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Melanie Cole (Host):  Welcome to Doc Talk presented by Montefiore St. Luke’s Cornwall. I’m Melanie Cole and today we’re discussing muscle sparing total knee replacement. Joining me Dr. John McLaughlin. He’s a Board-Certified Orthopedic Surgeon and the Medical Director of the Montefiore St. Luke’s Cornwall Center for Joint Replacement. Dr. McLaughlin, thank you for joining us today. Let’s talk about total knee replacement and what had been the standard. What have you been doing all of these years as far as traditional knee replacement? What muscles have you been cutting during traditional knee replacement and what’s changing now?

John McLaughlin, MD (Guest):  Well thanks for having me Melanie. So, in traditional knee replacement, the procedure is done through an incision that’s made in the front of the knee and traditionally, one or two muscles have to be detached from the kneecap in order to gain access to the knee to make the surgery possible. So, one or two of the quadriceps muscles, the muscles in the front of the thigh are detached from the knee. And that makes it a little bit more difficult to recover after surgery. While those muscles and tendons are repaired at the end of the procedure when the total knee replacement is completed; it does take the patient a longer period of time to recover as those tendons heal.

Host:  Well thank you for that. So, tell us a little bit about the new less invasive knee replacement surgery. What’s quad sparing knee replacement?

Dr. Mclaughlin:  Sure so, what’s exciting about this is we’re able now to do a knee replacement without detaching any of the quadriceps muscles. None of the four muscles that are attached to the kneecap are separated and we can work below those muscles, complete the knee replacement and it makes the recovery a lot shorter with a lot less pain and a lot quicker recovery.

Host:  So how does that happen? Is this image guided? How are you doing this?

Dr. Mclaughlin:  No, it’s actually not image guided. We do it through a traditional surgical procedure. It’s just that the location of the incision is a little different and by working under the muscles, and moving the kneecap over to one side by working below these muscles; we’re able to gain access to the end of the thigh bone and the top of the leg bone your tibia and able to do the procedure. And what’s great about this is that the patients regain their strength much more quickly because they don’t have to wait for those tendons to heal after the procedure is completed.

Host:  Well then speak about that since we’re on – talking about recovery. What’s the typical recovery time for a joint replacement versus the quad sparing knee replacement?

Dr. Mclaughlin:  One of the advantages in terms of recovery is how quickly the patient’s strength can return after surgery. With a quad sparing or muscle sparing technique that we are discussing, patients can often be walking the same day as the surgical procedure was performed. So, they can be up out of bed the same day, walking usually with some assistance but because their strength is so much better, they are able to put weight on their leg, usually using a walker or crutches in the beginning and can get up out of bed much more quickly.

That allows us to use less narcotics because there is also less pain associated with it. And they get up much more quickly and are often able to get out of the hospital in a shorter period of time. Many of these patients are able to go home the day after their surgery is performed.

Host:  Isn’t that amazing how you’re field has advanced. How long does the procedure itself take?

Dr. Mclaughlin:  The operation takes somewhere between an hour and an hour and a half depending on the type and perhaps the size of the patient. And that’s pretty typical for knee replacement. It doesn’t add any significant surgical time to the procedure.

Host:  Well tell us a little bit about how joint replacements have advanced as far as replacement implants. Is that changed in your field in the last ten years or so?

Dr. Mclaughlin:  Actually not so much over the last ten years. There’s always slight changes in the design of the implant itself but what’s nice about this procedure is that we didn’t have to change the design of the implant in order to do the procedure. We’ve been very happy with the implant that we’ve been using because it works so well. And there haven’t been any dramatic changes to implants because of the high success rate. It’s hard to make improvements when something works so well that we can just maintain the same implant but just do it through a different approach is what we call it.

Host:  That’s so cool. So, what do you want patients to do before surgery to prepare so that it will be a more successful outcome Doctor? Do you want them to be doing exercises and quad strengthening? Do you want them to lose weight? What do you want them to do?

Dr. Mclaughlin:  Yeah, actually those are two excellent points. One of the things that’s important before surgery is to exercise the quadricep muscles and the muscles that cross the knee. This makes the recovery after surgery much easier. The second point that you mentioned was weight loss. Many of the patients who undergo knee replacement have some obesity issues and if we can decrease that weight before surgery even by just a little bit, it can make the recovery much quicker and decrease the risk of the surgery significantly. So, those are the two things that we focus on. Sometimes we’ll send patients even to physical therapy before the surgery. We have a nickname for that we call it prehab instead of rehab. And that gets their muscles a little stronger, can improve their motion a little bit and can teach them a little bit about what the rehabilitation is going to be like after the surgery. So, we’ve had some pretty good success with that.

Host:  Well then tell us a little bit about what the rehabilitation is going to be like after the surgery. I would assume it’s a little bit different than when they have a traditional knee replacement. What’s different about rehab?

Dr. Mclaughlin:  It’s actually the speed at which they are able to go through that initial rehab period of time. Most patients after a knee replacement will typically use a walker to initiate ambulation to get up and walk. With the quad sparing or the muscle sparing technique we’re able to initiate that the same day as the procedure. So, if the procedure is done in the morning, usually by that afternoon, the patients are up out of bed walking with the use of a walker, putting some pressure on the leg that we operated on and getting up and walking very, very quickly. Most people will use a walker for about two weeks perhaps three weeks and then they’ll kind of progress from there. Some people will use a cane for a shot period of time but what we’ve found is that with the muscle sparing or the quadriceps sparing technique that we’re discussing; they are able to progress through that sequence much more quickly. And their strength is much better right out of the gate.

Host:  When can they get back to their activities like driving a car, even taking walks, doing any of those kinds of things? I understand you get them up pretty much right after but what about resuming their normal life?

Dr. Mclaughlin:  So, what I usually recommend for patients is in terms of driving, is we like them to obviously be off the walker which I mentioned can be sometimes in as little as two weeks, sometimes two to three weeks and we just have to be a little careful with them driving if they are using any pain medication or any narcotic medication. We obviously don’t want them driving under the influence. But many of my patients with the muscle sparing technique are driving around the two week mark or a little shortly thereafter.

Host:  And you mentioned pain management. And you said that it certainly might be less with this quad sparing technique. How is pain managed after joint replacement surgery and what’s different with this less invasive technique?

Dr. Mclaughlin:  What we’ve seen with these patients is that the need for the narcotics or the use of the narcotics after surgery is decreased which is terrific. We are really trying to minimize the use of opioids around the time of surgery. Patients using less narcotics are able to participate in physical therapy a little more aggressively, are less sedated and can move around a lot quicker. We use a combination of different medications, one of them is a narcotic and two of them are not narcotics so it doesn’t affect their level of consciousness or their breathing and they are able to participate in therapy right away. And most significant is that we have found that these patients use less narcotics, less pain medication than patients undergoing traditional knee replacement.

Host:  Doctor, before we wrap up and very importantly, we’re hoping not to have to need a knee replacement. What is your advice for keeping healthy knees? What do you want us to know about things that could affect our knees whether it’s footwear or the sport activities that we do or our weight or any of these, osteoarthritis, any of these other things that could affect our knees and cause us to need a replacement.

Dr. Mclaughlin:  Sure, so there’s probably three things that we have some control over. One is our weight as you mentioned. By keeping our weight down, we decrease the forces placed across the joints in our knees and can decrease the rate at which we wear down the cartilage and develop osteoarthritis. So, weight control is very, very important. The second one is exercise. We do want you to move and to walk and to exercise with low impact, I would not recommend running or high impact activities in someone who is already suffering from some degree of arthritis. But walking, exercise, biking, swimming, low impact activities can be very, very important to delay the need or hopefully even avoid the need of knee replacement later in life.

And the last part is avoiding injury. So, having injuries in your past, meniscus tears, fractures, ligament injuries do increase your risk for knee replacement down the road. so, injury prevention is very, very important.

Host:  And Doctor, tell us about your team at Montefiore St. Luke’s Cornwall.

Dr. Mclaughlin:  So, our team is just vital. We have a whole team of people everybody from the admission process, the nurse that meets you and our pre-education class, the nurses on the floor that take care of you after the surgery as very specifically trained nurses and we continue to work with the same small group of nurses who gain a tremendous amount of experience treating these patients. And then obviously the team in the operating room which is typically a nurse, an anesthesiologist, and a surgical tech which are all there and have done hundreds of cases with us, who gain a tremendous amount of experience in doing these types of cases.

Host:  Thank you so much Doctor, for coming on with us today and telling us about this less invasive technique for knee replacement. Thank you so much again. That concludes this episode of Doc Talk presented by Montefiore St. Luke’s Cornwall. Please visit our website at www.montefioreslc.org for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Montefiore St. Luke’s Cornwall podcasts. For more health tips just like you heard here follow us on your social channels. I’m Melanie Cole.