joints, as opposed to the lateral side. And then, uh, the X ray and clinical image on the right show. What a knock the patient could look like with a bad Valukas deformity. Pelvis also has a smooth cartilage surface, the acid tablet in the femoral head, and this is a ball and socket joint, which is supposed to allow smooth gliding in motion. But as you damage the cartilage there and as arthritis progresses, you do have the ability to lose the scarcity of the femoral head. And when that happens, you lose a smooth gliding. Patients can have stiffness in their joints, and they can have progressive, debilitating pain on an X ray. What you can see here on on the right side of the screen, there's a complete loss of joint space as opposed to the left side. Here, you can see that there's still a decent amount of space between the acid tablet and femoral head and, um, like the knee. The changes you can see on X ray includes sclerosis, subcomittee assist and loss of joint space telegram. Lawrence classifications can also be used to great hip arthritis, so switching over to inflammatory types of arthritis. These aren't your typical wear and tear like we just covered. This is Mawr, things that are caused by systemic disease, autoimmune disease, inflammatory type reactions where there's many different types of inflammatory arthritis. But we're really going to focus on the most common three types here, which include rheumatoid and closing spinal itis and psoriatic arthritis. I think it's important that you identify patients that may have a new inflammatory type of arthritis. Er three Event is very important because it can really delay and even sometimes prevent the need for surgery. Down the line of patients are treated appropriately on we're gonna abusively unique clinical on X ray. Findings of Visa three. Inflammatory arthritis So rheumatoid arthritis, the most common form of inflammatory arthritis is chronic systemic immune disease that affects women three times more than men, and you can have diffuse musculoskeletal joint destruction, including in the neck hands wrist, early diagnosis with medication on treatment with medications like NSAIDs, low dose cortical steroids and immune modify find medications like biologics and demarches Important. You can see on an X ray here in a patient with rheumatoid arthritis. You don't necessarily have, uh, same type of pattern of where the joint surface that you would see in routine primary asked arthritis like the image on the left. The image on the left shows that you you have Maura wear on the medial side of the joint. But the image on the right shows that you have a little more of a symmetric where and that's because inflammatory arthritis really attacked the entire joint service and not a focal point of the joint surface. And for this reason, things like partial knee replacement are really contra indicated in these patients. Ankle losing spondylitis effects, uh, males more commonly than females that effects 0.2% of the Caucasian population. The X ray on the right here shows really advanced and progressive progressive disease. But these are some of the X ray findings that you can see in patients that have severe ankle hosting spinal itis. You could see obliteration of there s I joints because they get sacred really itis You can also have ankle host hips and you can see there's no joint space here and it looks like the Federal head is gonna complete continuity with the assets pabulum. You can see bamboo spines on spine X rays and really progressive deformities. You could get this chin on chest deformities, you see in the bottom left picture. Um, so if you ever have a patient that show up to your clinic especially, ah, mail. It describes progressive stiffness and low back pain and some s I joint pain and you see that there may be some loss of the joint space and the S I joint, you have to consider ankle losing sponsors largest These patients have diagnosed should also be looked into for cardiac conduction abnormalities, pulmonary fibrosis and acute you be itis. They should be started on P. T. That's focused towards flexibility. And, uh, if it's severe than TNF, health of blocking agents are important. Um, so we attic arthritis effects 20% of 5 to 20% of patients that have psoriasis, and this disease is really characterized by having these silver like plaques along the extensive surfaces of their elbows and their knees. You can also see some significant findings in their hands. You could get the stack politis or also known as sausage digits and ticking of the nails and then on X ray of their D I P joints in their hands. Sometimes you'll get this what we call pencil and cup deformity on the bottom X ray in the lower right. It's a pretty a path demonic sign for this type of disease, and these patients need to be treated with a similar medications thio, rheumatoid arthritis and then just a side note for primary care providers. I think this is really useful information whenever we're planning on doing surgery for a patient that's been diagnosed with a auto immune or rheumatic disease, um, they're often gonna be on medications that air, uh, modify their immune systems. And some of these medications will place patients at risk for infection around the time of surgery. So it's important that we be aware of the meds that they're taking and that we have a good idea of when to stop their medications before surgery and when we're able to restart them after surgery in a safe manner. More often than not, most of these medications air held at least one dozing cycle before, and one dozing cycle after in this state was put together by the American College of Rheumatology and American Association of Hip Knee Surgeons moving on to a faster necrosis s. So this is a disruption of the blood supply of the femoral head, which leads to the Austrian disorder or on death. And, uh, as this bone loses its vascular supply, it can collapse. And you have sub conjugal bone collapse under the articular surface that could end up having leading to flattening of the family head and progressive, painful to build hitting type of arthritis. There's approximately 20,000 new cases of this a year in the U. S. And 80% of cases our bilateral and about a quarter of these cases don't have an identifiable cause. But we do know that there's a some common causes that I highlighted here in yellow and helpful pneumonic that I used to remember these public septic. So things like AIDS, steroid use, sickle cell disease. Alcohol use is very common people that have a bn, um, pancreatitis, Perthes prior trauma, infection, and then anybody that's had cancer or cancer treatments, especially if they have a history of leukemia. Lymphoma are they've undergone chemotherapy or radiation. This can lead to astronaut Croesus qua gulapa, thes or anything that can cause micro emboli in the circulatory system of federal head and in cases, Disease also knows the bends associated with barometric pressure changes with things like scuba diving. Um, a vaster necrosis has a grading system most commonly used the classification. There's a few others, but this was the most commonly used and looking at X ray and Emory findings. You can see that there's a big differentiation here, Aziz. You go from stage two to Stage three, and this is where the treatment options change. So what happens when you go from Stage two Thio to Stage three is that you end up having a a crescent fracture and sub conjugal bone collapse, and the federal had loses its Spirit City. And when it's no longer round that patients are going through their normal everyday activities, loss of that round, um, structure and shape is gonna predispose them to rapidly accelerating progressive, painful arthritis. And this is important for our treatment options because once you lose the spirit city of the family ahead, um, there's not much short of an Arthur plastic that's going to give you a good, predictable result. Um, and even with stages one and two. You know, I think, um, as you progress further along in those stages, the chances of you having a good result with something short of an Arthur plasticky aren't the best. But we do know that something like core decompression has proven have Cem pretty decent results in early a vast necrosis and what a core decompression is. It's really drilling of the femur into the area of location with a vast necrosis. And there's some thought that this decompress is, um, area that there's increased Brosius pressure, and this can help relieve pain and possibly slow the progression of a vascular necrosis. This 2019 Met analysis nearly 2500 hip show that if you were to perform core decompression in Stage one and stage two of this disease that you have a 65% chance of success early on, defined by no further a vascular necrosis. No need for short term conversion to a total hip and Harris hip score of greater than 70 you know, in our clinic. And this is my senior partner middle partner in my, in my opinion of this, but essentially, if anybody has a bashing across is even if they haven't developed collapse. But they're older, maybe, uh, 60 force. We really think that's going to something like a total hip art class city without the gate is probably a better option because it has more predictable results that in this day and age they last so long that they're likely to only need one surgery for the rest of their life and doing a total as opposed to a core decompression. These patients that are older, um, certainly will allow them to have immediate weight bearing, as opposed to having protected weight bearing for six weeks or two months and also maybe only a two third chance of that surgery working. So certainly going to a total hip of somebody a little older. Maybe a better idea for some of these patients. So a lot of patients, you know, they want to be active, but they want to know how they can avoid injury, but they don't want to feel like this, and they definitely would like to avoid this if possible. So the American Academy of Orthopedic Surgeons has released guidelines on the non operative management of knee osteoarthritis. They've reviewed the data, and they've made panels to sort of give recommendations on some of the best treatment options. And I've kind of highlighted these here. But there's moderate recommendation for weight loss and patients with AM I over 25. Exercise and physical therapy are certainly important, and there is a strong recommendation to initiate this early on. A non operative management Orel medications come with a strong recommendation. Here They described NSAIDs and Tramadol on. Do you know there's been a little bit of a move away from opioids and definitely more focus of on an seeds here and then intra articular injections. They say it's inconclusive, and a lot of that depends on what type of injection you're giving. We'll cover that in a second. But Ortega steroid injections could be considered, and the data for our fiscal supplementation and hyaluronic acid is mixed. But there's a fair amount of data that shows that the benefit may not be as great as some of our other injection options covering the non op treatment options that we go with our patients that that we described with our patients. As they come into our clinic, we talk about weight loss reduction of impact and training, the importance of stretching building muscles around the joints and avoiding improper training. And also this describing activity modification. So weight loss is important because the average person you know takes 1 to 3 million steps a year, 7000 steps a day. And, uh, if you are obese or overweight, we know that the stress forces that your joints experience are increased, and you can see up to five times your body weight just going up and down stairs. And, uh, there's been some really good data that comes out of multiple orthopedic journals. That suggests that your likelihood of, uh, under undergoing an Arthur plastic procedure if you're obese or morbidly obese is increased. And we've seen that for morbid obesity of being migrated than 40 your risk of needing a total knee replacement your lifetime could be 30 time, 32 times higher than the general population. Yeah, so the things that really caused progression of arthritis once there's been an injury to a meniscus or there's a little bit of mild arthritis and you're worried about not causing a further progress, patients need to avoid repetitive, pounding type of exercise in which the body weight, Um, is repeatedly pounding and wearing away at the cartilage in the joints. And three, um, alternative low impact exercises that I recommend to my patient include cycling, elliptical and swimming is all work to reduce the repetitive pounding oceans and normal exercises and to reduce some body weight that is going across the hip. A need joint mhm. So stretching, um, often is important because as people develop arthritis, stiffness tends to set in and patients have tight muscles and tendons. And, um, stretching will allow patients to maintain flexibility, which is important to keep range of motion and function. And, uh, we know that one of the biggest predictors of postoperative range of motion after something like a knee replacement is what you're preoperative range of motion is. So even if patients are going on to need a knee replacement, I prefer that they do the best they can to maintain their motion is that will ultimately give them a better result after surgery. Building supporting muscles around the knee joints is important because muscles act like a brace to support the joint to help reduce the likelihood of injury and working opposing muscle groups like quads and hamstrings, hip flexors and extenders is important. I personally like close chain exercises or exercises that we use bands or free weights because it's less stress and less sheer force across the joints. And then lastly, you know, activity modification. There's something to be said for speaking with patients about what their exercise regimen is and what their what their activities are because what they're doing has a big impact on on how it's affecting the progression of their arthritis. And I have patients to come in who have, you know, pretty significant arthritis. But they still like to be involved in things like CrossFit or pivoting type sports that put a lot of stress and strain on their joints. And we have to have pretty frank discussions that, you know, if they change their exercise, their sport and the intensity of their training, they may be able to reduce the progression of their arthritis and reduce their symptoms. Moving on to medical treatment options. We have pain medications, anti inflammatory medications, injections, arthroscopic surgery, partial joint replacement in total joint replacement, so medications and pain relievers such as Tylenol and tram, It'll they concertante. We work to provide some pain relief, but they may not be the best option terminal being an opioid. We know the potential for addiction in the country's dealing with an opioid crisis. So certainly if we have other options that are better, we consider those, um, you know, and there's also data support. The chronic opioid use prior to a total knee replacement places patients at a greater risk for complications and prolonged painful recoveries. Um, having said that, if patients aren't a candidate for things like NSAIDs or other, um, Orel pain medications and a no opioid is needed. Um, there is some recent data that was just published in May in the Journal of Arthur Flashy. That suggests that tramadol maybe a better option to some of the more traditional opioids like hydrocodone Percocet because it has a lower risk of postoperative complications. Uh, and said for really are go to medication for hip and knee arthritis that patients are able to take them and don't have renal disease or gastric ulcers. But I like being, um, believe ibuprofen, um, naproxen and and some of the newer things that I think we really try to introduce to patients are things like selective cox two inhibitors, um, sort of reduce some of the other symptoms and gastric issues you could get with NSAIDs. But Matlock, Zicam diclofenac do great. Um, certainly, I think the best um impact that insects have is they reduce the inflammatory reactions and arthritic joints, and reducing that inflammation really helps to reduce the pain that is experienced in thea joints. And I think being a physician before starting insides is important for a fair amount of patients. Because, like I said, if they have underlying renal disease or history of gastric ulcers, you don't want to just in this recommendation, um, and not know the potential side effects for patients. They can't take coral on zero anti inflammatories. We do often recommend some topical type options and Voltaire in jail. Although it is a topical, non steroidal anti inflammatory, there's less systemic absorption than some of the oral medications, and there may be less propensity for developing side effects injections for patients to come into our clinic if they've never had an injection. Generally, one of the first things will discuss and offer is a cortical steroids. I think they have a little more predictable pain relief. We can't give these more often than every three months, but certainly this is one of the first injection options we try in our clinic. And viscous is often requested and sometimes used. But I would say, um, there's plenty of options out there, including Sin Vis Q Flex Orth of ISC and there's limited efficacy of this and the American Academy of Orthopedic Surgeons is really state taking a recommendation, saying that they can't necessarily advocate for the use of these. But certainly like I said, there's patients that will come and asking for this and the time that will certainly consider using it is that patients have had success with these in the past. Andi request these, then we certainly will offer this to them as an option. Yeah, the European stem cells have become much more popular over the last 5 to 10 years. The early results in laboratory trials showed that there was some encouraging data. However, we haven't had any great level one qualitative data that suggests that this is having predictable improvements and and pain relief and, you know, reversal of degenerative disease. And, uh, you know, the academy is not really endorse these. I think there's still data coming out on this, and this is still somewhat experimental. But, you know, in 2019, the general market plastic came out and take a stance and said that the, um, enthusiasm for stem cell um, NPR P introductions is really outpacing the science behind it. But hopefully more studies will come through to support use these treating osteoarthritis and also for primary care providers out there. If you know that the patient has possibly an upcoming hip or knee replacement, you may want to consider not giving an injection within three months of surgery because there's good data to support that an injection within three months of surgery can increase the chance of a prosthetic joint infection. Arthroscopic surgery is certainly an option, um, in in three generative disease, but mainly what I tell my patients. If you have moderate to severe arthritis and swims offering you an arthroscopy procedure, um, to clean out the arthritis, you need to really consider, um, possibly other treatment options because there's no great data to support. That arthroscopic surgery and in the setting of arthritis can provide long term predictable relief. Now, the time that I do feel that this could be useful if somebody has minimal arthritis and they have a significant meniscal tear that is causing mechanical symptoms, which we would describe his painful, popping, catching or locking where there, any may actually get stuck in a certain position. Then they may benefit from a arthroscopic procedure to really, um, uh, remove those mechanical symptoms. Hip arthroscopy could be done early on if there's label tears and not significant osteoarthritis. Um, and then really, what we do in our clinic when we failed conservative treatment options, we focus on Arthur plastic surgery and joint replacement, and the goals for us really include four things. One. Reduce pain. We want to correct deformity. We want to improve motion and overall quality of life. And patients, you know, have different ideas of what it's like to have a position, you know, cutting on them and everyone has a different imagination. It could be scary, but I will say that this day and age we've really advanced Arthur plast E, and this is not the same as it used to be. 10 to 20 years ago, patients of younger ages and higher activity levels air having Arthur plastic procedures. This patient, the bottom left, had a hip resurfacing. And then he went and won a gold medal for Russia and fencing. So certainly there's potential to do higher levels of activity in this in the right patient, the materials have really evolved over time, and, uh, we started with ivory and plaster. But we've made our way to evolve to things like ceramics, titanium, polyethylene in modern day implants and the goals of surgery in this day and age of really worked thio lesson pain and include a quicker return to activities of daily living and prove overall function and patient reported outcomes. And a lot of what we've had success with could be attributed Thio things that were introduced in the mid two thousands, including modern postoperative pain control. So we really more often use something like spinal epidural anesthesia as opposed to general anesthesia on. We also focus on multimodal pain regimens, including indwelling catheters, peri articular injections and different modalities of payments. And, um, the rehab protocol is is vastly different. Now. We encourage early independence. We want patients up and walking within three hours of surgery, and we prefer that they go home with a now outpatient physical therapy or an impatient home physical therapy plan is opposed to a rehab facility. UM, the introduced introduction of trans examine gas. It has reduced bleeding, the need for transfusions and the chance of developing infection. And we've also improved our surgical techniques. So different types of procedures. We've focused more on minimally invasive type stuff, and we've used technology to improve outcomes, and this is really changed the way that people are recovering after their joint replacement surgeries. Some of the things that have really gained some traction over the last decade include doing more partial knee replacements. Um, as you can see here on the on the left X ray. That's just one side of the knee that's replaced as opposed to the entirety of the knee on the right, and it allows patients to recover faster. There's a lower complication rate with this, and it feels a little more like a natural need because you don't have to mess with ligaments in the middle of the, including the A. C. L in the PCL and tear muscles bearing replacement has become very popular. The image on the left shows that muscles are kind of just pulled to the side. A supposed to the image on the right, which is a post your approach to the hip. And it's still the most commonly used approach to the hip in the United States. But in the post your approach, the muscle is split, and that can lead to, um, some delayed recoveries early on. Um, robotic arm surgery, Um, is what I'm gonna sort of focus on discussing in the next few slides here. And, uh, you know, what we're also gonna cover is the 2020 Knee Society Studies. The Knee Society is a very prestigious society that has surgeons from all over the world that are experts in the field of New York placement kind of submit their research, present their data toe other surgeons. Um, but I want you to remember this. The keys to a successful joint replacement surgery include that implants must be well sized, well positioned, well aligned and well balanced. And, uh, robotic technology has really helped to do this, um, surgeon, a surgeon I in hand when we have so much accuracy and decision, and the robot helps us really hone in on there. and act Christian, which is important for outcomes in these patients. And I'm gonna discuss that moving forward. So, um, how a robotic knee replacement works or a hip replacement is we start by getting a preoperative cat skin to define the patient's anatomy size and Yama yeah, that C T scan to pre operatively. Template and place are implants in a three dimensional type of template, which will guide us and sizing and position and, uh, in surgery weaken. Do inter operative mapping of the bones as well as do range of motion assessments. And this helps us define what the soft tissue balances around the joints. In surgery, we will remove the arthritic bone, and the robot has what we call haptic feedback. And if we're ever leaving the boundaries of our surgical plan, the robot will just stop in the board. And this can really help prevent injury to the patient in surgery. And lastly, we have implant placement with position verification so we can place this where we think it's appropriate, and the robot can help confirm that we're doing what we set out and plan to dio. Here's an example of some of the preoperative planning, and we can move our implants in space to best position them for that patient. Custom Surgical Planning Here's some intra operative photos showing how this works. You see these, um, arrays here. Basically, we temporarily place pins into the bone to hook up these arrays, and this gives the robot eyes and surgeries. We have a receiver here that identifies where the legs and space, and then it could give us life feedback on the surgical maneuvers that we're doing during the procedure. There's a precision and cutting in surgery because you can see there's a bordered green outline here, and basically what we're trying to do is remove bone that's highlighted in green and we're trying to avoid bone that is not highlighted in the machine will essentially stop you from going out of this boundary. That's important. Eso Once again, implants must be wealth sized, positioned, aligned and balanced, and this is an example. Uh, some different types of improperly balanced me. So on the image on the left, you can see that the contact points between the federal component in the tibial component are symmetric, as opposed to this image. Here. There's a gap on one side and not on the other side. And depending on how many degrees you're often surgery, you could have larger gaps. And those gaps are important because I really describe the knee replacement patients. Kind of like getting an alignment of your tires on a car. If you have one wheel that is just one degree or two degrees out of alignment with the others, you're gonna wear out the tread faster. And one of the studies that came out of the knee society this year really showed that radiographic and early clinical outcomes after robotic surgery has proved to be more accurate. And you have less outliers in terms of mouth position, normal alignment. And they think that this is gonna be a important for really improving the longevity of the implant and avoiding early failure. Um, you know, we do know that implants that aren't well balanced can have a symmetric contact pressures, and, as you can see here in the middle picture, this is a plastic liner between knee joint knee replacement, and it has a symmetric where because this wasn't very well balanced, this patient needed a revision procedure. So aside from balancing which the robot really gives you intra operative feedback in terms of what your gaps are, um, in surgery, and to make sure that everything's balanced. There's also the factor of implants, sizing and position. And as you can see from this photo, um, if you're this, this tibial base plate is overhanging. The bone and millimeters matter here because if it's not flush and contained within the boundaries of the bone, this medal will irritate the tendons that are around the knee joint. And as you can imagine, if someone has a knee replacement put in and they have a piece of metal sticking out and rubbing their answering or I t band, that's gonna be a chronic source of pain for them going forward and another, you know, study out of the UK from Dr Haddad. Really, uh, they looked at the 30 different patients that underwent conventional versus robotic totally Arthur placidity, and they also identified that, uh, robotic totally Arthel classy had reduced inflammatory markers at seven days after surgery, including reduced I'll six too many Croesus factor out. Ah yes, Thorn crp, and I think is this. There was less damage to the soft tissue envelope because there was more accurate placement in the robot allowed for haptic feedback to avoid us venturing into areas outside of the plants. Uh, surgical resection, Um, and they also verified that component positioning and sorry component positioning of the femur and the tibia was much more accurate with robot. So we know that accuracy and precision is improved. But is this correlating to patient reported outcomes? And we could say that at least this year, there is also another study it from the Knee Society that demonstrated the patients that underwent Robotic Total Knee Arthur Classy, as composed as opposed Thio. The conventional manual totally Arthur Plastic had higher outcome scores. Um, this was the robotic outcome scores for the Knee Society, and this was the non robotic outcome scores. And they did find there's a statistically significant difference in this group of approximately 880 patients. Um, so, in summary, hip knee arthritis can come in many forms. Um, it's important to identify inflammatory arthritis these early to initiate medical treatment. The main on operative treatment include weight loss, physical therapy, activity modification, injections and training exercises. Um, surgical advancements have really changed how people are recovering after these types of surgeries and improved their outcomes and the benefits of robotic surgery are becoming more and more apparent. And this includes improved accuracy and precision, decreased likelihood of soft tissue injury and improved early patient reported outcomes. Thank you. Any questions? Uh huh. And we got a little bit of time, so I may just do one last thing here and do what we call myth busting. Um, but common things that patients will ask me or other providers that community will ask me is they'll say, Well, um, I too young or too old for a joint replacement. I would say that age in this day and age is really just the number. What matters more is what your medical problems are. What, your co morbidity czar, because I have patients that are 95 years old but physiologically they're like, 70. And we've done elective joint replacements. And I didn't elect to join placement in 94 year old woman who is as happy as could be with her hip replacement. Um, and what I tell thee, all my patients is, um, the advancements we've made with spinal anesthesia and reduced blood loss. It takes less of a toll on your body to have a hip and knee replacements. So a za, long as you are able to get cardiac clearance and the appropriate medical clearance clearance is there is no age cut off. And given that hip and knee replacement technology has advanced, implants are lasting longer. We're doing surgery and younger and younger patients who have debilitating arthritis patients in their thirties forties fifties that are candidates for joint replacement surgery. And they have great outcomes. Um, certainly, if you're younger, there's a higher likelihood that you may need a revision down the line. But with the advancements in technology, people can still have a good result that last them for decades. Um, and that's the second myth. Here is my hip and knee replacements, states. It'll only last 10 years. I would say that the current data for hip replacement after the, um, you know, invention of highly cross linked polyethylene. We've seen that implants can last up to 20 years with little to no where in clinical data and we have 30 year laboratory data right now, knee replacements, you can get about somewhere changed 15 and 25 years. But a lot of it's dependent on the patient's activity level. Um, if if patients are avoiding running and jumping activities, they're certainly going to avoid a faster where on their joints. Um, myth. The recovery time is too long. I'll be bedridden. This is false. In this day and age, we have patients up and walking 2 to 3 hours after surgery. They become independent quickly. Most patients stay in the hospital one night and go home the next day. And there's plenty of patient surgery, same day surgery for the for the right patient. Um, another myth is I'll be an even more pain after the surgery. I won't be able to get home. This is not true. We have. You are. People do have soreness after surgery, but generally the combination of our multimodal pain regiments to peri articular injections, the Indwelling catheter, the aural pain meds can have people being comfortable doing their exercises and they'll be able to be independent home. Lastly, I'll never recover 100% and I won't be able to do the things I used to dio. So I would say that a fair amount of our patients that have hit the knee replacement will come to us and say, I can't I wish I had it done sooner, especially in hip replacement. The Lancet voted hip replacement the surgery of the century previously, because of how much of a positive impact that could make in a patient's life, how it returned them back to the activities they love and allow them to be a contributing, happy member of society. So certainly, um, there's plenty of myths enjoying replacement. But as technology and surgical techniques advance, I think we're going to continue to see and, UM, further improvements and recovery and outcomes. And I think that Arthur Plastic is a very successful procedure that can really improve people's lives for the better. I barely have one quick question. What are protocols? Replacements with women with you? So that's a really good question. Um, osteoporosis does not change the the ability to have a surgery, but it does increase risk factors for things like Perry. Prosthetic fractures occurring in the bones. I, you know, advise lots of my patients to supplement with vitamin D and calcium. Having osteoporosis in itself is not does not forbid anyone from having a joint replacement surgery if they have arthritis, But it does change some of the surgical techniques that we dio in a hip replacement. For example, if I see the patient has significant osteo paralysis instead of using a traditional, non cemented style of hip replacement, I would opt to do what we call a cemented ah, hip replacement because there's good data to show that a lot of it's from the European literature that cemented hip replacements, have a lower chance of having a fracture around the time of surgery and later down the line and you know it zits something that I think is gaining in popularity. I spent several months working at a hospital in the NHS just outside of London, and cemented Hip Replacement is actually Mawr common in most parts of that country there than it is for UN cemented, even for younger patients. So I think Americans generally, um, do less cemented hip replacement. But if somebody that has osteoporosis, they need to speak with their surgeon about having a cemented type of surgery and certainly avoid things like falls, which can predispose them having something like a fragility fracture during the recovery period. Yeah, awesome. Thank you for giving me the opportunity to speak with you. If you ever need anything, please feel free to reach out to us. Easy number to get a hold of our clinic is 51 to help me.