Are you tired of suffering from hip pain and searching for a solution? We're excited to welcome Dr. Victor Ortiz, a board-certified, fellowship-trained orthopaedic surgeon at the Kayal Orthopaedic Center, to share his expertise on revolutionary advancements in hip replacement surgery. Discover how the cutting-edge Mako robotic arm assisted total hip arthroplasty, and minimally invasive direct anterior total hip replacement techniques are transforming the field and offering life-changing relief for patients.
In our conversation, we unravel the complexities of arthritis, its various types, and the symptoms you should be aware of. Dr. Ortiz will guide us through the critical role that the labrum, joint fluid, and articular cartilage play in hip health, and how these components can be damaged by arthritis. We'll also discuss the importance of consulting an orthopaedic surgeon for any musculoskeletal issues.
Lastly, Dr. Ortiz compares the traditional posterior approach in hip replacement surgery to the minimally invasive anterior approach, which results in less pain and better functional outcomes for patients. Learn about the crucial role of the MAKO robotic system in ensuring proper implant positioning and sizing, as well as its impact on procedure efficiency and patient outcomes. Don't miss out on this fascinating exploration of the future of hip replacement surgery with Dr. Victor Ortiz.
Are you tired of suffering from hip pain and searching for a solution? We're excited to welcome Dr. Victor Ortiz, a board-certified, fellowship-trained orthopaedic surgeon at the Kayal Orthopaedic Center, to share his expertise on revolutionary advancements in hip replacement surgery. Discover how the cutting-edge Mako robotic arm assisted total hip arthroplasty, and minimally invasive direct anterior total hip replacement techniques are transforming the field and offering life-changing relief for patients.
In our conversation, we unravel the complexities of arthritis, its various types, and the symptoms you should be aware of. Dr. Ortiz will guide us through the critical role that the labrum, joint fluid, and articular cartilage play in hip health, and how these components can be damaged by arthritis. We'll also discuss the importance of consulting an orthopaedic surgeon for any musculoskeletal issues.
Lastly, Dr. Ortiz compares the traditional posterior approach in hip replacement surgery to the minimally invasive anterior approach, which results in less pain and better functional outcomes for patients. Learn about the crucial role of the MAKO robotic system in ensuring proper implant positioning and sizing, as well as its impact on procedure efficiency and patient outcomes. Don't miss out on this fascinating exploration of the future of hip replacement surgery with Dr. Victor Ortiz.
Hello and welcome to another edition of the Kale Ortho podcast. Today is June 22nd 2023, and I'm very privileged to have our very own Dr Victor Ortiz with us today. Dr Victor Ortiz is a board certified, fellowship trained orthopedic surgeon at the Kale Orthopedic Center. Dr Ortiz has completed two fellowships one in the area of sports medicine and arthroscopy and the second in the area of hip preservation. His focus is going to be all about how Dr Ortiz introduced two cutting edge technologies to the Kale Orthopedic Center in the field of hip replacement surgery. The first is the introduction of the Mako robotic arm assisted total hip arthroplasty and the second is the introduction of the minimally invasive direct anterior total hip replacement through the front in a very minimally invasive manner. So we're so honored, privileged and pleased to have Dr Victor Ortiz with us today. Welcome to the podcast, dr Ortiz.
Victor Ortiz, MD:Thank you so much, Dr Kale, for having me today and look forward to discussing hip replacement and robotic surgery So happy to have you.
Robert A. Kayal, MD, FAAOS:So before we get started, why don't you just tell the audience a little bit about yourself?
Victor Ortiz, MD:Dr Ortiz. So I grew up in Puerto Rico, born and raised. I came back to the States approximately seven years ago with the whole family. We were probably never looking to do the move, but luckily we came to New York. My wife is also a healthcare provider So while she was doing her training I was practicing in another New York City And so far we love everything. We've been a very happy adaptation to the whole family and we're excited about it.
Robert A. Kayal, MD, FAAOS:And we're very excited to have you. It's also a little bit about your professional education as well.
Victor Ortiz, MD:So I did my medical school in the School of Medicine in Balamond, puerto Rico. After I finished my medical school, i went on to orthopedic surgery and I did my residency in orthopedic surgery in the University of Puerto Rico Medical Science Campus. After I was done with residency, my next goal was to do a sub-specialty in sports medicine And I went to Chicago. I did the University of Illinois, chicago, where I trained in sports medicine mainly arthroscopic procedures of the shoulder and knee During my fellowship. I always had an interest in doing hypertroscopy. So I met one of my mentors at that time and he invited me to join his fellowship called the American Hip Institute in hip preservation surgery And during that year I was really able to focus on two main things that I really want was the hypertroscopic procedure, but also the direct anterior approach.
Victor Ortiz, MD:So I did a second year in Chicago doing these two outstanding procedures that I think have really changed my practice. Also, it is interesting because during training during residency, i always said that I would never do hip replacement And now it's part of my practice is what really has allowed me to build up a practice and reputation in the area. But the long story short, during my fellowship in sports medicine, i said I really want to improve my skills in hypertroscopy. So when I decided to do the second fellowship, the downside for me at the time was well, you have to learn anterior approach and robotic surgery. So I said, okay, let's do it. Long story short, i went in there. I love the approach, i love the outcomes of the patients and now it is probably the majority of my practice And I'm passionate about it. I love the direct anterior approach, the robotic surgery. I do everything that way. I don't have the robot under the surgery And it's been really a game changer for my career.
Robert A. Kayal, MD, FAAOS:Wow, dr Ortiz and I have been great friends and colleagues for many years now, and this is the first time I'm actually hearing that story, so that's something I didn't know about you, dr Ortiz.
Robert A. Kayal, MD, FAAOS:It's very interesting.
Robert A. Kayal, MD, FAAOS:Well, thank God, you did receive that training from one of the finest institutions, not only in the United States of America but in the world. That fellowship is very much considered a thought leader in this area of hip replacement and hip preservation technology, and we're just so privileged that you learned from a master surgeon and were able to bring that technology to Northern New Jersey and the tri-state area and introduce it for our patients and our community to benefit from. You certainly have become, and are now, a master surgeon in the area of hip arthroscopy and hip replacement surgeries, so we're very fortunate to have that technology, especially with us at the Kaila Orthopedic Center because of Dr Ortiz. Before we continue our discussion regarding what that technology is and why it's so beneficial to our patients, i think we need to start with the basics, the fundamentals, and let's just even talk about arthritis. What is arthritis? What types of arthritis exist and why do they exist and how do they present? What are the symptoms that are associated with arthritis, and which types of patients would ultimately benefit from your expertise?
Victor Ortiz, MD:So I think there are multiple types of arthritis that affect the hip. I always think that when I explain to the patients, the common denominator here is that the patients are losing a cartilage in the joint. It's like the wear and tear, the bone and bone, and it can happen in different ways or modalities. The one that we know, the wear and tear of the hip, or osteoarthritis, is the most common one, the one that a lot of the patients have And they present with this bone and bone disease, stiffness, difficulty, like pain along the groin, difficulty getting in and out of the car, really difficulty with prolonged walking and affecting really their daily life activities It's hard to put your socks and shoes and it's really hard to do the things that they enjoy, like playing golf, playing tennis So simple things that the elderly population want to enjoy is being really affected.
Victor Ortiz, MD:There are other types of arthritis and, for example, inflammatory arthritis that can see in patients with chronic autoimmune disease, like rheumatoid arthritis, like lupus, for example, where the immune system creates a response against the hip joint, causing the same wear and tear.
Victor Ortiz, MD:There's another arthritis, like post-traumatic patients that have car accidents, where they have acetabular fractures or fractures in the socket. They can have fractures in the femoral head that can lead to a bands or progressive wear of the joint, where they subsequently need a procedure. There's also infectious process or septic arthritis, where an infection creates inflammation of the hip joint, causing the same common denominator of wear and tear And, interesting, with the septic arthritis you can see the damage as soon as eight hours after the infectious process. So we in orthopedic surgery are very aggressive in treating them because we know the sequala and what can happen in patients with possible infections. There's also osteonecrosis or abascular necrosis, where there's a blood supply insult to the hip joint. Where the patient develops lots of blood supply or circulation to the femoral head, they develop necrotic bone and subsequently end up with having wear of the joint that might need surgical intervention.
Robert A. Kayal, MD, FAAOS:Yeah, so you mentioned. We've mentioned the term arthritis right. So to break that down for our viewing audience, arthro means joint and itis means inflammation. We've talked in the past that inflammation can be associated with redness, warmth, swelling and pain, and then arthro represents the fact that the joint is involved. So arthritis is inflammation of the joint, so you can get redness, warmth, swelling and pain in that joint, as Dr Ortiz alluded to.
Robert A. Kayal, MD, FAAOS:That arthritis, or inflammation and pain, is associated witha destruction of the joint for a whole myriad of different reasons. The most common, he said, was the typical wear and tear, degenerative osteoarthritis. But there are other types, all of which can definitely benefit from treatment, ultimately, with Dr Ortiz, with a hip replacement. The worst of those that was described was the septic arthritis, because that's where you have an infection in a joint And certainly that becomes very, very complicated because you'd never really want to put an implant in the presence of infection. But for the most part, all the others osteoarthritis, inflammatory arthritis, avascular necrosis those would benefit tremendously ultimately from a hip replacement.
Robert A. Kayal, MD, FAAOS:So we talked about some of the definition of arthritis and some of the classic presentation symptoms groin pain, difficulty getting in and out of cars, difficulty putting on socks and shoes, restricted range of motion and a limp. But there are changes going on inside the joint that are very characteristic of that arthritis. Dr Ortiz mentioned essentially bone on bone, wear and tear of the cartilage. There's other changes, right, dr Ortiz, going on with respect to possibly the labrum, the fibrocartilaginous labrum, and also the fluid inside the joint as well. But before you even answer that question, just for our viewing audience, what are the different types of joints Like? what kind of joint is a hip joint as compared to, say, a knee joint?
Victor Ortiz, MD:So the hip joint is a ball and socket joint similar to the shoulder compared to the hinge joint of the knee, so every joint is made different and has special roles. I think when we have a ball and socket joint there are multiple things. I think for me the most important one is that the hip joint is a joint that is made ball and socket with the extension of the labrum. So the labrum is an extension of the socket, creates a suction seal mechanism to first provide stability but also allow the function or mechanics of the hip to function correctly, you know, to be able to you have adequate mobility, that the properties of the synovial fluid, of the cartilage are protected to decrease the inflammation, because at the end of the day, inflammation is what causes pain and is what causes the damage. So our goal really with the treatment of are any type of arthritis is really to bring that inflammation down, to decrease the chances of having subsequent or more damage in the hip joint right.
Robert A. Kayal, MD, FAAOS:Yeah, it's interesting you mentioned the labrum and, by the way, we will allude to the labrum in the future. Doctor Ortiz, as I mentioned, is a master Hip arthroscopist as well as a hip replacement surgeon. In a subsequent podcast we will be interviewing doctor Ortiz on the subject of hip preservation, where he addresses labral tears. So stay tuned for that. But with respect to the hip arthritis and the role of the labrum and the joint fluid, what we call the synovial fluid in the joint, i often give the patients the analogy of a gasket on a car engine. Right, because we have a car engine, we have the cylinders, we have the pistons going up and down and the most important thing in there is the oil, the engine oil that's lubricating that mechanical construct. Right, if there's a gasket leak and that fluid can leak out the oil, can you can you can freeze up a piston in a cylinder and it can jam and cause engine failure. The same analogy I give when I'm talking about labral tears and referring patients to you for that. When There's a labral tear in, that fluid can see about and you lose those mechanical properties inside that ball and socket joint, that seal from that labrum that helps to keep that fluid in there and provide those mechanical properties. But again, we're digressing a little bit because it's also very, very important in the area of hip preservation Where we're actually referring patients to doctor or a tease to fix and repair the labrum so ultimately they hopefully do not end up needing a hip replacement.
Robert A. Kayal, MD, FAAOS:So that's, that's another podcast, but for now I think it's important to just understand the anatomy, the fact that the hip is a ball and socket joint. You have this big round ball sitting inside a big bony cup and around that cup is a labrum, a fibro cartilage labrum that basically seals that joint, that construct to allow that fluid, the synovial fluid inside the joint, to stay inside the joint, just like that car engine gasket we talked about, to provide those mechanical properties to that ball and socket joint so that the patients like doctor or T said, less inflammation. So now you understand the function of that fibro cartilaginous ring of tissue that seal. Are there other anatomical structures that come into play in a healthy, non arthritic hip joint? Vic, Absolutely.
Victor Ortiz, MD:I think one of the most besides the label and the most one of the most important structures is the articular cartilage, and we know that our ticket or cartilage in every joint is a little bit more smooth than the label is a collagen type two And it really gives some of the properties of the joint, like load bearing, and when we start losing that, that's when we as you mentioned before with the gasket and it, that's when we develop problems and that's when you know about inflammation And pain right.
Robert A. Kayal, MD, FAAOS:So what? what you're essentially saying is that this articular cartilage is essentially different from the cartilage in the labrum right, the labrum There's. There's something called collagen that we have in our body in different areas, but in orthopedics is relevant primarily in the area of bone and cartilage. Okay, in bone that's type one collagen, but in the meniscus and in the labrum and in the inter vertebral disc of the spine that's also type one collagen, but in the healthy joint there's a different type of collagen in what we call the articular cartilage, the cartilage that is essentially stuck to the end of the bone. So if you have a hinge knee joint of the knee, that type two collagen makes up articular cartilage, the cushion on the spine, and the same thing applies in the hip to right in the ball and socket joint you have that type two collagen, highland articular cartilage on the end of the bone, different from the cartilage That's in the labrum right.
Robert A. Kayal, MD, FAAOS:So you're saying that with arthritis that can wear down, correct and become thin, very thin, to the point where sometimes bone can be exposed right and that knee Normal smooth surface is now sort of eroded and it's not smooth anymore. It's bumpy like potholes in a road right. And then what about the joint fluid, the synovial fluid inside a bone socket joint? we talked about the labrum that contains it, but what about the fluid itself? So the synovial fluid provides lubrication to the joint, helps in the low distribution.
Victor Ortiz, MD:Has a good amount of proteins that, when we have our triad, is the, for example. The high loronic acid gets diluted. So those properties are not the same. Right and all that, it contributes to the whole spectrum of hip pain. Right, it's a whole downward spiral.
Robert A. Kayal, MD, FAAOS:You're wearing the articular cartilage, you're tearing the labrum and now the synovial fluid is markedly diluted over the entire spine Right, and that's why the the FDA has approved some what we call intraarticular injections of high loronic acid. But it's only FDA approved for the knee, where we can inject these products, such as sin visc and ortho visc and others, into the joint to try to restore the normal concentration of high loronic acid into the joint. Unfortunately it's not FDA approved yet for the hip, but maybe someday. Thank you so much, doctor Ortiz, for that very elaborate and and thorough explanation about arthritis. How does arthritis typically present? besides the pains you're talking about, are there other symptoms that are commonly associated with arthritis?
Victor Ortiz, MD:I think the main comment besides pain, which absolutely is one of the first signs that patients feel limitation in range of motion. So patients feel stiff, they feel that they are limping, that they need to use a cane to move around because they cannot really stand on that feed, and then there's difficulties in their activities of daily life. Right, the most common one is like this is I want to go to New York City, i want to couple walk for a couple blocks and I have to stop every block because I don't feel comfortable. And that's usually the. What brings into the office is because they are really trying to do things that they enjoy and they're not able to.
Victor Ortiz, MD:And another thing for example, if we go to sports and we know a lot of our patients, you know they like to play golf, they like to play pickleball which is the new thing out there And they have limitations and they say, like I cannot perform, you know I get pain during the, during playing. At the end I'm miserable for a couple days. So those are usually the type of signs or symptoms that patients are feeling them. Bring them to our practice to look for care.
Robert A. Kayal, MD, FAAOS:Right And I noticed over the years that it's often the family members that finally get them to come in right. They're sick of them seeing them limp like this and not participate in family events And they really strongly encourage them to just get it taken care of so they can restore their quality of life. So thank God for those family members, because a lot of times patients just opt to live with things and or don't even know that options exist that we can actually get them out of that pain and restore that quality of life. And that's one of the reasons for this podcast to try to educate our community of patients that you don't have to live like this anymore. There's a lot of things that can be done to help you, which we'll get to in a minute. But besides the pain loss of motion, stiffness, instability sometimes their joints can buckle and give way Besides that, do they sometimes have pain in other areas and not the hip, even though it might be coming from?
Victor Ortiz, MD:the hip Right. There are two main places when I look at that. I think the first one will be the knee And we have had a good amount of patients that they just come to the office with knee pain. You look at the x-ray everything looks perfect In the knee, the x-ray looks perfect In the knee.
Robert A. Kayal, MD, FAAOS:it's perfect.
Victor Ortiz, MD:You do an examination, it feels pretty good And then you start feeling the hip. If the hip feels stiff, and then you get x-rays and out of the blue it's bone on bone And it's not uncommon to see that that you have radiating pain. I think one of the reasons being is that there's a small nerve under the hip joint that can get irritated and cause pain going down the knee, but it's really coming from the hip joint.
Robert A. Kayal, MD, FAAOS:I think that other one it's very common, By the way, not to interrupt you, but on that note I mean sometimes it's hard to convince patients that the problem is the hip. Not that we get in arguments with our patients, but sometimes they don't believe us. They say there's nothing wrong with my hip, My pain is in the knee, And that is often sometimes the only presentation Because the patient's having pain in the knee. We evaluate the knee, We take the patient's word for it, We get an x-ray of the knee but there's nothing wrong with the knee And the only thing sometimes that is wrong is the hip, And I've done many hip replacements over the years for a chief complaint of knee pain. It's interesting Ultimately the patients concede because they understand we're the experts in that regard But it is hard for them to believe that the problem is stemming from the hip and not the knee And where else.
Victor Ortiz, MD:And I think the other one which would be one of the most commonly missed is when something that I described to the patients as a hip spine syndrome, where patients are constantly told the pain is from the back, we can do anything else, and a lot of times patients with hip pathology can present with posterior hip pain. It gets confused. It might take two or three office visits for them to well. the problem is the hip.
Robert A. Kayal, MD, FAAOS:When he says post-do your hip pain he's talking about in the butt. Is that the head In the buttocks, like where possibly sciatica may present?
Victor Ortiz, MD:And usually they'll go to the primary care doctor, they'll go to the chiropractor or physical therapist and they're told well, is the back, is the back? keep working the back and out of the blue, same as the knee, you start looking at the hip. you maybe sometimes do an injection and they are whoa like everything changed.
Robert A. Kayal, MD, FAAOS:We see that all the time. We see it all the time And it's important that patients see an expert and get a physical examination by an expert orthopedic surgeon with a tremendous amount of experience, because we tend not to have tunnel vision When we listen to our patients. We know the potential etiologies of pain in certain areas. Oftentimes patients don't understand that the hip to the orthopedic surgeon is not the outside of the hip, it's the groin. So the hip joint for the orthopedic surgeon is the groin. There can be pain, like Dr Ortiz is describing, in the area of the buttocks. That's still the hip, but usually pain in the buttocks is coming from the back. Pain on the outside of the hip is coming typically from soft tissues around the hip joint but not the hip joint itself. But pain in the hip and pain in the groin can very often be stemming from the hip joint itself. Now that we've described hip arthritis and we've described the symptoms that are often associated with hip arthritis, does everyone with hip arthritis get a hip replacement?
Victor Ortiz, MD:No? I think that the answer is no. I think that is a very common thing for patients to come to or not want to come to the orthopedic surgeon because, as the word says, it's a surgeon and they don't want to have surgery. But I think that the first line of treatment and for almost every orthopedic problem, is a conservative approach And we do that with our patients. We try two or three months of conservative treatment, which includes a gamma of treatment that includes diet and exercising good weight in our patients, physical therapy, where there's 70 muscles going around the hip joint. So if we work around those muscles the load to the hip joint can be less and the patients can have a significant amount of relief.
Victor Ortiz, MD:We try anti-inflammatory medications, sometimes combined with pain medication, and sometimes it's being shown that cortisol injections as a short-term pain relief can provide significant relief. And one of the things how I incorporate these injections in my practice is that when the patient comes to the office, when they decide to come, they're in pain, they need something, and that's where that injection really plays an important role brings the inflammation down, allows our therapies to work with the patient in a better way. Sometimes these patients will go through physical therapy, they'll flex the hip and they're not able to finish the session. The cortisol injection allows them to do that, allows them to be comfortable, allow the therapies to really do a better work and they come back after six 12 weeks and they have significant improvement of symptoms.
Robert A. Kayal, MD, FAAOS:Just to elaborate on what you were just discussing, vic. There is a common misconception that, just because patients are coming to an orthopedic surgeon, that that's all we do. Like you only come to us when you need surgery. Nothing could really be further from the truth. Right? If we see a hundred patients, we'll probably end up just scheduling five of those patients, right? Most of those patients are being seen for physical therapy prescriptions. We just do a physical exam. They might need a cortisone injection, they might need an X-ray and told nothing's wrong.
Robert A. Kayal, MD, FAAOS:Most of what we do is primary care and non-operative orthopedics, right, so you don't have to be scared to see us. Okay, don't be scared to get assessed by an orthopedic surgeon, because I've always and I say this during every podcast for the most part, most of what we do is non-operative. We should be your first call when you have anything wrong with your musculoskeletal system, because you're being evaluated by an expert in the field of orthopedic surgery, where we can assess and do a physical examination. We can interpret x-rays and MRIs and cat scans. We can write prescriptions for medications, anti-inflammatories, give trigger point injections to help alleviate some of your pain. Order physical therapy, chiropractic, acupuncture, massage therapy. Again, most of what we do is not operative, so you should really rely on us to help quarterback your care and then ultimately, if you do need surgery, we can do that too, but most of what we do is not operative, so I did want to drive that point home.
Robert A. Kayal, MD, FAAOS:Also, you mentioned that you offer it Cortisone injections. Right, and that dovetails off the fact that osteoarthritis is associated with inflammation of the joint and there's no better or more potent anti-inflammatory than what we call an intraarticular injection of a corticosteroid. You know, arthritis, inflammation of the joint, inflammation is associated with redness, warmth, swelling and pain, and when we give you a cortisone injection, it very often alleviates that. For instance, what's been your experience when a patient is coming in To the office in severe pain with a horrific limp and you lie him down on the fluoroscopy table in our procedure room and give him a cortisone injection into the joint? what's been your experience immediately thereafter?
Victor Ortiz, MD:So you know I think that we also put some light of hand in there that usually a lot of times when you put the needle in you get some fluid out, so that fluid immediately decreases the pressure of the joint. So they feel sometimes immediate relief. And then when the joint is numb, it's like when you go to the dentist right, you know the joint, they're like, wow, my hip feels great. And when they come for follow up, you know the amount of relief that these patients get, how happy they are.
Robert A. Kayal, MD, FAAOS:It's unbelievable yeah, i can't tell you how many patients have gotten off that table just gave me a huge hug and thank me. I don't think there's anything that's more rewarding than that injection. When patients are limping and suffering in pain and you give them that injection, they're just so thrilled and after I experienced that with them I say guess what? that's exactly how you're going to feel after Dr Ortiz does your hip replacement. I always tell patients that of all the conditions we treat in the field of orthopedic surgery, i don't think there's any operation or any disease entity that does better postoperatively then hip replacement surgery. It is probably the most rewarding operation. We do that, and probably carpal tunnel release as well. They're just incredibly, incredibly successful operations. So now that we've spent a lot of time talking about all of this, let's get to the focus of the of the podcast, and that is the fact that you brought to the patients of the tri state area here this incredible technology to incredible technology simultaneously, and those are, just to reiterate, the Mako robotic arm assisted total hip arthroplasty combined with the minimally invasive direct anterior approach. There were some surgeons that were doing the direct anterior approach. There were some surgeons that did robotic surgery, but Dr Ortiz, really pioneered these two cutting edge technologies simultaneously in our area and has done hundreds of different types of surgeries And hundreds and hundreds, if not thousands, of these operations over the past few years. Just a master surgeon.
Robert A. Kayal, MD, FAAOS:So let's, let's talk about one at a time. Ok, so the let's first talk about the technology of the Mako robotic arm assisted total hip replacement. Just what is that? First of all, even before we get there, what is a hip replacement? Can you compare and contrast for us the difference between the traditional posterior approach that everyone's familiar with, and compare and contrast that with this new technology that you are bringing to the table, that you've brought to the table, you know, about five years ago now, in the area of hip replacement surgery? that pertains to the minimally invasive, direct anterior approach.
Victor Ortiz, MD:So the conventional approach, which is the posterior approach with, as you mentioned, has been, has been a very successful procedure in the surgery and is the most of the surgeons in the country performs that approach. But I think that we always never satisfied. We're never satisfied in orthopedics, we always want to see how we can make a great procedure even better And I think that's where the approach, with the direct anterior approach, we have been able to achieve that. When we do the posterior approach The main you know, to get into the hip joint we have to cut through normal anatomy So that a lot of the times translates to having either either temporary or permanent limitations or restrictions where patients are not really able to flex the hip too much to cross their legs. They have to sleep with a pillow between the legs, they might need a bathroom mold or, you know, they spend some time to recovery. The functional recovery is a little bit longer in the acute phase. When we do the anterior approach, the biggest benefit of the approach is a minimally invasive technique where instead of having to detach normal anatomy, we go between the muscles, so we go into front of the hip, you separate the muscles and right there you're in the hip joint. I always tell the patients you know the biggest difference when we look at the ball and socket and we'll do it later with the model The hip, the socket is always looking to the front of the patient. So when you go to a house you want to knock the door to the front, not to the back. It's harder to get in. So when we do the anterior approach we separate the muscles, open the joint and we can see the socket in front of us.
Victor Ortiz, MD:I think if you make a pole, a lot of the orthopedic surgeons would say I would never do a replacement because I'm not comfortable doing the socket. And I can tell you, with the anterior approach the socket becomes the easy part of the procedure And I think those are the biggest difference between approach. I think we look at evidence based medicine. It's been clear that in the first three months in that acute recovery that the patients remember forever, the pain is less and the functional outcomes the functionality of the patients is is much better And I have had a lot of patients that I do their their hips when they had the other side done through a posterior approach And they always say it's a night and day experience.
Victor Ortiz, MD:If I knew about this. I will only do it through the anterior approach And I think it's really been a game changer for my practice as being a game changer for the patients, it is allowing patients to be more comfortable doing our patient total joint replacement, which is the future of medicine and orthopedics And, you know, i think that is the way to go. Yeah, definitely, we've seen it in in our practice.
Robert A. Kayal, MD, FAAOS:It's really revolutionized the way that we do hip replacements in our practice and the outcomes. Like you said, our night and day. Patients have been able to compare and contrast with the patient. Patients have been able to compare and contrast posterior approaches to anterior approaches and it's it's much more rewarding early on, especially Through that posterior approach. You know you can do that in a minimally invasive manner. But it does not change the fact. Even if the incision is small, it does not change the fact that surgeons are taking down important tendons and structures, detaching them in order to gain exposure and then reattaching them at the end to provide stability. So that is really a major concern. The sciatic nerve is right there as well. There's a concern, patient. There's a concern possibly about causing some iatrogenic injury potentially to that sciatic nerve. There have been patients in the literature that have woken up with foot drops because of injury to that sciatic nerve through the posterior approach. Clearly there's a higher dislocation rate because you're taking down those soft tissues and that's a problem. And so now that can, for the most part, all be avoided through this minimally invasive, direct anterior approach.
Robert A. Kayal, MD, FAAOS:This minimally invasive, direct anterior approach is often done through an incision. How big? would you say this, this, yeah, about that, about this big? I mean to do the operation routinely. This has allowed us to, for the most part, really pioneer outpatient hip replacement surgery in the area. You know these are routinely done as an outpatient. Patients are now walking the same day on this hip and home in the comfort of their home Within, often four hours after surgery. So much less pain, much less invasive. Essentially, you don't even restrict the patients after surgery at all.
Robert A. Kayal, MD, FAAOS:Right, with the posterior approach, our training is that some surgeons say for six weeks you can't cross your legs, you can't sit, bend your hip more than 90 degrees, you can't internally rotate your leg more than 20 degrees For six weeks. Some people say for life. With the direct anterior approach, there's no restrictions. You know, after the posterior surgery, patients would always get either a neomobilizer or that big blue foam pillow between their legs And they're sitting like this or trying to, you know, go to sleep like this and with this big foam pillow between their legs. For six weeks you don't have that at all. Right, you don't use the pillow, you don't restrict them from sitting in a sofa, sitting on a soft sofa or a toilet seat. You don't make them use a elevated toilet seat. Nothing like that, right? Nothing like that. Those are the beautiful advantages of this minimally invasive approach, but it doesn't stop there, right? You didn't just introduce this minimally invasive, direct anterior approach. You combine that with the second technology, and what is that?
Victor Ortiz, MD:So that we combine the direct anterior approach with the medical robotic guidance, and that's been amazing. I think that right now, as I mentioned initially, if I don't have the robot, i'm not doing the surgery, and that's how confident I feel that the robot is a compliment to what we're doing. And the biggest things that we get with the robot is two things. I think that we do a CT scan on the patient before the procedure. That allows us to customize the implants. We can design the implants to every patient's need.
Robert A. Kayal, MD, FAAOS:And let me make something clear. Dr Ortiz mentioned he's not doing the operation if he doesn't have the robot, not because he can't do it without the robot, but because he relies on the accuracy and precision of the robot. You see, he's designed these hip replacements on a computer before surgery And the robot ensures that he doesn't inadvertently deviate from that preoperative design. So, for instance, if he inadvertently were to angle his arm or his hand one way or the other, the robot would shut off and not allow him to proceed. Because the robot ensures the precision of installation of the hip replacement to be consistent with his preoperative design on the computer and on the proprietary software program.
Victor Ortiz, MD:So before we start the procedure, we have the computer and we design the implants the way we want it to have a right tension, the right sizing of the implants. So once we go into the procedure we can reproduce that to the patient's anatomy. And this is, for example, an example of the socket. So if we look at this, this will be the cop. So after we prepare the area where we rim the whatever is left of cartilage, we have adequate bleeding bone because these implants grow into the bone, grows into the implant. That's part of what we call in growth, bone in growth, which is an important characteristic of this implants to incorporate into the hip replacement. So what that means is that the bone grows into the implant to avoid any movement or loosening of these devices. So that when I'm looking at the cop and when I'm looking at the CT scan from a three-dimension standpoint, we wanna make sure that the cop is exactly flush And you can see how there's no prominence, the cop is not too deep, that we don't remove too much bone, that it's not a cop that is too small. Those are things that are very important. Sometimes we look at cop started too big And when we have a cop that is too big, that creates problem in the soft tissues around. We don't want any soft tissue to be irritated because we have a prominent cop. Then when we have cops that are not in the right position, we make patients.
Victor Ortiz, MD:Patients can be prone to dislocation, as we mentioned initially, but also when the distribution of load in the hip is not even my belief is that we're gonna load over one area of the implant more and that implant will wear faster. So robotic has allowed us to put this implant where the patient needs And we incorporate the balance of the spine, we incorporate the rotation of different bones to make sure that the patient doesn't have impingement that doesn't dislocate, to get the patient a hip that resembles the native hip. And one of the things that I like to tell the patients is my goal with this procedure, with the direct anterior approach, with the robotic surgery, is that three to six months later you forget that you have a replacement, that you think this is my normal hip. So the MAKO robot has really allowed us to work with the socket to make this procedure that doesn't have that. The patients resemble itself So and then we go ahead and we do the stem.
Robert A. Kayal, MD, FAAOS:So essentially what you're saying you're installing that cup perfectly each and every time. You're trying to restore the normal anatomy of the patient. So if the cup is too big, it can result in some impingement of some soft tissues and some pain. If it's improperly positioned in a certain plane, it can result in instability as well. And so that's where the benefit of the robot comes in, where you design the precise placement on the computer and then the robot ensures that you put it in exactly that way, so it's perfectly sized, positioned and aligned each and every time.
Victor Ortiz, MD:Correct. so I think that the first important interoperative role of the robot As it pertains to the cup.
Robert A. Kayal, MD, FAAOS:As you mentioned, many orthopedic surgeons in this country will not even attempt hip replacement for fear of the acetabulum, right? I don't. I wanna make sure we emphasize that point, because with this minimally invasive, direct anterior approach, you're staring right at that acetabulum so you can see it so perfectly, and then now with the robot, the robot will put in that cup exactly in the right position and angulation that you designed on the computer. So it essentially eliminates that fear of taking on the acetabulum right. It's ensuring that it's perfect each and every time, and that has traditionally been the most challenging part of this operation that has typically dissuaded so many orthopedic surgeons from even doing hip replacements. And let me just drive home one other point, and that is that Dr Ortiz is doing the surgery. It's not the robot doing the surgery. The robot just ensures that he does the surgery exactly the way he designed the surgery, and if he doesn't, for whatever reason, it just shuts off, it stops. And so one of the other advantages of using this robot as a pertain to the acetabulum is that it becomes a much more efficient surgery, right? You're doing the surgery more rapidly, and that's important to get patients off the table, right?
Robert A. Kayal, MD, FAAOS:Traditionally we used to prepare the acetabulum in a sequential manner. If we were reaming, to say, a size 52 cup, we would maybe start at a 48 and then go to a 50 and then go to a 51, and then you know gradually. This is a one-time ream for the most part, right? The robot knows exactly the angle, the depth, and it's a one-time shot and it makes it perfect every time. So the robot comes in, dr Ortiz is guiding the robot, he sets the angle for that robot to ream and the size It's a one-stop shop And then boom, you put the cup in, you're done And you're moving on now to the stem. Right, correct? So let's talk about the stem.
Victor Ortiz, MD:And then we will do the stem in a traditional manual way. So we have a. This is a sample of the stem. This is a titanium stem with a ceramic head. So what we do is that we first prepare the canal to the size of the patient. That was already planned with the CT scan And then we impact the implant. And same way as there's bone ingruth in the acetabulum or the socket, there's bone ingruth in the femur. The bone will grow into the implant and will become part of it. So once we have the right stem that we need, we go ahead and we do something we call trialing. And when we're trialing, we are making sure that we have a balanced hip. And that's where the second function of the robot comes into play. As I mentioned, we want to recreate this hip to be as the hip, the native hip, the hip that you have before. That was functional.
Robert A. Kayal, MD, FAAOS:So And we talk about offset and leg length, right, right.
Victor Ortiz, MD:So that's where we put the joint together.
Victor Ortiz, MD:And when we have the joint together, we can look at the robot and we can make sure four important things And then it's gonna be that the leg is not too long or too short And that the tension in the gluteus or the AB doctors or the muscles in the side is adequate, that they are not too tight, that they are not too loose. So those are the things that really allows the patients to feel better when you have the right tension and the right length And it's a hip that is stable. We test the hip in different range of motion modalities and the hip stays in the socket. That's when this not too tight, when it's not too short. Those are the most common complaints of patients When they have trouble my leg is too long, i feel so tight. And those are the things that the Mako has really allow us to perfection. It Just the bouncing of the soft tissues around the hip that are very important, and not only in the acute process, in the acute rehab of patients, but along the road.
Robert A. Kayal, MD, FAAOS:Maybe even more important, right It's. You know we say with knee replacements it's a soft tissue operation And same thing with hip replacements. It's so important The soft tissues have to feel good. Right, it's one thing to resurface or replace a joint, but it's the soft tissues that have to feel good and have to provide stability and proper stability. Right, if the soft tissue envelope is too lax, you might have an unstable hip. If it's too tight, you might have a long leg length inequality or a painful hip because the soft tissues are just too stretched and too tight or limited motion. So both hip replacement, knee replacement and you can probably extrapolate to shoulders and ankles they're soft tissue operations And that's where this incredible software technology allows us to tension the soft tissue envelope, with me for knees and with you for hips, to make it perfect.
Robert A. Kayal, MD, FAAOS:So not only are we putting in implants perfectly, perfectly aligned, sized, positioned, but now the soft tissues are also happy. You know, i'm sure you can elaborate on patients that you've seen over the years where the doctor might have done a beautiful job on X-ray. Right, the X-ray looks perfect. We're looking at an X-ray doctor's telling the patient I don't see anything wrong, it's perfect. Just take some more Advil and do physical therapy, but really the soft tissues are not properly tensioned in one capacity or another. Same thing with knees Like the X-ray could be perfect but the knee might not be balanced and the knee might be tight or stiff or unstable. The soft tissues are very, very, very important And unless you're a high volume surgeon, you may not know how to handle the soft tissues as well as the high volume surgeons, right?
Robert A. Kayal, MD, FAAOS:The literature is clear on that. The American Academy of Orthopedic Surgeons makes it clear that high volume surgeons have the best outcomes. So you really want to go to a surgeon that's highly skilled, trained and experienced in his or her area of expertise, because you know it's just like any other thing, right? You want a good plumber, you want to get electrician, you want a good, you know, you name it profession. You know High volume surgeons really have the best outcomes. We've seen it all, we've handled it all and I think that's just important for our viewing audience to know and appreciate. And there's never anything wrong with getting a second opinion, because it's very important that you know what's out there and to get the latest and greatest technologies. And that's really what we pride ourselves on at our practice right. We're always trying to offer our patients the latest and greatest technologies in the area, and I think that's important to emphasize.
Victor Ortiz, MD:And what I was preparing for. Today. I was reading about a study from Cleveland Clinic and they were saying that by 2030, they were expecting, they were projecting that 60% of the patients will be having robotic-assistant hip replacements. I think that is something that we have brought to the practice, where almost I do 100% of them.
Robert A. Kayal, MD, FAAOS:So, Dr Ortiz, this has been a fantastic conversation with you. I really appreciate your time.
Victor Ortiz, MD:We went over a lot of things today and I'm very grateful. Thank you so much, dr Kale, for having me today.