Joint pain? You are in the right place! w/ Stephen Mendelson, MD

Stephen Mendelson, MD is back talking about joint pain and the innovations like peripheral nerve stimulation (PNS) and robotic-assisted, total joint replacement surgeries. Conservative treatments like PNS can be a drug-free solution to pain. Robots, like the ROSA, have revolutionized total joint replacements, and when used at ambulatory surgery centers, you go home the same day.  We’re talking about everything, head to toe, on this latest podcast episode of Head to Total!

#Knee #hip #roboticreplacement #Stimulator #MD #Doctor #Pain #Joints #Medical #Medicine #podcast #Synergy #podcast #healthcast 

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Transcript

Colleen Young: Hi, welcome everybody, welcome back to Head to Total, the podcast that pulls back the curtain on all things medicine. Everything from the administrative questions that you have to the surgical questions that you have when you see your physician. I'm excited because we've talked Dr. Steve Mendelson back to coming back with us and talking to us about robotic joint replacement, which is something new. It's cutting edge as with everything with Dr. Steve. So welcome back Dr. Steve Mendelson.

Dr. Stephen Mendelson: Thanks for having me.

Colleen Young: One of the things that I have heard about you is that your hip replacement is done robotically, which I think a lot of people don't understand, right? How do you do a robotic hip? What happens there?

Dr. Stephen Mendelson: The goal of a joint replacement is to select the right patient, put the right component in, right implant in, and put it in the right alignment. To do that, we used to use what I would say our standard carpentry jigs, which are very good most of the time. We use alignment rods, we use saws, we use routers, we use reamers, and they would do a wonderful job most of the time. But somewhere between 5 to 10% of the time, we would find that the alignment of our implants wasn't perfect. Bent one way a little bit, bent one way another way a little bit, rotated a little bit. And so in orthopedics, we've been really trying hard to figure out how we can decrease this variation. So along comes the robot, and what we're able to do is either through an MRI or a CAT scan or special kind of techniques, we can input into our computer system the exact dimensions of your knee. And when we go to do our surgery, we place special kinds of trackers on your body, and that allows us and the computer to know exactly where your knee is in space, exactly what angle every part of the knee is at, and we can plan to make cuts that not only are precise but also take into account the unique knee you have.

So everybody's knee sits a little differently. Everybody's knee has a different amount of play, if you will, and the computer, with our simulation, we're able to predict and place where those cuts should be. And how much bone we should take off, how much we should put back in order to get you with a very nicely balanced knee that is right for your body.  Now to execute that, that information goes into a robot. And so while I, the surgeon, am doing the case, I am using the robot to help me make exactly those precisely identical cuts that we wanted with the surgical plant. Now, I have to be there. I would love to be somewhere else, I would love to be in Florida, but I have to be there because it's a tool, and sometimes the tool's perfect, and most times it is, but you need a surgeon there to pick up if there's something a little unusual to help guide it. And the robot, though I will tell you, has been wonderful. If I look at my X-rays now, when I do knee replacements, they're perfect. They're exactly where I wanted them to be. You know, not everyone who has a total knee does well. Some people have problems, some people have pain. And the last thing you want is a surgeon is to say gee, if I had put the knee in just a little straighter, they wouldn't have that pain. 

So if I do one, if I do 10, I know every knee is gonna be where I want it to be and that is wonderful. It is just such a leap forward in the technology of joint replacement. And frankly, we’re learning a lot. We're learning even more every day from our robots about how knees move. Because when we do the operation, the robot helps us capture all of this information about how the knee bent, how it turned, and what components we put in and that's fed into a national database. And so now all over the country we're learning, hey, these are how all these knees were done. And we followed them over time to see which one succeeded, which one didn't and so that's really the proof that we can all learn from.

Colleen Young:  It sounds like the ideal situation is to go from the stimulator as the first step and then eventually, if my bad days outweigh my good days, I come to you and I say hey, let's take the next step. Let's replace a joint and then have that in there for the getting better part, right? I mean that way I'm not taking any Motrin or anything.

Dr. Stephen Mendelson: You're one step ahead of where we are in technology now. I'm still trying to limit the stimulators to people who aren't good candidates for knee replacements. I think that's where we are. I think that's where I'm most comfortable using it, because today, a well-chosen patient who has a well-performed knee replacement, has a very high likelihood of having 20, 25 years worth of, if not pain free, very low pain, significant improvement in their knee. But you take someone who maybe their diabetes isn't controlled, or maybe they have neuropathy, or maybe they have dialysis or maybe they have very strong blood thinners. Now you operate on that person and their risk of complication goes up. So they're not a great candidate, they're the ones for stimulators.

Now I would predict 10 to 20% of my stimulator people will correct some aspect of their risk factor. Maybe they'll have bariatric surgery and fall out of this high morbesity and be able to be within a safe zone to have the knee replacement. Maybe people have had kidney transplants then they become candidates for having standard knee replacements. I think that's where I'm at with it. Now, do I think that the stimulators will change? Will we learn more? It's possible. We may learn that we can do them for people who are bridging, you know, they're not ready for a knee replacement, but they're bridging to that zone. There are techniques where we can put them in for a short period of time, 60, 90 days, and people can have relief. We are exploring that for people who've had fractures, right? If you break a knee and it hurts you, we can put a stimulator that can substantially cut down on that pain for the, let's say, six weeks to six months while you're healing, and then it's removed. These are options we're exploring, but I think a lot of it is we're gonna learn more as we do more of our peripheral nerve stimulators.

Colleen Young: Dr. Steve, the other thing I wanted to ask you about is the expectations when I get a total joint replacement. Whether you do it robotically or what I'll call the old way, right? I think a lot of people think, oh, I'm gonna get a brand new knee. I'm gonna have a whole new life. It's gonna be great. I'm gonna be bionic, I'm gonna run miles. What really are the expectations that I should be going into a total joint surgery with?

Dr. Stephen Mendelson:You know, you break people down into different categories. There are our seniors whose expectation is to walk and to be able to get around walking. And I think for many of those people, it's truly an amazing operation. It is restorative, it's uplifting, it removes the pain, it allows them to forget that they have a knee and that's a wonderful thing. As the younger a person gets and the more athletic they are, the more it can be challenging because their expectation is to be able to run and to run exactly the same as they did before and to have the same endurance is not always matched by a total knee. Some of the restrictions we know such as deep knee bending can be very difficult. So if you're a catcher, if you're a goalie, if you are genuflecting in church, if you're prostrating yourself in the mosque, that can be hard because a total knee doesn't do that so well. So that's some of the expectations we have to manage.

The other part of it is 90 to 95% of people have a total knee and they do wonderfully. They're happy. They may make some activity modifications, right? They may not go run like they used to exactly the same, or they may perhaps not engage in soccer at the same intensity level, but they do well. But there's a subset of people who still have discomfort. And if you have a total knee and you're not doing well, it can be very frustrating. And I learned this because what happens is a person sees their surgeon, they have a total knee, everything looks good on the x-rays. They go seek second opinions from other doctors. Any other doctor is gonna say, well, this looks good or well, it's a millimeter off here and there, but basically it's where it should be and they still have discomfort. That is where I got most interested in trying to solve that problem and that's what led me to stimulators.

I started talking with some people who are in California who were exploring, how do we treat total knee people who still have pain? And they tried bracing or surgeons would say, you know what, we're gonna just revise the whole knee. Oh my God, to have a revision knee is a big deal, especially if you don't have a clear problem. So I said let's try nerve stimulation for this. And lo and behold, I was able to really help people. I mean, people who for years had had pain from their total knee and had gone from doctor to doctor and everyone's saying it looks fine, but they just weren't feeling good. There's something about a subset of people when you cut into them and you do surgery, they heal on the outside, but their nerves remain tingly and uncomfortable, and they can't always put it in words. They'll say things like ah, my knee feels heavy, feels tight. It feels like I just can't move it the way I want. It feels burning. Those are the people that, orthopedics from a mechanical perspective, doesn't have a great solution for. So I said let's look outside that box at an electrical solution. And so that's one of the things I see frequently for stimulators. I have within my group and outside of my group and through the internet, people will come to me because they have a painful need that looks good and they're uncomfortable and they wanna try another option. That's how I got into stimulation.

Colleen Young: So Steve, a little bit more about the process of the neuromodulation, the stimulator, you said that it gets inserted underneath the skin. Nobody will see it, nobody knows I have it, but what's that like for the patient? Are you putting us completely under? How big is the incision? What's that look like?

Dr. Stephen Mendelson: Well we have different patients with different needs. So there are people whom general anesthesia, going to sleep is the right choice. And a person goes to sleep. We place the stimulators through very small straws or cannulas. They're probably about the size of when you get a mixed drink and you have that little straw you stir with, but you can't suck the fluid through. That's the size of the cannula that we percutaneously through a little nick in the skin use to go down to the nerve, and then we slide in the stimulator, that little piece of spaghetti or angel hair through that. We have patients who maybe don't wanna go to sleep, they want to be a little relaxed. We give them sedation, which might be the equivalent of having five or six drinks and you're there, but you're happy. And we use some local anesthetic to numb that area and put in our stimulators. And I have people for whom even sedation is risky and they don't want it. And we will do those completely under a local anesthetic. I will numb the entire field, I will numb the entire area and without any kind of drugs in the system beyond the local anesthetic, I will go ahead and put those little cannulas to the areas I need to and place the stimulators.

Colleen Young: Or am I in a surgery center? Am I in a hospital? Am I in your office? Am I in your living room? Where am I at?

Dr. Stephen Mendelson: We do this typically most of the time in a surgical center. We don't do it in a hospital for a variety of reasons. Certainly hospitals and COVID are a concern. Also, frankly, this is a procedure where the acuity or the intensity of it is much less than an invasive surgery. I haven't had an infection, and that's not to say it can't happen, but very low. The blood loss is essentially zero. The difference between that and maybe a hip replacement where you're having blood loss and other kinds of things, you need to have backups and all kinds of equipment, that's different. But here, no, we do them mostly in the surgery center. There are occasions when we can do them in a procedure room in an office, but that's rare. In the foot, we'll do a little bit more of those. We'll have some people who are really brittle diabetics or have bad COPD, and we can just percutaneously through a little nick in the office, slide in one of the trials. We can also slide in one of the permanent stimulators.

Colleen Young: Dr. Steve, can't thank you enough yet again, another podcast where you have wowed us with all things orthopedics and seriously, total joint replacement with a robotic hip, with a robotic knee, with the robotic shoulder. It's just amazing the recovery time; so much shorter. I can't thank you enough for all the help that you've provided us today.

Dr. Stephen Mendelson: My pleasure.