Transcription:

Melanie Cole (Host): Several conditions, such as osteoarthritis, can cause joint pain and disability and lead patients to consider joint replacement surgery. If nonsurgical treatments like medications, physical therapy, and changes to your everyday activities do not relieve your pain and disability, your doctor may recommend total joint replacement. My guest today, is Alon Antebi. He’s an Orthopedic Surgeon who specializes in Trauma and Joint Reconstruction, and he’s a member of the medical staff at the Palmdale Regional Medical Center. Welcome to the show, Dr. Antebi. What conditions would lead someone to these kinds of pain and disability, decreased range of motion? What are we talking about as far as conditions?

Dr. Alon Antebi (Guest): The most common condition that would lead to somebody having a joint replacement after they failed conservative treatment includes osteoarthritis. There are different forms of arthritis that people can have. Osteoarthritis is the most common. Osteoarthritis is what we consider wear and tear of a joint. It’s usually not hereditary, but there are forms of hereditary arthritis. This one is one that is usually associated with people who are in the middle to late ages in life.

There are other forms of arthritis, including rheumatoid arthritis, which is more of an inflammatory arthritis. This is where your body actually attacks the joint, and it’s what we call an autoimmune arthritis. These people – these patients’ population could be younger or could be older. Usually, in the younger stages, we try to treat them with medication, injections, physical therapy, but as they also continue to age, their joints just get completely eroded and destroyed.

Melanie: Dr. Antebi, is it true that you’re seeing younger and younger patients that are coming to you with hip issues and even knee issues, and possibly needing replacements in their 40s and 50s, which you didn’t used to see?

Dr. Antebi: Absolutely. Back when I was in training 15 or 20 years ago, the average age of a person needing a hip replacement was probably somebody in their 60s and 70s, and today, it’s early 50s. Most of my patients today requiring hip replacement are in their mid- to late-50s. That’s usually where we see a lot of the patients. A lot of this has to do with genetic factors. I’m a firm believer in people’s diets, in addition to some people are just born with bad joints. There’s a condition called congenital dysplasia of the hip. Essentially, even a lay person may look at an X-ray of the hip and say, “Hey, that’s just a normal looking hip.” Us, as orthopedic surgeons, we are trained – or especially people who specialize in hips and knees -- were trained to look at an X-ray a little bit different, at more of the small intricacies of the hip.

The best analogy I can give you is, for example, when somebody buys a car, they have four brand new tires, but one of the wheels on the tires is just not rotating right. The car may go for 15, 20,000 miles, however, as the car continues to accrue more miles, the tire on that car will wear out because that tire is just not well-balanced on that hip. It’s the same analogy for people’s joints. If the joint is not perfectly balanced – for example, in the hip where you have a ball rotating with a socket. If that socket is not perfectly formed as the person ages during their adolescent years, then that hip will wear out before its time. This is why with today’s society when people are playing multiple sports during school and teenage-hood, they’re a laborer during their life – or whatever career they’re doing, their hips just wear out a lot earlier. People know it because they come in with severe pain.

Melanie: Doctor, in the intro I mentioned non-surgical treatments as a first-line of defense. When would the total joint replacement be recommended?

Dr. Antebi: Right, so when I speak with my patients in regard to Osteoarthritis, everybody responds to pain a little bit differently. We try to treat most patients similarly in regard to conservative treatment. One of the things that we do when I first meet a patient with arthritis of a joint is obviously, get a history. How long have they been having pain? When did it start? How often is it? How long can they walk before they start having pain? Are they using a cane or a walker? Are they taking any medications? Have they tried any medications? We want to make sure that these people are taking a conservative route before undergoing any surgery.

Most of the time, we try an anti-inflammatory, whether it’s over-the-counter or prescribed – something like ibuprofen or Aleve – and to see if that alleviates the symptoms. A lot of times somebody can have moderate to severe arthritis, and just a one pill medication can alleviate a lot of their pain where they can go on and function during their daily activities. However, most patients, by the time they get to me, they’ve already tried that.

Then, there are other things that we can do like physical therapy. If we’re talking about the knee, we can do a brace on the knee to help with the symptoms. None of these modalities will cure your arthritis. People need to know that. It will not cure your arthritis. Your arthritis will continue to progress as you put more miles on your joints, as you continue to age and remain active.

Other things we can do are injections both in the hip and in the knee. Injections include – there’s three different types of injections we can do. We can do what’s called a corticosteroid injection, which is a Cortisone injection as people would know. That basically coats the joints, alleviates some of the inflammation in the joint, and is a temporary fix for arthritis. It will help alleviate the pain, and it can last anywhere from a day to a year. Everybody responds a little bit differently.

Other things that we can do are what we call viscosupplementation. This is almost like a clear-looking gel and mostly prescribed for knee arthritis. It’s a series of anywhere between one and three injections separated by a week. Again, another modality to try to help with pain. And lastly, is what we call a stem cell injection, or PRP injection, which stands for Platelet-Rich Plasma Protein, another modality that I offer patients. However, a lot of those type of injections are usually not covered by insurance, and people have to pay out of pocket for those. Those can help symptoms as well.

Once those modalities are exhausted, and people are just continued in pain and their symptoms are not alleviated, at that point, they become a surgical candidate as long as they continue to have pain, and their X-rays and other radiographic modalities correlate with their pain. They need to have validation of X-rays showing they have a bad joint as well.

Melanie: What is surgery like these days, Dr. Antebi? And what are some of the unique advancements that you’ve noticed whether it’s in material or in positionings – such as the anterior hip replacement approach – or any of these kinds of things that you can tell patients about that let them know that this is not quite your grandmother’s hip replacement or knee replacement?

Dr. Antebi: Sure. There’s several technicalities and factors that one needs to consider when having a joint replacement. The first thing is the technician – what I mean by that is the surgeon doing the surgery. People are always concerned about what kind of material is it and how long is it going to last me and everything else? You can take what I call the Ferrari of a hip replacement, and if a surgeon doesn’t do a good job, then that implant will fail no matter how good it is it will fail. Or, the patient will have what we call dislocations. If the hip implant is not positioned correctly in the body, the person can pop the socket out every time they move their leg a certain way if the hip implants are not positioned correctly.

There's different what we call bearing materials when we use – when we're talking about hip replacements. What we mean by that is what is the articulation made out of? About ten years ago, the big Panacea was what we called metal-on-metal articulation where you have a metal socket and a metal ball. Anytime you have any two surfaces grinding together, there will be those particles eluded into the soft tissue, so metal-on-metal will produce metal shavings. These are microscopic – something you cannot see. And then you have metal-on – what we call polyethylene, which to the lay person will look like a white piece of plastic, or you can have a ceramic head on the polyethylene or on the plastic. What I tend to use is the ceramic of the polyethylene plastic, which is what we found, study after study, to show that it probably provides the best wear rates. What people are looking for is something that will last them the longest with the least amount of morbidity or complications associated with it.

One is the surgeon, two is the components used, and three is the way the components are put in. Anytime somebody has surgery there are always risks. Usually, orthopedic surgeons are always concerned about three major risks. One is bleeding, which everyone bleeds. If you have a heart pumping on the table, you’re going to bleed a little bit. Two is infection, and then three is blood clots. As surgeons, we try to minimize all of those by giving you medication before you even undergo surgery. Right before, you get a medication called Tranexamic Acid. This is an IV medication that is given through the IV or can be put in locally to help minimize bleeding during surgery. In addition, you also get antibiotics before the knife ever touches your skin. That is in your blood all ready to fight any potential bacteria that may enter the wound. You also get antibiotics after surgery, about three to four doses.

In addition, after the surgery, you are put on a blood thinner. There’s a big variation between surgeons around the country and what they like to use. Some people use prescribed medication. I use Aspirin for about three to four weeks after the surgery in addition to using what we call a mechanical device, meaning either a compression sock or pumps on your legs to try to help promote circulation. Anytime blood is stagnant in an extremity, especially after surgery, there are always risks for blood clots.

Melanie: What an amazing explanation, Dr. Antebi. I can see that your patients really get the answers from you and that makes them feel much more confident. Wrap it up for us, and in summary, what would you like to tell people who are considering joint replacement surgery, and what you would like them to know about this big decision.

Dr. Antebi: Sure. A lot of people come to my office saying – whenever they come in, they’re very anxious and apprehensive about what we’re about to say. I always tell them that surgery is not mandatory. You can live with arthritis for the rest of your life if you want, but you will be crippled. You will not be able to get out of bed comfortably. You won’t be able to take your dog out. You won’t be able to play with your grandchildren. I tell them that this is not something that we will force on you. This is something that you need to choose as long as you are a candidate, and that makes them feel a lot more comfortable when they come to my office. We also make sure they are exhausted conservative treatment.

Now, once they come in and the surgery decision is made, they are still a little anxious about it. Usually, the biggest anxiety or the biggest fear that they have is a pain. Now, with today’s modern surgical techniques, we institute a whole protocol – at least in my practice – that controls the pain. Before a patient goes back to surgery, they are given what we call a cocktail of medication, so the pain medicine is already in the bloodstream before the body ever sees pain. And then, the anesthesiologist comes in play, and we have different modalities with blocks, and injections, and spinal, and light generals, to try to minimize pain during surgery, and when they wake up they have no pain because they already have pain medicine that I injected in the hip or in the knee during the surgery. They literally wake up with no pain. They are absolutely amazed. Most of my anterior hip replacement patients go home the next day, and I'm actually doing them as an outpatient in some facilities as well. I have done them outpatient at Palmdale Regional Medical Center where somebody comes in in the morning, has their hip or knee replacement done, and they’re home by the afternoon.

Pain is the biggest apprehension that people have. Now, not everybody is healthy for a joint replacement. Some people have diabetes, high blood pressure. They may have cholesterol problems. They may have other medical issues, but again, treat it appropriately and medically optimized by their primary care doctor before surgery, the complication rate is very low in the right hands with joint replacement – less than 1% is what the studies usually quote.

Melanie: And tell us about your team at Palmdale Regional Medical Center and why the listeners should come there for their care?

Dr. Antebi: Sure. I do probably about three to four hundred joints a year at Palmdale Regional Medical Center, and without the team, I would not be able to do that. The first starts with the people when you come in at the admissions. They’re the ones that are taking your history. They’re the ones checking you in. They’re the ones starting your IV. They’re the ones giving you that cocktail medication that we talked about.

Then, we talk about the surgical team, which is the team in the operating room. With each total joint that I do, I have three or four assistants in the OR that are trained to help me, so I don't even need to ask for anything. I just put out my hand and that device or instrument or hammer or saw – whatever it is, is in my hand. We do so many of these; they anticipate my moves. It’s kind of like when someone’s on the dance floor. You don’t need to tell them to twirl or lift up their leg; they already know what to do because they practice it so long.

And lastly, the post-op recovery. Once you are awake and actually know what’s going on – in the recovery room and in the post-surgical suite at the Joint and Spine at Palmdale Regional Medical Center, we have trained physical therapists as well as nurses who take care of you and make sure that your pain is controlled, your nausea – if you have any – is controlled, make sure that you’re eating, make sure that you’ve got your fluids going, make sure that you’re doing the appropriate exercises. Each person has a task as to know how to treat each patient. And if God forbid, there is a small complication, they immediately contact me, and we address the issue.

Melanie: Thank you, so much, Dr. Antebi. What great information for listeners. Thank you, so much, for being with us today. You’re listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to PalmdaleRegional.com, that’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks, so much for listening.