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Everything You Ever Wanted to Know About Joint Replacements | Starting Strength Radio #46

Mark Rippetoe | March 06, 2020

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Mark Wulfe:
From The Aasgaard Company studios in beautiful Wichita Falls... From the finest mind in the modern fitness industry... The One True Voice of the strength and conditioning profession... The most important podcast on the internet... Ladies and gentlemen! Starting Strength Radio.

Mark Rippetoe:
Welcome back to Starting Strength Radio. It's Friday and you're here. And so are we. And we're here this weekend with my old friend, Owen Kelly. Owen is orthopedic surgeon practicing in Russellville, Arkansas. He's from Wichita Falls. And Owen and I have known each other 34 years. And we're buddies. We're buddies.

Mark Rippetoe:
Owen is... He's got a very, very successful orthopedic surgery practice in Arkansas. And his specialty, I guess if you could say it's a specialty, is knee and hip replacement. He does knee in hip prostheses and he's done lots and lots and lots of these. And this is a topic of interest to lots and lots of people because of the fact that the surgery is now available and you don't have to be crippled anymore if your knees and hips are worn out. The surgery is, when done correctly, is very, very good. We have people squat with knees and hips all the time and they're able to train productively and successfully and they are out of pain. And so we're going to discuss this, the surgery today, and we're going to talk to the man about this.

Mark Rippetoe:
Thank you for being here, Owen.

Owen Kelly:
I'm glad I'm here. Glad to be here.

Mark Rippetoe:
It's good to see you again.

Mark Rippetoe:
So you went to the University of Arkansas, went to medical school, University of Arkansas. Tell us about your your experience and your practice.

Owen Kelly:
So I went to the University of Arkansas in Fayetteville for undergrad and UAMS, in Little Rock for medical school. And then I trained at the V.A. hospital, at the Arkansas Children's Hospital and UAMS in Little Rock. And I've been practicing in Russellville for nearly 17 years.

Owen Kelly:
I'm a board certified orthopedic surgeon. I recertified in 2015. My practice being a general orthopedic surgeon in a smaller area where there's not a lot of specialty. I can kind of guide my practice where I like it. So I do a lots of the... most of the joint arthroplasty or joint replacement surgery and then lots of the trauma in the area. I try to stray away from a lot of the sports stuff. I'd do it, but I have more of interest in joint replacement and trauma.

Mark Rippetoe:
Right. So somebody comes in with a compound fractured femur. You deal with that.

Owen Kelly:
I have, man. It's I love that. Yeah, man I love that. But I like it.

Mark Rippetoe:
You like the way it looks when you're in the E.R. and there's...

Owen Kelly:
I like the physical aspect of the... I like.

Mark Rippetoe:
You like to solve the problem.

Owen Kelly:
I like the physical aspect of orthopedics. I like the bigger stuff. There's obviously the arthroscopy and the ACL stuff and the stuff that's more kinda in vogue with sports is... I do it, but it's not my favorite thing to do.

Mark Rippetoe:
Right, we'll talk about the meniscial repairs cause that... You need to hear this, boys and girls.

Mark Rippetoe:
So knee and hip replacement. What is the history of that surgery? When did that all start?

Owen Kelly:
I don't know the exact time, actual year, but actually a hip replacements Dr. Charnley in Europe started. And he would actually put a plastic polyethylene cup in, cemented it with bone cement. And then he would cement in a metal prostheses into the thighbone. And I think over the first... when he when first started doing his... He's not the father of it, but he's the one that really started it.

Mark Rippetoe:
When was this?

Owen Kelly:
I can't give you the exact time, I apologize.

Mark Rippetoe:
70s probably?

Owen Kelly:
60s, 70s, because Carl Nelson....

Mark Rippetoe:
It's been a while.

Owen Kelly:
Yeah. Carl Nelson, who was our chairman, trained with... He started at Arkansas in '74 and he trained with him before that. So six... late 60s or early 70s. And he had a significant, you know, failure rate, obviously, but that.

Mark Rippetoe:
Prototypes being what they are.

Owen Kelly:
And so he eventually perfected he perfected it. And then it's advanced from there from to now where you do what we call a press fit hip. Where the the you know, the implant is placed into the thigh bone without any bones cement. It basically gets stuck in there and the bone grows in. And the same thing with the acetabulum, which is the socket part, it and it grows into the socket as well. And implants have gone through their stages of what's kinda in vogue. But it's pretty much stayed the, stayed about the same.

Mark Rippetoe:
What about knees? When did that start taking place?

Owen Kelly:
I'm not 100 percent sure.

[off-camera]:
1968.

Owen Kelly:
68. So late 60s, early 70s. There you go.

Mark Rippetoe:
Our researchers assistants.

Owen Kelly:
And so it's it's I think the natural history of knees isn't as exciting as it is with hips, but it's the same type of process. And we really different from from the hips and we can go into this. You know, most knees are cemented in with bone cement, whereas most hips are press fit. And that's not an absolute, but that's what the majority of them do.

Mark Rippetoe:
So the technology of knee and hip replacements has essentially been advanced through advances in the prostheses themselves. The surgery, is it fair to say that the surgery has not evolved? The surgery has evolved as a result of the development of the prostheses?

Owen Kelly:
Yes. And there is you know, there is some technology in it. But I would say over the last several decades that the change in the implants is - they're small changes, but they're not big.

Owen Kelly:
The approach to a knee replacement is the approach to a knee replacement. They've tried it different ways, but it really doesn't change.

Owen Kelly:
The approach to a hip. There's you can do it. There's there's an anterior approach, antero-lateral approach, direct lateral posterior approach. But the approach of the hip is is, you know, it hasn't changed either. They're the same surgical approaches that you that you get to the knee and get to the hip and other types of surgeries, too. So and, you know, it's just kind of surgeon dependent. What surgeon choice? What kind of what type of approach do you want to do with the hip?

Mark Rippetoe:
So do who actually develops this technology? The companies involved in it? Are they working with you guys?

Owen Kelly:
Yes, there are. There are lots of physicians that like to be involved in the process of implant design. And that makes a big difference, especially the the the big joint replacement guys, as that's all they do in the big centers. They can make some some impact on on on types of implants. And it makes a big difference. But really, the implants that I use, I've been practicing for 17 years - there's been some small changes, but nothing drastic.

Mark Rippetoe:
Right. And Biomet and Stryker.

Owen Kelly:
Biomet zimmer and Stryker Yeah, two of the big probably three players. So there's some other ones that get thrown in there, but they they do a significant amount of the joint replacement.

Mark Rippetoe:
There is a there's a lot of money in this. I guess that these companies have invested a hell of a lot of money in the production of of this equipment and technology. And I guess they're probably in a position to spend a lot of money on R&D. And , you know, that's probably a good thing, isn't it?

Owen Kelly:
Is. I mean, competition is good. I mean, it makes things better. And people say, well, that implant isn't any good or that, you know, that's not true. Most implants out in the market today, if they're not any good, nobody's using them.

Owen Kelly:
So if... whatever type implant, whatever surgeon chooses to, whatever type implant he, he or she uses, it's gonna be a good implant that's been tested. I mean, that's the one thing about the United States.

Mark Rippetoe:
Well, nobody wants to be sued.

Owen Kelly:
United States, they try to make things safe. I mean, you have to there's a lot of legal stuff. But but it does give you a lot of safety, especially with what we do.

Mark Rippetoe:
Right. Don't go to China to have this done. OK. Stay here to have it done.

Mark Rippetoe:
You know, one of the one of the interesting things about these types of procedures is that you and I [the audience] really don't know what they hell happens between the time they put us to sleep and the time they wake us back up in recovery.

Mark Rippetoe:
So, Owen, tell us tell us what the hell goes on here on a hip and on a knee. Let's let's start with the hip. They wheel me in. I'm out. Anesthesia has already been done on me. I'm out. They wheel me into the OR. What happens next? What do you do?

Owen Kelly:
Well, let's back up a little bit before that. You come to my clinic. You have some hip pain. People believe hip pain is here. And I know you can't see me, but your hip is your groin and your thigh. Hip pain is your groin, thigh pain. One of the main complaints people come in when they have a hip problem is they have thigh pain. They think it's their knee because they have this aching knee. They can't pinpoint.

Owen Kelly:
You come in, we x ray, a standing x ray. We find out you have bone on bone arthritis. You hear arthritis thrown around. What arthritis means if you take it and break it down: arth means joint, itis means inflammation. You have an inflamed joint. Arthritis really isn't a condition of having something. Actually, you don't have something. You don't have your normal joint cartilage. Your car may be in good shape, but your tires worn down.

Mark Rippetoe:
The inflammation has eaten away the cartilage. And then and now you've got arthrosis.

Owen Kelly:
And so you have, instead of a nice smooth surface to for your hip or knee or whatever is moving, now you have a painful joint surface. And so we have that. We give you your options, which for hip, hip arthritis is minimal. You put a cane in their hand, take anti-inflammatories. If it's bad enough, then hip replacement.

Owen Kelly:
So we sign you, make sure you're medically clear. It's an elective surgery. We don't want to take you to surgery if you if you have some health issues that haven't been worked out. Most the time when you have a hip replacement, you know, you're going to be a little bit less young, so there can be some heart issues, you know, diabetes, lot of that. So we get that cleared up.

Owen Kelly:
You come, but the most the time you go to sleep and it depends on what your surgeon choice is, what approach is he going to do? Is he going to do a posterior approach is he going to do an antero-lateral approach, is he going to do an anterior approach? That's just surgeon preference.

Mark Rippetoe:
This is how they get that, how they get to get to the hip.

Owen Kelly:
So. Right. I am going to bring a model. So this is your hip, guys. This is your hip. All right. That's your pelvis. The best way is this is where your belt line is. When you put your hands on a hip, that's it. So here's the ball. Here's the ball and socket joint right here. If I dislocated your hip, there's the socket part, there's a ball. The red shows you your weight bearing surface. There's not much left in there.

Owen Kelly:
So we go down to the hip. You dissect down to the hip and you dislocate it. Okay.

Mark Rippetoe:
So you're going to just you're gonna flay the skin back.

Owen Kelly:
Go through the skin. You go through the fascia. I go through an antero-lateral approach. I take the abductors off which moves the leg off to the side and then I put retractors around the front of it.

Mark Rippetoe:
You take down the abductors off?

Owen Kelly:
A third of them. Take a third of them off the greater trochanter.

Mark Rippetoe:
Off the trochanter.

Owen Kelly:
Elevate it up. At that point with the anterior side of the road greater. So really I'm going in through the anterior, but going through an antero-lateral approach. Okay. We find the capsule, which is the overlying layers, like a water balloon, what covers the hip.

Owen Kelly:
And we open up the capsule. Every time you open it up, if you got a bad joint it's going to be filled full blood or fluid or, you know, loose bodies.

Mark Rippetoe:
Goo of some sort.

Owen Kelly:
You dislocate the hip. Okay, pop it out of the joint.

Mark Rippetoe:
Now there there is an iliofemoral ligament. Is that going to be intact in a patient like this?

Owen Kelly:
It's a little bit more medial. It's a little medial. So you try to stay - most the time you can retract it and get it out of the way. Right. Okay. But when you get into the hip after you dislocate it, then you cut the top of the cup, the top of the ball off, bam, it's gone.

Mark Rippetoe:
So the ligament's now gone.

Owen Kelly:
Part of it is gone. You have ligament structures in there. But they're, then you have...

Mark Rippetoe:
The capsular ligaments. What we have left. Right.

Owen Kelly:
And so there you are. You take a reamer. It looks like a cheese grater. Like a circular cheese grater. You put it into the acetabulum. Yeah. Put it into the acetabulum. You turn it on, and you ream it. Okay.

Mark Rippetoe:
Like with an electric motor.

Owen Kelly:
Exactly right. This is a drill. Once it's out, then you have a hole and you've measured it to your reamer, you... and a lot of this is some art. Now there's a lot of techniques that people use now. They can measure it directly without them having to ream it, but it's reamed out. Then you put the artificial implant in. You put artificial implant in there. It's stuck. It gets stuck in there. You you hit it in with a mallet and gets stuck.

Mark Rippetoe:
I'm glad I'm asleep for this.

Owen Kelly:
Yes. Once that's done, you expose the femur, expose the top of the femur, and you rasp it. You take a rasp. And it looks just like a hip replacement, but it looks like a rasp.

Mark Rippetoe:
OK, so so we've already cut the head of the femur off.

Owen Kelly:
It's gone. Right.

Mark Rippetoe:
Femoral neck, everything, all that's gone.

Owen Kelly:
There's your cut [shows cut line on model].

Mark Rippetoe:
And now we've got that.

Owen Kelly:
You ream it out, which means basically first thing I do is I take this thing called a Ben-Hur reamer. You've seen the movie Ben-Hur when they have the chariot with the thing. It goes in there, it opens it up. And then I take a lateralizing device, which always goes right down the canal, it'll tell me where the canal is. And then I take rasps. They look like this implant, but they're but they're like you're filing something.

Owen Kelly:
You put them down there until you get a good fit. Once you feel like you have a good fit, I have X-ray in the room.

Mark Rippetoe:
So you're going to rasp the hole, size it,.

Owen Kelly:
Till something's stuck.

Mark Rippetoe:
Till something sticks. Right. If you can't get it down, if you can't get the implant down into the cavity then you continue reaming it just like you would size anything.

Owen Kelly:
Right. And it's technically. Yeah, it's not. It's just learning it. Once you get the implant that's right at the edge here of right above the lesser trochanter and the medial area. Once it's there, you got a pretty good fit. I get an X-ray. Some people don't. I get an x ray. I use a C arm, which is a fluoroscopy, it's a real time x-ray. And I look at the implant. I'm like, I like that. I like it where it sits. Once you have the size that fits and you have a neck length and head length, then you put your implant in.

Mark Rippetoe:
And this is how long this thing is?

Owen Kelly:
It it the thicker it is, the longer it'll be, OK. So it goes in. It's stuck in there.

Mark Rippetoe:
And how do you choose the size of this? This isn't a nail, but this is a.

Owen Kelly:
You choose this size by what size it's stuck in there. Now there's different...

Mark Rippetoe:
Does it vary with the patient?

Owen Kelly:
Yes. There's different neck lengths. There's different... there's an offset stem.

Mark Rippetoe:
So one hundred and twenty pound female is gonna have a different implant than and a two hundred and fifty pound male.

Owen Kelly:
And what is opposite is that your implant goes into your canal. So one hundred and twenty pound lady who is osteoporotic is actually going to have a wider canal, not a bigger bone, but a wider canal, because her cortex is probably only this thick, right. So she may get a bigger implant than a 250 pound man.

Mark Rippetoe:
That would be to her advantage because now there's more surface area bone in contact with the implant.

Owen Kelly:
So the implant isn't based on the size of the femur. It's based on how much medullary canal is in there. So if you have a big thick cortices, then you you know, you beat it. You can beat one in there that's bigger, but it ain't gonna work.

Owen Kelly:
Certain implants have - and this is very technical - but have a high offset. OK. If you have somebody that doesn't have very good muscle mass and you're worried about dislocation, then they'll do an offset stem. So this [points to stem] will actually be over here.

Owen Kelly:
So what that does is it gives you a tighter hip by pulling on the abductor muscles, but not lengthening your leg.

Mark Rippetoe:
Changes the mechanics of the way the hip relates to.

Owen Kelly:
Yeah. So two ways to make it tighter or to make the neck longer - push it farther out - or to make the abductor's tighter. Well if you already have equal leg lengths on your x ray when you have the implant and you don't want to you don't want to make her tighter by making leg longer, you want to do it by pushing the leg out to the side and letting the abductors. It's all you know, it's force and and it's it's. Once you do enough and you kind of get used to it, it's just second nature to you.

Mark Rippetoe:
So do you ever have any trouble in osteoporotic females with a fracture when you try in place the...

Owen Kelly:
If you're not breaking a couple femurs a year, you're not cracking them, you're not putting them in tight enough. And so we have cables on the... I know that sounds crazy, but you put a cable around it like this [uses fingers to encircle the femur] after you see it crack, you take it out, put a cable on it.

Mark Rippetoe:
Reinforced the fracture.

Owen Kelly:
And put it back in. And you can weight bear on that. You can weight bear on it immediately. Immediately. You don't restrict them or anything. It's just part of the process.

Owen Kelly:
Once you get the implant in, you reduce it, which means you push it back into the joint.

Mark Rippetoe:
Turn it around so everyone can see. Now, if you... so you have in effect reduced the surface area of the femoral head in contact with that acetabulum.

Owen Kelly:
Right. And it used to be when I was in training, we would have 22 millimeter and 28 millimeter heads. The metal on metal prostheses you could have heads that were... basically they were I think they were eight millimeters below the size of the cups. So if you had a 50 cup, you had a 42 head. I mean, they're big. So your so your risk of dislocation was very low.

Owen Kelly:
But now that we go mostly we'll go ceramic on polyethylene or they do metal on polyethylene the head... there are some bigger heads like 32 mm heads which I'll use and some 36 mm heads. Most of the heads are not bigger than that. So the bigger the head the more circumference you have, the more less likely dislocation rate you have. And dislocation rate is also directly related to the approach you use.

Mark Rippetoe:
So the dislocation rate as it is is a function of the size of the of the ball in the cup and it's higher the smaller the size is.

Owen Kelly:
The dislocation is basically, I think it's more of a function of implant placement, because if you put the cup in a little bit what we call anteverted, that you can have different areas where the ball will come out. In 17 years I think three times I've had trouble with that and would have to go in and put the cup in a different position.

Owen Kelly:
A posterior approach, doing a posterior approach, you know, more people put more pressure on the hip posteriorly, especially when they're getting off a toilet or getting up from a chair. So with a posterior approach you're more likely to dislocate, because posterior is more unstable.

Mark Rippetoe:
Right. So if I'm going to squat on this implant, I'd prefer an anterior.

Owen Kelly:
Absolutely. Anterior or anterolateral approach. Absolutely. And with a fracture cause there - and this is logistic once again, this is way branching out - but like, if you if you do a hip replacement for somebody that broke their hip who's an active person in their 70s, you would want to do an anterolateral approach, because if you do a posterior approach for a hip fracture, the chances of dislocation, I think is three times what it is if you do an anterio-lateral approach.

Mark Rippetoe:
Right.

Mark Rippetoe:
Well, while we're talking about the prostheses itself, you'd mentioned a metal on metal approach where you have a much larger ball, much larger replacement femoral head and a much larger cup. Much larger replacement acetabulum. Why are those not used as much anymore?

Owen Kelly:
Well, about a decade ago, maybe less, there were some problems with one type of implant, metal on metal implant, causing metalosis, which basically means that the metal ions weren't getting... were wearing down, causing metalosis that was basically based on if the cup was too much, I believe anteverted. Which means it is too open. So you had too much metal irritate. And don't quote me on this, but too much metal irritation or metal movement on the rim of the cup. And so they took it off the market.

Mark Rippetoe:
Well, that sounds like a metallurgy problem more than a mechanical problem.

Owen Kelly:
Right. And it's more of a placement of implant problem

Mark Rippetoe:
They could fix this to make a more inert prostheses if they want to do it would seem like to me. I mean...

Owen Kelly:
The bigger the head and I like to do and I did I did specifically only metal on metal for a long time. And then when they started taking them off the market, they wouldn't let us do it. I mean, the surgeon that did my mother's hip replacement in the Dallas-Fort Worth Metroplex, I talked to him and literally he had done thousands of them without any problem.

Mark Rippetoe:
Metal on metal.

Owen Kelly:
Metal on metal.

Mark Rippetoe:
Is it still available if you want it?

Owen Kelly:
No.

Mark Rippetoe:
Really, it's not even available now.

Owen Kelly:
Not even available. In fact, I had a gentleman that I had done a metal on metal on, and he fell and dislocated his metal on metal hip. So I had to revise his hip. He actually broke the implant. Popped the head off and everytihng. I mean he did the splits. And so metal on metal was not available. So I had to use a special type of plastic head that the big polyethylene had that looked like one, but it wasn't metal. So.

Mark Rippetoe:
So you didn't have to revise the acetabulm?

Owen Kelly:
No, no. I didn't have to revise the acetabulum or the femur.

Mark Rippetoe:
Just the head.

Owen Kelly:
The head and neck. Yeah.It was fortunate.

Mark Rippetoe:
So how much less stability do you think this thing provides in the absence of the iliofemoral ligament tying the thing together? I mean, that would that seems like a mechanical problem. That could possibly show up.

Owen Kelly:
It could. But when you do a revision on a hip, which means when you go in and revise one - take an old one out, put a new one in there. You're not opening up the joint and it's full of air. I mean, there's soft tissue everywhere. Surrounds it.

Mark Rippetoe:
The whole thing is being held together with muscle tension...

Owen Kelly:
It's soft tissue. There's scar tissue. So your body learns for the range motion it needs, but everything else in there kind of locks it down. So stability with implants, it's an occasional question. It's ah, it's not a very common occurrence anymore because implants, just techniques and approaches have changed and have improved. So it's not an issue. I would say that.

Mark Rippetoe:
And I would also venture to guess that somebody with a with a hip implant is going to tend to protect the hip as well. You don't go jumping off of buildings and shit.

Owen Kelly:
What you do hear from people is they'll say, "I forgot about it because I feel so much better."

Mark Rippetoe:
Yeah, I guess that's true. Doesn't hurt all the goddamn time like it used to.

Owen Kelly:
It's a quality of life issue. You know, if you had a hip... You got a pain problem. You know, that's what a hip and knee replacement. I don't save anybody's life. I don't do that. When you're doing replacements, you're not saving someone's life, you're improving their quality of life.

Mark Rippetoe:
This is important and we're going to come back to that. This is a very important aspect of this of this discussion.

Mark Rippetoe:
So you get the implants in place, you got hip done, you got femur done. And now what happens?

Owen Kelly:
Close them up. Close them up. You either sew... if you're doing the direct anterior approach it's just a muscular. If you're doing a posterior interlateral, you take the abductors, sew them back. You close the...

Mark Rippetoe:
Sew them back onto the...

Owen Kelly:
Sew them back tendon-wise. You can... some people use sutures through the bone. It's technique wise, however you want to do it. And then I close the IT band, subcu skin, recovery room, get him up and walk him the next day.

Mark Rippetoe:
Do you split the IT band or?

Owen Kelly:
I do. Split it right down the middle...

Mark Rippetoe:
Right down the middle to make room instead of cutting it.

Owen Kelly:
I just I just split. Retracted it...

Mark Rippetoe:
That doesn't really affect its strength. Not at all.

Owen Kelly:
Not at all. Incisions heal side to side.

Mark Rippetoe:
Right. So then they wake up in recovery and they're in there about an hour and then they go back to the room. And then...

Owen Kelly:
Well, some people do it differently and try to give them the first day off and then the next day I get them up and walk them. That's it. With a hip replacement recovery, a hip, getting up and walking. Get up from a seated position, walking is the best rehab you can do. I limit abduction for six weeks. I don't want to do active abduction, which means use their own muscles to abduct.

Mark Rippetoe:
That way they...

Owen Kelly:
You let them heal. Most people with an antero-lateral approach will have a little bit of a painless... you know, most the pain from hip replacement, the surgical pain is gone with somewhere between two to six weeks. You know, most people are regretting their surgery the first two weeks. They forgive you about four weeks. By eight to 10 weeks, they they really love you.

Mark Rippetoe:
Everything's fine. What causes the problem? The bone?

Owen Kelly:
Yeah. Taking the saw and cutting your bone. That hurts. It does. It hurts. And it's hard to explain to people how bad it hurts. But with an antero-lateral approach, they'll have a you know, they'll have a little bit of a limp. I can notice it, most of them don't notice it, but I can see them limp in. And usually that limp is gone at six weeks.

Owen Kelly:
And there's lots of controversy, not controversy, but there's lots of debate on what approach is best. And this is what... Whatever, you know, pick a surgeon you trust and and you believe in them and has done a good job for you. And don't worry about what approach they use. Just pick somebody you trust and you know they'll do a good job.

Mark Rippetoe:
There's probably an argument to be made against a posterior approach.

Owen Kelly:
There's an argument to be made against every approach. Posterior approach is a it used to be very, very common. People do it. It's a good approach. People have good results with it. Anterolateral approach, the same way. And the anterior approach was kind of the new in vogue thing. But there's there's negatives to every single one of them.

Owen Kelly:
And so. The negatives aren't on the patient. They're on the surgeon What what is what does your surgeon feel that he's best able to do? I've done postior approach and antero-lateral. I feel best with antero-lateral. That's how I trained. My results for me, are good for me. I don't bad mouth somebody else's technique because it's not something I like.

Mark Rippetoe:
If you go in anterior, how long is the incision?

Owen Kelly:
It just depends. It all depends on patient size, patient anatomy. Anterior approach is kind of the new in vogue. You have to have a special table to do an anterior.

Mark Rippetoe:
Oh really? Because lay on your back.

Owen Kelly:
You do. But you have to completely... you have to do.. you have to extend the hip about 90 degrees to dislocate it, straight back extension.

Mark Rippetoe:
Oh, God. So, the torso is elevated.

Owen Kelly:
No, you're flat. You're flat. And then you take a - there's a special table that drops it down. Drops it and then extends it and you cut it.

Mark Rippetoe:
So you're standing where next to the patient?

Owen Kelly:
Right next to them. Yeah. Right over the top.

Mark Rippetoe:
They're at chest level to you?

Owen Kelly:
Yes. Chest or whatever, you know, whatever height you want. Plus, on the anterior approach you have to use special acetabular reamers and you have to do it under x-ray. Most people do. Whereas anterolateral approach, posterior you have direct, but with an anterior approach the reamer, the one you're reaming, they have to be curved to get around the anatomy. And there's certain guys that do it. There's colleagues of mine and are just they are joint specialists. That's all they do. A lot of like the anterior approach. They've done enough. They feel good about it, have good results with it, and they do a good job.

Mark Rippetoe:
Is the... how long does it take, relatively speaking, between the three approaches? Is one of them shorter?

Owen Kelly:
Everybody's different. You know, traditional antero-lateral approach that I do with a with a patient that is average size - and Arkansas has a little bit different average size - I can have implants in and be closing somewhere between 35, 45 minutes.

Mark Rippetoe:
Wow. From. From first incision to closed?

Owen Kelly:
Yeah. From getting down exposure to that. But closing takes 15 minutes, sometimes 20. Anterior approach probably an hour, posterior approach, you know, about the same as that.

Owen Kelly:
The exposure is the exposure is is really not the difficult part of it. You know, the difficult part of it is making sure you have one that fits, getting an x-ray and making sure. But when you have a team, you're only as good as people you work with. So if you have a good team, that can make you very efficient. All right. I've got a team I've worked with for a long time. They're very efficient.

Mark Rippetoe:
So do you close or do you just do that...

Owen Kelly:
Yes. I don't have a P.A. - physician assistant or or a nurse practitioner - I change my own bandages. I do all my own stufff.

Mark Rippetoe:
You do the whole procedure from open to close. Because I I've I've heard some people do the implant, then they walk right out.

Owen Kelly:
I have colleagues that have physician assistants, that's that's that's what they do. They aren't they close all their wounds. I don't do that. I don't. There's a you know, I just don't I choose not to. And I make it wrong. Right. Just makes it right.

Mark Rippetoe:
You just want to make sure that the whole damn thing is your work.

Owen Kelly:
Right. You know, when there's always complications with everything, there's a complication rate every surgeon has. Everybody's about the same. And it just happens. You know, complications are part of risks of doing surgery.

Mark Rippetoe:
Now, what about a knee? Which would you rather perform if you...Are you rather ambivalent about it. Or do you like hips are better than knees?

Owen Kelly:
I'd rather do all hips.

Mark Rippetoe:
Really? Knees are more variable?

Owen Kelly:
Yeah, they are. Hips do so much better. The problem is and this is it. I mean, if you're gonna do them, you know, you have to take care of the complications and knee complications, you know, revision knees or or are a little bit...

Mark Rippetoe:
Probably more common than hip revisions.

Owen Kelly:
Yeah, than hip revisions. Hip revisions are difficult, and if I have trouble, you know, I'm not too proud to say I got a colleague of mine who does lots of - that's all he does is revisions. And, you know, I asked for his assistance and send them to him to do.

Owen Kelly:
But I like hips. Patients... The two most patient satisfying surgeries and this is by studies, carpal tunnel releases, hip replacements. All right.

Mark Rippetoe:
Because you know that now you're not hurting more. Very important.

Owen Kelly:
And if you've ever had hip pain, it's miserable. I mean, yeah, people are miserable and they're angry, angry, miserable, because they you can't get comfortable. A bad knee? Prop it up, put some ice on it. Your hip, you can't prop it up because you're propping up your body, you know, and it's a big joint. So, yeah. Hips. Hands down.

Owen Kelly:
Now onto knees.

Mark Rippetoe:
Let's talk about how we do those and same kind of thing.

Owen Kelly:
Same kind of thing. So knees can be... looking at any if you're gonna get a traditional total knee replacement, there's a lot more variables on the implant. Okay. And I'm going to try to make this as simple as I can. There's a three basic types. There is a poster cruciate retaining. And this is a total knee. This isn't like a unicond

Mark Rippetoe:
Where you save the posterior cruciate ligament.

Owen Kelly:
Posterior cruciate retaining knee. There's a posterior-stabilized knee, and then there's a constrained knee. Okay. Now you can throw a fourth one in there, which is a linked or prostehsis that's actually attached together like a hinge. That has that has a bearing in there that does not separate, you know. A constrained, posterior-stabilized and a posterior cruciate retaining.

Mark Rippetoe:
Do we ever retain ACL in one of these things? It's just not possible?

Owen Kelly:
We don't. Here's my - and this is my thinking on a poster cruciate retaining. I do a better job, I can recreate a posterior stabilized knee better. The problem with a retaining knee is that a lot of times, not all the time, but a lot of times if you've had a PCR done, the native PCL that you maintain, loosens over time. So you have people that now...

Mark Rippetoe:
Because it's under so much more stress.

Owen Kelly:
So people develop instability posteriorly six months, a year, year after it when they've had an excellent surgery done. Like what's going on? And the problem is they've had a PCR. And so you have to revise that to a posterior stabilized.

Mark Rippetoe:
Now, for everybody watching us here. Anterior cruciate.... Here's the femur. Here's the here's the tibia. Anterior cruciate keeps that [forward movment of the tibia] from happening.

Owen Kelly:
Anterior cruciate ligament.

Mark Rippetoe:
Tibia translating forward relative to the femur. And PCL prevents the opposite from happening. So this is posterior instability.

Owen Kelly:
Right. So ACL prevents anterior translation of the tibia on the femur. And it's very... at 30 degrees of flexion, that's when it's really just your ACL that's doing it. I mean, that's when you see if you've been watched, ESPN watched somebody go down or watch a basketball game, they come down and they do a Lachman's test. You know, they're checking it and just for show, really. They could do it on the sideline.

Owen Kelly:
And so poster poster cruciate ligament is is is posterior translation. And how I explained that to people: A common way to injure your posterior cruciate ligament is if you're in a car wreck and a dash hit you below the knee and takes your tibia and shoves it straight back. And so you have posterior movement.

Owen Kelly:
Now, a posterior cruciate ligament is not as in is not as vital to repair. You can rehab a knee and make up for the deficit. The problem is when you do a... if you have a insufficient posterior cruciate ligament after a knee replacement, you don't have your muscle strength and stuff doesn't, it doesn't play as big a part in helping know that stability.

Owen Kelly:
So I do a posterior stabilized and I'll explain that here in a minute. So you come in it gets you sign up for surgery. And basically people think that you've taken the whole knee off. But but you're not really taking the knee off.

Mark Rippetoe:
Not anymore, right?

Owen Kelly:
No, you're basically it's like a bad... like you're crowning a tooth. You're taken off the layer above it.

Mark Rippetoe:
You're resurfacing, basically.

Owen Kelly:
This is what you're taking. You're talking about this much off [holding up model]. And this is a posterior cruciate retaining. I'm sorry, I don't have a posterior stabilized. So that's what it goes on.

Owen Kelly:
So it's not like you're... if you look at it from the side view. I mean, you're got a metal layer there. In the front it looks more, looks like the whole knee is made of metal, but it's not. So then you take the top of the tibia off and this is all cuts done. You know, you have a measurement guide and then you press the tray in here. The polyethylene, which is this [pulls polyethylene part of model off].

Mark Rippetoe:
And this is actually the substance.

Owen Kelly:
That whole, that's the real deal.

Mark Rippetoe:
This is this is what you're placing in there.

Owen Kelly:
High-density plastic.

Mark Rippetoe:
High density, very slick. The attempt is to, of course, to recreate a frictionless surface.

Owen Kelly:
Right. And so the normal wear I think I think is point zero one, one millimeters a year.

Mark Rippetoe:
Oh, really? How does this thing withstand compression?

Owen Kelly:
It stands compression well. I have people that overdo it.

Mark Rippetoe:
You know, a couple of those.

Owen Kelly:
...in my mind.

Mark Rippetoe:
Our friend Phil Anderson.

Owen Kelly:
Yeah. He's had both of his knees replaced.

Mark Rippetoe:
He is a he is not a smart person.

Owen Kelly:
So that's what you do. Now a posterior cruciate stabilized I use has a little plastic post in here that goes in here. And what that does is prevents posterior rollback. So with it, your knee can't go this way So yeah. So when the notches is there it prevents posterior rollback, which means when you do that [pulls model apart] it won't dislocate, okay.

Owen Kelly:
That's the stablized. The constrained just has a thicker plastic post in there. So it also gives you... cause when you're doing a revision and you need a constraint, your collateral ligaments, they're obsolete. They're no longer there. They're scar tissue. So you want something that...

Mark Rippetoe:
No, I guess if you pull the whole damn thing apart the MCL, LCL have to go with it.

Owen Kelly:
Well, yeah. Or they're scarred in and they're incompetent. So now you have medial lateral stability and you prevent that. Now if you get to the point where you have a tumor prostheses, which is a hinge prosthesis or you're doing another revision, which basically means you're losing lots of bone, then you link it together. And I mean, you can replace an entire femur if you have to with a metal.

Mark Rippetoe:
Really?

Owen Kelly:
You can.

Mark Rippetoe:
The whole femur?

Owen Kelly:
You can do it. The tumor guys, they do it all the time.

Mark Rippetoe:
They've got a they've got a titanium femur?

Owen Kelly:
A whole femur. Those guys are slick. I trained with Dr. Richard Nicolas at UAMS during my training.

Mark Rippetoe:
How do they attach the adductors to the medial diaphesis of a fucking titanium femur?

Owen Kelly:
They don't. It just scars in. And then Corey Mcgomery is a tumor guy. He's a orthopedic oncologist. He's Richard Nicolas's. And he does it all. I mean, those guys are slick. They are. They are slick. It's amazing.

Owen Kelly:
And the joint guys that... and I'm not just plugging these guys just because I know them, but Paul Edwards and Lowry Barnes are the head of the joint and Simon Meers at UAMS. They are the the academic guys at UAMS and they do all that kind of stuff too. They do all kinds of prostheses. It's impressive. It's impressive thing there. It's an impressive. Very much so. I give credit where credit is due.

Mark Rippetoe:
So let's start like we did with the hip. Guy walks in the hospital. He lays down. Put him in a white gown. Embarrassing. You know, have him tie that thing in the back. He lays down. They tell him. Count backwards from a hundred and he gets to ninety nine and he's asleep and he's in your OR. What do you do now?

Owen Kelly:
Put a tourniquet around his leg. OK.

Mark Rippetoe:
This is an interesting thing that you have to do that to control the the the operation site, right? You don't want blood pouring into the knee.

Owen Kelly:
Right. Is it, you know, knee... a hip is a you know, with a hip, you can't do that, but you try to lower pressure during a hip so that there's more... so that there's not as much blood.

Mark Rippetoe:
Is there any procedure you can do for a hip to reduce the perfusion to the thing?

Owen Kelly:
Hypotensive anaesthesia.

Mark Rippetoe:
Oh, they just do it with chemistry.

Owen Kelly:
Yeah. Right. Hypotensive anaesthesia, which means lower blood pressure.

Owen Kelly:
So you put a tourniquet high on the thigh. And I explain to people, you know, when you get your blood pressure taken and it hurts really bad? That's about 250 millimeters of mercury and it's up for, what, three seconds? We would put one on the thigh at 300. And leave it there for something like 20 minutes. Sometimes an hour. So you can imagine the muscle pain that people have when they wake up.

Owen Kelly:
So you do an anterior approach to the knee.

Mark Rippetoe:
But while we're on that. What happens... if you're not perfusing past the tourniquet. I know we got to keep the blood out of the open knee wound and everything, but what about the tissue? Is there any... is necrosis ever a factor in a situation like this? And why not?

Owen Kelly:
That's an excellent question. Less than an hour you're okay. But if it goes past an hour, a lot of people release that tourniquet for about ten minutes. Let it perfuse. Rewrap it, put it up again.

Mark Rippetoe:
Right. And you're okay like that.

Owen Kelly:
You're okay.

Mark Rippetoe:
Let's say we've got unusual things to do down there.

Owen Kelly:
Then people will do that. And then some people because after they'll do it, some people put the tourniquet down an hour and just neutralize any aggressive bleeding, and then do the remaining surgery without it.

Mark Rippetoe:
Oh, really? Just cauterize some stuff.

Owen Kelly:
And I know some people got a rare, rare, rare. I've done it, I think, in 17 years. And of all the joints I've done out, there's been three times that I've just said take the tourniquet down because it's such a venous tourniquet, a lot of fluid around their leg. Wrap it in it all the venous blood has stayed down there and you just can't see. Put it down. You stop the big bleeders and then you do the knee replacement with it without a tourniquet. So, I've done that. A couple of them. There's some people that do that. Some people did, not many. I mean, not many. But. But I've heard of it and I actually read articles or people on that.

Mark Rippetoe:
Right. Well, we'll come back to that because I've got a question about the effects of the tourniquet post-up.

Mark Rippetoe:
But so we've got the tourniquet on. And now the knee's painted with betadine and you're going to cut the guy open.

Owen Kelly:
So we zip him, we use an s mark, which is like a rubbery ACE wrap. Get the blood out the knee, put the tourniquet up. Make a direct anterior approach and we do it. Then we do a medial parapatellar approach, which means we found where the quad, patellar tendon and we do a medial approach where you invert the patella. Okay. I do what we call...

Mark Rippetoe:
Because we have to keep the patella. We have to keep the patella and the quadriceps tendon and the patellar ligament.

Owen Kelly:
Or you won't straighten your leg.

Mark Rippetoe:
Or are we don't have a functional leg.

Owen Kelly:
And there's no need to have a leg if you can't straighten it.

Owen Kelly:
So we do we call a... I do a medial peel. Just take he medial tissue off the proximal, off the top of the tibia here. There's a fat pad in the front, right in the front of the knee. I take about half of that off. Then I invert the patella, which means you take it...

Mark Rippetoe:
Lay it to the side.

Owen Kelly:
Place the knee in extension. Then I take a saw. Lotta people use a guide to cut the patella, I do I do it freehand. I take a saw and do it. And then you actually replace the patella with a button. Looks like a little plastic button like that.

Mark Rippetoe:
You replace the patella?

Owen Kelly:
A third of it. The undersurface.

Mark Rippetoe:
Oh, ok. OK. So you've got plastic on on the metal. OK. Right. Not cartilage on metal.

Owen Kelly:
So then I do that tibia first. I place an extra medullary, which means a guide outside the internal aspect of the bone. So we put one down in the middle. I do it on their ankle. You cut it perpendicular to the tibia shaft, cut about three millimeters, maybe four off the most diseased side of the knee, which the majority time is the medial. Make your cut. Take that out.

Owen Kelly:
You enter the femur. And I cut a 6 degree - between 5, 6, 7 degree valgus cut the femur. Okay. All femurs are valgus, which means a little knock kneed. From about five to seven degrees.

Mark Rippetoe:
Sure, because of the Q angle out of the hip.

Owen Kelly:
So put it in there. I cut - it depends - and this is all once again, this is all... you learn this. If they have of extension contracture, which mean they can't straighten their leg out, you can do cleanout more posteriorly or you can cut more femur. You measure that before you cut femur. I cut between 11 and 13 millimeters. Once you cut that, then you measure it. Put a measuring device. It's not like we have an implant that sized. Now, some of the other techniques for robots have them. You size it. They got all the sizes, you pick your size.

Mark Rippetoe:
Oh, you'll have a variety of prostheses on the table?

Owen Kelly:
Not on the table. We'll have sizes, but we have available. Right. Right.

Owen Kelly:
So I do a posterior stablized. So I cut a box in the end of the femur to allow the box to be put in there.

Mark Rippetoe:
Let's see what it looks like.

Owen Kelly:
Now, I don't have that [model on hand], but there's a box that's cut instead of what you're looking at here. The posterior stablized will have a box cut that goes all the way through there. OK.

Mark Rippetoe:
So but you've got that facet cut and that facet cut in this facet.

Owen Kelly:
Well, we have the medial for the condyle

Mark Rippetoe:
To match the angles in the...

Owen Kelly:
So it matches it. It's like a mold. Stick your hand in the mold, pull it out, you got a mold with your hand and fits it. Then I put the neon extension. Remove the remaining portion of the medial meniscus, the lateral meniscus, and the posterior cruciate. I take it out completely out. Save the MCL. I'll save the LCL.

Owen Kelly:
At that point I balanced it tight. Medial collateral ligament. You want to make sure that they're equal. You don't want a tight medial tight lateral. Now I flex it back up. Put tractor's around the tibia, measure the tibia, tamp it in, size it, put the implant in like this and I try it.

Owen Kelly:
Once I have the trials that I think work, we check flexion and extension check her flexion extension gap. That point we mix the bone cement, which is polymethylmethacrylate or methylacrylate.

Mark Rippetoe:
It's kind of a derivation of superglue. Acrylate glue.

Owen Kelly:
So you get that, you put it on your implant. I do this tibia first. I always I don't have this plastic on there, have a little trial on it. Everybody does. You cement it out. Cement your patellar button. Once this... I release the tourniquet. Neutralize any bleeding. Check the back of the knee because there's a big artery here. You don't want to get that.

Mark Rippetoe:
Make sure you're not nicked. Right.

Owen Kelly:
And then by that time, by the time I've had it out and I've cleaned up the knee, any bleeding. You know what poly ou're gonna use, you pop your poly in and you close it up. You close the retinaculum, close subQ and then you do the skin. Put a big dressing on it.

Owen Kelly:
The next day I get him up, start moving him. Some people use a CPM, which is continued passive motion. The research studies show that the CPM doesn't make any difference.

Mark Rippetoe:
Okay, that was my experience with my knee.

Owen Kelly:
It makes a difference at 2 weeks only. There's about a 5 or 10 degree increase at 2 weeks. At 6 weeks, there's no difference. You're not going to let a machine hurt. You're not gonna let a person hurt you, you're not going to let a machine hurt you. The only thing the CPM has been proven to do 100% percent is make you lose more blood and make you use more pain medicine.

Owen Kelly:
So a lot of people will disagree with that and will argue with that. And I understand that. I'm not saying it's not good to use because I've used it on patients that patients ask for it. I say, yes, we can use it. So I'm not I'm not criticizing. I'm not criticizing it. I'm saying what I do. I used to use it in training. I mean, I didn't use it in training. I used it when I started private practice. And only the reason I used it because everybody else was and I wanted to be just like them. And then at some point...

Mark Rippetoe:
At some point, your own preferences become.

Owen Kelly:
And a CPM, just like any other machine, it's made for the average person and nobody's the average person.

Mark Rippetoe:
Constant passive motion.

Owen Kelly:
Continuous.

Mark Rippetoe:
Continuous, continuous passive motion on machine and it just operates your knee back and forth kind of slowly and stuff.

Owen Kelly:
right. And so a lot of people say -- and I hear this a lot -- I hear, well, my you know, my my husband or my grandmother or a friend of mine used it. And they had a good result. They had a good result because they likely put the time in physical therapy. Your therapy progresses direct effort that the patient puts in

Mark Rippetoe:
Right. Always.

Owen Kelly:
I have patients that come in with bad knees and they're sitting up in a chair the very next day flexing their knee at 100 degrees. That patient doesn't need anything. That needs some home exercises. Hey, work on it. Slide your heel back. You're gonna do fine. At 100 degrees. You're fine.

Owen Kelly:
I have patients that come out in that and they are well, they won't move their knee for 40 degrees. You know.

Mark Rippetoe:
Everybody's got different tolerance for pain. Everybody's different laziness, different ambition.

Owen Kelly:
Knees hurt more than hips post-op. They really hate you for two weeks. But most time by six or eight weeks, they forgive you, they forgive you.

Owen Kelly:
So that's the basis of a hip and knee replacement. There's a million things you can go into this. There's a m... There's I don't know how many orthopedic surgeons are in the nation. I think ten or twenty thousand. And so that means I'm you know, there's about nine thousand nine hundred nine nine or nineteen thousand nine hundred nine who are smarter than me. But that's the basics of hip and knee replacement.

Mark Rippetoe:
All right. Let me let me. Let's go back to the tourniquet situation. All right. When you set a tourniquet, has it been your experience that the tourniquet causes problems for proprioception at that leg post-op. In other words, the ability to feel search for the ability to tell where your leg... where it is in space. Does that have to be reset? What's the situation with that because that's a that's a potential concern, especially for like a younger athlete. If you have to do knee surgery on a younger athlete who is expected by his scholarship program to get back on the field. What happens with respect to the tourniquet?

Owen Kelly:
I'm trying to use this cliche every time we answer questions, but let's back up. On rehab. When we talk about rehab, there's four phases of rehab. There's four phases. Okay. There's the inflammatory phase. OK, so basically that's the first part of rehab is to get the swelling down, OK? The second phase is to get the range of motion back. The third phase is to get the strength again. The fourth phase is function proprioception falls into that.

Mark Rippetoe:
Late in the process.

Owen Kelly:
So if you speed those processes up or skip it, you're not rehabbed correctly. If you get your swelling down, start strengthening, then you're going to be strengthening a joint or an injury.

Owen Kelly:
That's still swollen.

Owen Kelly:
No, if you get the swelling down, but start working on strength, you're gonna be working on a joint that doesn't have proper range of motion. So you're gonna be strengthening a joint through a limited range of motion. That's not good for anything. You know, so you have to get the range of motion back. You have to get the swelling down and get the range of motion back. A lot of times you do that together. Then you get the strength. Okay. Once you get that, then you have all the tools you have to perform your activity, whether it be walking, whether it be powerlifting, whether it be playing football or be playing basketball.

Owen Kelly:
People like to skip the function part. They they like to skip it. Oh, well, I'm strong and I got full motion. Well, I can go back and play football. No, you can't. You have to...there are certain things you have to do to be a football player and basketball player and a soccer player. You have to be able to cut. You have to be able to change position. You have to be able to feel proprioception. And proprioception is extremely important.

Mark Rippetoe:
Proprioception - for those of us that don't know what that is - it's.

Owen Kelly:
I jusually describe it as the ability to feel uneven surfaces. It's the ability for your body to feel where its foot is in space or it is in space.

Mark Rippetoe:
The the ability to to to identify your position with respect to your environment surfaces, water, whatever it is.

Owen Kelly:
With a knee replacement, when you have a tourniquet on there and you've squeezed these muscles. Yes, proprioception is very important. And you would be surprised amount of people that take their first step and they feel like their leg is going to collapse because they don't know where it is.

Mark Rippetoe:
I remember very clearly.

Owen Kelly:
And I don't know where my knee is.

Mark Rippetoe:
I remember very clearly having that happen.

Owen Kelly:
So that is a vital part.

Mark Rippetoe:
And that's a function of the tourniquet?

Owen Kelly:
Some of it is some of is a function of having having your quad tendon cut. Some of it is a function of having your bone cut.

Mark Rippetoe:
If the quad tendon is cut.

Owen Kelly:
Yes. Well, the quad tendon is cut. It's cut, it's cut longitudinally.

Mark Rippetoe:
Oh yeah, it's split. It's not sectioned. Right.

Mark Rippetoe:
So proprioception is i...so if if there was a way to do a knee without the tourniquet, would that be better post-op?

Owen Kelly:
Pain wise? Function wise? Rehab wise? My answer to that would be yes, I think so. And it just it would be difficult to do it to get true hypotensive, safe anaesthesia, to get a knee that's just not... And it's hard to explain unless you've seen it - that's just really bloody.

Mark Rippetoe:
Well, you can't see anything. I can understand why it's done. It's obviously... We've got to have a clean picture of the anatomy or we can't work on it.

Owen Kelly:
My answer to that is that there's a lot smarter people to figure it out. And I'm I'll follow their lead until they tell me not to do it that way. I mean, because they've... The guys I started joint arthroplasty, they figured it out. And I'm... I guarantee you, they tried every way possible until they found a found the technique that worked the best.

Mark Rippetoe:
All right. Now we know how the procedure takes place. And I think this is good information for a lot of people because there's there's just I mean, this seems like it's awfully complicated and it is awfully complicated, but how many of these have you done?

Owen Kelly:
Hips and knees?

Mark Rippetoe:
Yeah. How many hips and knees have you done? You have an idea?

Owen Kelly:
Just joint replacement. You know, around probably hundred fifty two hundred a year for 17 years.

Mark Rippetoe:
Hundred and fifty two hundred a year for 17 years.

Owen Kelly:
And that doesn't include hip fractures and you put implants in on some hip fractures so you can... I don't throw those in there.

Mark Rippetoe:
So, you know, several thousand. Three or four thousand of these things. And the experience of having done these makes the procedure faster and it makes the procedure much more reliable. So you reproducing what you've already done hundreds and hundreds of times and you're real good at this.

Owen Kelly:
I don't. Now let's back up.

Mark Rippetoe:
I'd say that's an honest assessment.

Owen Kelly:
I think a surgeon's success based on experience. And here's the greatest quote I've ever had. And this was from a guy at the VA that I trained with, Dr. Walter Solocovik, he was awesome. Done it for a long time. And, you know, good results and good decisions are based on experience, which are based on your bad results and bad decisions. You know.

Mark Rippetoe:
So that's what you learn from, yes.

Owen Kelly:
So I, you know, my volume of these is is is is is relatively high. A lot of guys don't like to do them. And I understand that. I like just that. They choose not to. So good surgeon/bad surgeon. I think the good term is experienced. You have a volume of them. You've seen a lot of them. I think that's a good way to put it. I think so.

Mark Rippetoe:
Well, I would much rather go to a guy who's done a procedure three times that day and me be the fourth one, because I have a higher degree of confidence in the outcome, since he's more than likely, you know, real good at this. You know, you don't want to you don't want to go to a knee replacement guy who's done three this month. Right?

Owen Kelly:
Right. He may do an excellent job of those three.

Mark Rippetoe:
He might. Right. But it's more likely that the guy that's done three of them that day is going to have done a better job because of the experience.

Owen Kelly:
Right. And the best way to explain that is nowadays, if if, you know, a lot of people get their medical information from billboards and the internet and...

Mark Rippetoe:
Pharmaceutical company advertising.

Owen Kelly:
So you hear this big push for for robot assisted knee replacement. And and I get it. And I and one of the big things a robot assisted knee replacement is they they tend to promote their procedure by criticizing other procedures. Well...

Mark Rippetoe:
Right. Criticizing your experience, essentially.

Owen Kelly:
The the recent most recent study of eleven thousand one hundred ninety three knee replacements done half robot assisted half without the robot show there's no difference. And the independent variable - here is the variable - and I think the number is 100. If your, if yoursurgeons doing more than one hundred of these a year, there's and it may be even lower, that there's really no difference.

Owen Kelly:
The robot is an excellent tool. It makes cuts on the femur and the tibia. It doesn't open the knee up. I doesn't balance your knee. It doesn't cut your... it doesn't cut the patella. It doesn't close. It doesn't open it, doesn't take out the meniscus, it doesn't balance it. What it does is it gives as precise a cut on your femur and your tibia that you can get. If you do enough of these, your cuts, your cuts with the guides that you use - it's not like you're just freehanding. You have guides and you have to nail them in and they're stuck. They're not moving right - are negligible as compared to a robot. On the hip...

Mark Rippetoe:
That's an interesting. This is an interesting observation. If experience is the critical factor in terms of there actually being no difference in outcome between this precision robot and the surgeon, A) an inexperienced surgeon could benefit from a robot, B) That guy that's using a robot is not gonna get the experience.

Owen Kelly:
That's true, that's true. And once again, I'm not criticizing the robot because I know some experienced surgeons that that like it and they want their cuts to be exactly the same every time. And my answer to that is that that is your preference. Don't but don't criticize the other procedure that works to promote yours.

Owen Kelly:
My second follow up to that is when you do a revision knee replacement, which means you take out an old implant or a failed implant or an infected implant and put a new one in. There is no robot that does that. So revision knee replacement is a direct relationship to experience of the surgeon and technique. So that's my follow up to that. And that makes sense to me.

Mark Rippetoe:
But I can see that an increased reliance upon these external aides would over time have a detrimental effect on the surgical community's ability to accumulate experience on this thing, you know. And I don't know if that's a good thing or a bad thing, but certainly it's a factor.

Owen Kelly:
I think it's I think it's a factor in it, in it and in anything. I think if you use a computer for months and months and months, then somebody asks you to write a letter with your hand, it's hard to do it. You can't. Your cursive isn't as good, even though you know how to do it.

Mark Rippetoe:
Everybody's writing left handed now is what it looks like.

Owen Kelly:
So. But I understand that technology is moving in that direction. And if if they if five years from now new study comes, studies comes out, says, hey, hey, the results are changing. We've we've made improvements in the robot. It does a better job. At that point in time. I have absolutely. I would I would. I would get on board and say, OK, then let's let's start the process. When when that becomes the answer, then that is what you should do. I believe right now you have a choice that surgeons have a choice. I think some use it, some don't. I'm not once again, I have lots of colleagues use the robot and like it.

Mark Rippetoe:
Well, here's an here's an even more important question. When when a patient presents - and I I've had this comment submitted on the forums quite a bit over the past 15 years that we've been running this damn thing - when when a patient presents in the surgeon's office with a clear hip replacement situation, he's got hip pain. He's got - and once again, as Owen mentioned, hip pain presents in the groin, not lateral. It presents medial and it's going to radiate down the thigh. And you may think sometimes something else is wrong and you go to the doctor and they have you do a standing X-ray and you've got bone on bone arthritis in the hip.

Mark Rippetoe:
I've had lots and lots of people tell me, well, he didn't want to do hip replacement because they they're afraid they're gonna have to replace it again in 10 or 15 years. And we want to get as much mileage out of the original equipment hip as possible before we go in and replace it. And I think that is crazy. I don't think it's just stupid. I think it's crazy because if you can't move boys and girls, if you can't move, you can't train. And if you can't train, you can't maintain your muscle mass. And what happens to your quality of life? And Owen mentioned quality of life earlier and this is a terribly important thing to think about.

Mark Rippetoe:
So tell us what your thinking is on this. Because this does happen all the time, doesn't it?

Owen Kelly:
It does. And I see I see a lot of of of people and patients that come to my clinic and they've been told they can't have surgery. And the majority of it is is two reasons. One, they have a significantly elevated BMI. OK. So they're hearing a lot of excess weight. Or number two, they're they're too young.

Owen Kelly:
When I first started in my training, there was a hard and fast rule at the V.A. when we saw patients - nobody gets a knee replacement before the age of 50. It's kind of what you taught you know. Now, when I got out, I saw as a high, not a high. I mean, not every patient, but I saw lots of patients or abundant amount of patients that came in with hip and knee arthritis or a dysplastic hip. They were born with hip dysplasia had a bad hip. Or they had a tibial plateau fracture or the end of their distal femur fracture.

Mark Rippetoe:
And there were some other reason for them for the surgery that didn't involve bony arthritis.

Owen Kelly:
And as and as people became more active in life with sports, and especially with the increase in women competing in sports at a younger age, there's a lot more wear and tear on joints. So this is my opinion on it. And I have done hip replacements in in in somebody as young as 17 who had a dysplastic, painful, hip, no quality of life.

Mark Rippetoe:
I've had people in the gym like that several times.

Owen Kelly:
I've done knee replacements... The youngest knee replacement I've done is in their 30s. I've done many in their 40s. And I get more and more every day. And here's my... And this was told me by a joint replacement surgeon because I called him and asked him. And he said, this is what I tell my patients. And this is... He believes it and I believe it too. "When would you rather have a better quality of life? When you're in your 30s or 40s or in your 60s or 70s? My answer is in your 30s or 40s."

Mark Rippetoe:
Well, yes.

Owen Kelly:
If you can become... If you're active and pain free in your 30s and 40s, you can do the things to your body that it needs to to do to be healthy when it's in their 60s and 70s. If you went to your 60s and 70s and you've had an arthritic knee for 25 years, what are the chances that you've been out walking, lifting weights...

Mark Rippetoe:
Having fun.

Owen Kelly:
Sleeping.

Mark Rippetoe:
Sleeping. Something as fundamental as that.

Owen Kelly:
Going on vacation with your family and being able to walk and look at things. I mean, if you haven't done those things, you know, why do it.

Mark Rippetoe:
Why have you been here? You know, what have you done by... All right. So. So this is so obvious an analysis that it it really needs to be emphasized as often as we can emphasize it. And I do this on the board all the time. But but look at this: People! This is your responsibility. If you if you're miserable and you can't walk and the doctor you go to tells you that now he wants to wait 10 years cuz they don't want to have to revise the surgery later on. Get another opinion.

Mark Rippetoe:
Get another opinion. This this is terribly critical. You're the one that's not sleeping. You're the one that's sitting around on your ass because you can't move. Not him. And you're the one that needs this fixed. And you cannot allow medical authority to keep you from quality of life. That's just all there is to it.

Owen Kelly:
Right. And any this any physician who is offended by a second opinion isn't a physician that you need to see. There's nothing wrong with a second opinion. There's there's nothing at all. There's nothing wrong with asking for your X-rays, seeing somebody and say, hey, I know I'm young. This is what I'm told. What do you think? And the decision for surgery has nothing to do with you on your podcast, your physician. If your surgeon is willing to take the risk with you to do it, the decision is up to you.

Mark Rippetoe:
It's your knee, it's your hip.

Owen Kelly:
Yeah. Nobody can force a physician to do it. And I don't recommend go up, people go out and doctor shop. I can't stand that. But just because you get a second opinion doesn't mean that's the right opinion. Maybe the second opinion is wrong.

Mark Rippetoe:
Maybe it could be that the second opinion is wrong and the first opinion was right. That's absolutely true. But what it all boils down to is the simple fact that it's your hip. It's not his hip. It's not my hip. It's your hip. And if your hip is preventing you from enjoying your life and from doing the things that you know you need to do to continue to enjoy your life for another 30 years, then you need to get another opinion.

Mark Rippetoe:
And this this seems terribly obvious, doesn't it? But I think that people are just, you know, "Well, the doctor said..."

Owen Kelly:
I get that. And a lot of physicians are, you know, and I'm biased -physicians are trying to protect their patients. But this is what I tell a patient who's young and we're going to undergo a hip or knee replacement. Look, there's risks to it. The likelihood of you having to have it revised is going to be high. If you're willing to accept the risks, then let's get this done. When you're... If if you're having a dime and you're 40 and you're 55 and it wears out, you and I can have this discussion. I'm 55. What to do next?

Owen Kelly:
That discussion might be, hey, we need to revise this. The discussion might be, hey, you know what? You got a good 15 years. Let's modify a little bit of our lifestyle and realize that there's some things that you were fortunate enough to do the last 15 years that you can't do anymore.

Mark Rippetoe:
Right. And now that's obviously the case. But here's another here's another scenario that that I don't think is considered often enough. You've got... Medicine advances. We've got medical advances that take place all the time. We have advances in technology. Not all of them as basic as this, but we have subtle advances in in manufacturing techniques, in metallurgy, in material science that make that potentially replaceable without much revision into a situation where it wouldn't ever need to be replaced again. You don't know.

Mark Rippetoe:
What you do know is that if your quality of life right now is bad enough that you can't do the things you need to do, then something must be done. And if you can afford the surgery, if it's available to you - God help you if you're in, you're in the UK. But if things are available to you and you can take advantage of them, you need to do it. And it's it's just a damn shame if you let somebody scare you into not getting your knee fixed when your knee needs to be fixed.

Owen Kelly:
I agree with that.

Owen Kelly:
And to jump from this subject to the subject of it and why it... People ask why is it important to have strengthened, to have a painless knee, or or a near pain free hip or near pain free knee? Because activity prolongs your life.

Mark Rippetoe:
Let's talk about that study you got with you on the table, this is boys and girls. We talk about this all the time. And listen carefully. OK.

Owen Kelly:
So if you if you pick up a magazine in the grocery store or anywhere, you go to a health webbsite, you know, unfortunately, you see unclothed male men showing that their pecs and their biceps.

Mark Rippetoe:
At 4 percent body fat. That sort of shit.

Owen Kelly:
So. The the actual scientific proof and this is an older study. There's multiple studies. The health ABC study shows that leg strength is an independent variable for life expectancy. So that means...

Mark Rippetoe:
It's an independent predictor.

Owen Kelly:
Yeah, So if you're... If it's directly proportional, your leg strength is direct, can be, or is directly important to your life expectancy. All the way back to 2006 that showed that low, lower muscle strength in adolescence is a predictor of mortality. The stronger your legs like legs are, the lower risk of mortality you get. And that's an adolescent study that that follow into adulthood.

Mark Rippetoe:
Right. Right. And, you know, it it's not hard to understand why this would be, is it?

Owen Kelly:
No. And I'm not saying and, you know, you can jump to... Anybody can give their opinion on that. But this is scientific. This is scientific studies that it's your big your actual act. Their actions actually an exercise science that these never proven. These are actual studies.

Owen Kelly:
So what what does that say that says that lower body strength, muscle strength, increases your risk of living longer. No, that's not saying if you go strengthen your legs, you're going to live longer. What that means is that...

Mark Rippetoe:
Correlation causation kind of thing.

Owen Kelly:
The more active you've been, the more likelihood it is, is that your legs will be strong. The more likelihood everything increases. There's a study in here that shows it's leg strength as a direct relationship of cardiovascular death. You're less likely to have cardiovascular deaths if your legs are strong. That's because you've been active.

Mark Rippetoe:
It's.. This is a correlation. Do you understand why? If your legs are strong, then you have been active. If you have been active, then everything else that you've done is more likely to be a contributing factor to longevity.

Mark Rippetoe:
So we're worth seeing essentially leg size, leg strength is a proxy for the lifestyle that keeps people living longer. This is an important thing to understand, but by the same token. If your knee pathology, your hip pathology, is preventing you from doing the things in life that keep your leg strength high, then that is also a proxy for a sedentary lifestyle. And - because if you can't move, you're sedentary -

Owen Kelly:
And a sedentary life is proven to be lower lifespan.

Mark Rippetoe:
It kills you. Not only is it less fun and is a lower quality lifespan, it's a shorter lifespan. And. You know. I really hate I really hate it when people post stuff on the board that indicates that their wife or their or their cousin or their father has been told to not have this kind of a procedure done. Because that's just.. it's irresponsible. It really is. You're not really thinking of your patients when you're...

Mark Rippetoe:
I'd I'd hate to say this, but I think if you place your own professional liability ahead of your patient's well-being, then I'd add you're not a doctor. I want to see. You're really not.

Mark Rippetoe:
Owen has got this absolutely right. You guys, your quality of life is is intensely dependent on your ability to use your body. And if you need a knee and you need a hip then the damn thing, OK, go ahead and get it.

Mark Rippetoe:
And I mean, how often with one of these operations is there actually an adverse outcome?

Owen Kelly:
You know, I think most surgeon complication rates, if you put all everything in there, infection, pain, all of the things, you know, ranges, you know, infection rate is about 2 percent, maybe 1 or 2 percent. You know, other problems, you know. Ninety six percent success rate with knee replacements.

Mark Rippetoe:
That's awfully good odds. It certainly as hell is better odds than the thing healing it by itself isn't it?

Owen Kelly:
Yeah, that's not gonna happen.

Mark Rippetoe:
Yeah. Which doesn't occur.

Owen Kelly:
And hip replacements are very patient satisfying surgery. Patients are very happy with hip replacements. And if you're hip has got to a point where it's that bad and you get it fixed and you're pain free... I mean, your life changes, your life changes. You walk, you you become active. You do things you haven't done before. And it does make a difference. And I'm not just promoting it because I do it. I see it every day.

Mark Rippetoe:
And you you care about your patients and. And more important than that you may have to have this done yourself one of these days.

Owen Kelly:
I hear ya.

Mark Rippetoe:
And it's it's good to have thought in advance. And we're asked what we're asking you to do is to think in advance. This may not be an issue for you right now, but if at some point in the future or if it has a bearing on somebody you love right now. This is good surgery. This is important surgery. We train people in the gym all the time. We see people every month at a seminar, 2 or 3 of them have had a knee or a hip.

Mark Rippetoe:
They all squat. They all deadlift. If they all can train, they're all active. Every one of them is happy as a clam that they had this thing replaced. And it's a it's a it's something for you to consider. And look, don't call Owen's office and bother him about it. He's got all the work he needs. This isn't an ad. This is a this is it. This is a public service announcement. OK.

Owen Kelly:
And my recommendation...

Mark Rippetoe:
In you need the thing replaced. Get it done.

Owen Kelly:
My recommendation is this is don't look for a technique. Don't look in a magazine on somebody is using this or that? Talk to a surgeon that you talk to a surgeon. If you trust him, ask questions. You're going to get the answers you want. You'll you'll know. You'll know it's right for you.

Owen Kelly:
And if you've had a surgeon that's an orthopedic surgeon and does these and and he's done things for you. He him or him or her have done things for you in the past. Trust him. Don't. Don't change surgeons for techniques. Go to go to somebody you trust. And that's the key.

Owen Kelly:
There may be, you know, all hospitals when you're in the O.R., they're all the same. You know, one hospital may have newer paint and shiny new stuff, but you're still using the same implants, the same saws, the same scalpels, the same stitches and rehab.

Mark Rippetoe:
The variable is the doctor.

Owen Kelly:
Yeah.

Mark Rippetoe:
The variable's the doctor.

Mark Rippetoe:
Thanks again.

Owen Kelly:
Thank you.

Mark Rippetoe:
Thanks for being here. Wonderful discussion. I hope that you guys have learned something today. And if if you've got somebody that that needs this information forward, this shit to them. Ok. This is this terribly important that people understand why and when these things need to be done and don't be afraid to get it done.

Mark Rippetoe:
Thanks for joining us on Starting Strength Radio and we'll see you next Friday.

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Mark Rippetoe and Dr. Owen Kelly discuss hip and knee replacements and the role of strength training in rehabilitating joint replacement patients.

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