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>> Well hello and welcome to HealthLine this Tuesday evening.

I'm Jennifer Bloomquist.

I'll be hosting the program tonight.

I'm so glad you joined us.

We have a wonderful guest, a returning guest who's been with us many times.

It's Dr. Jonathan Lynch who is an orthopedic surgeon we're going to be talking about outpatient joint replacement is amazing the things they can do and you don't even have to stay overnight in the hospital.

It's amazing.

So we're going to be talking about that.

We have the phone number up at the bottom of the screen as you'll notice.

We're going to keep it up throughout the show because we'd love you to call in and ask Dr. Lynch a question.

Free advice.

You can't be that.

So it's (969) 27 two zero if you're outside of Fort Wayne it is still a free call as long as you put it 866- in front of there and want to remind you in case you're new to this program you have two options when you call in.

The first option is one I like the most.

It's allows you to interact with Dr. Lynch so you can call in, you'll talk to a call screener first and then they will let you ask your question.

That's nice because Dr. Lynch can talk to you.

Maybe he needs more information from you to give you a better answer.

The other option if you prefer not to ask life is to just tell the call screener what you want to know and they will relay that to me and then we'll get your answer for you that way.

So either way you get a great answer but wanted to let you know your options.

So let's go ahead again if you are a regular you probably have seen Dr. Jonathan Lynch a number of times with us so we appreciate you coming back.

>> It's great to be back.

Thanks for having me.

Thank you so much.

Of course we've been doing orthopedic programs for a long time and I know even when I started doing this show 16 years ago the theme is always you know, you start conservative surgery is kind of the last resort after you've exhausted all other possibilities.

But I have over the years been amazed at all the things they can do and you don't have to stay overnight in the hospital.

The outpatient is really the big trend.

>> Yeah, absolutely.

And that's that's why I picked as a topic is because I think to the patient it can be a little bit confusing and surprising to hear that you're going to get your joint replaced and suggest to go home the same day.

And as I was preparing for the show and I kind of thought back, you know, it was twelve years ago when I was in medical school and often patients would stay several nights everybody would be put on Coumadin warfarin which is, you know, rat poison essentially.

Yeah.

So you'd stay in the hospital till that that got to an appropriate level and then you were discharged after that.

So you used to be several days and so now now we're doing about half half of our joint replacements are going home the same day and that's that's kind of a nationwide number about have people go home the same day so it's become quite popular and I think a big part of that has been covered .

So during covid we couldn't keep people in the hospital because there wasn't capacity but there was a lot of people still need joints replaced and during that time a lot of studies were done to look at readmission rates, complications, patient satisfaction scores and really all of them were in the positive.

So patients tend to like going home.

You know, they can get up and move around.

A lot of times the complications actually go down because you're less likely to get a blood clot.

You get moving quicker.

The recovery started faster.

So we found that safe and effective.

But I think like throughout the shows we talk like it's always going to be the number one factor for us is safety and it's always going to trump anything else.

And so far we're concerned we still have the ability to keep people overnight, keep them in the hospital and safety will certainly always trump anything else.

>> I agree just from having surgery, various surgeries over the years with my children.

I mean they just want to go home and nothing against the hospital.

I mean I you know, it's you really the joke was always hey, if you want to get rest don't go to the hospital because they do they do come in to your room a lot and even you know, even just when I was having children it was like can I sleep?

>> You know, the first night I get yeah we just go right right.

You just don't get a lot of rest and yeah you're in your familiar surroundings so I can appreciate that.

>> Yeah for sure.

So how what kinds of things do you have to evaluate eight or consider before you tell somebody whether they can do it as outpatient and that's a common question we get because a lot of times we'll have patients go to like a class beforehand and get educated on the process.

Yeah, some people will be like awide my doctor I and I got to go home and ultimately it's it's unfortunately it's a little bit of an art and it's not a perfect science yet at this point.

But the biggest factors are tend to be like age whether or not you use the aid at baseline and what kind of help you're going to have at home.

So those tend to be the biggest thing.

So if you're younger, if you don't use any military aid, if you have good social support, those are people that are typically going to do well going home.

We certainly look like medical comorbidities.

Right.

So obviously more comorbidities, Secher.

Other things that that come into play typically people who are on narcotic pain medications that's a big red flag because we want to make sure pain's controlled who usually if you're on a narcotic before surgery we usually want to keep you for that reason I see a history of urinary retention, another common one that there's certain red flag ones.

But in general if you're like somebody who's otherwise healthy walks without any military aid and has good support at home and is motivated to go home, you're probably someone who is able to go home.

So they're scoring systems that take that on to account but that's kind of a generalized kind of overlook it.

And you know, as you kind of work through the algorithm, you make sure that that people check all those boxes and if they do then we typically try and encourage them to consider going home if they can.

>> I had somebody tell me because I was writing an article about an ambulatory surgery center that was being built out further out west like in Kosciusko County years ago and they were they kind of referenced insurance that insurance loves the outpatient.

>> So I don't know if that kind of played a factor because I'm assuming it lowers your cost.

>> Yeah, well so actually like for like for Medicare and it can actually be a confusing part for patients because every outpatient every joint patient for Medicare right now is outpatient.

So whether you stay the night or go home, it's basically Medicare is way like they're going to basically reimburse the same regardless if you stay or not.

But so the onus is on us as physicians to make sure we do the right thing for patients.

So obviously we still keep them a night in the hospital if that's the right thing to do.

>> But yeah, but like for Medicare, everything is outpatient.

So some people are confused by that because we're like well why am I thinking that if I'm considered outpatient but that it's a few years ago total total hip and total they were taken off the inpatient list so they're all considered outpatient outpatient.

>> All right.

So I just want to remind people that we love to have Dr. Lynch with us all night but he has a family to go home to and the show ends at eight o'clock.

So call if you have a question call sooner rather than later.

It looks like we're getting somebody calling right now but our phone lines are available and open and we have a really nice call screener that you get to talk to.

I should tell you that they don't just throw you on the air.

You do get to talk to somebody first.

So if you're a little nervous for that reason, don't be.

But again, there's the number at the bottom of the screen (969) 27 to zero.

>> Let somebody ask you a question right now but I don't have the full question on the computer screen so we'll we'll just keep talking a little bit and it doesn't necessarily have to be about the outpatient joint replacement if there's something else orthopedic related.

I think Dr. Lynch could at least you know, even if it's not his particular specialty could could help you out there so the the one question I had was are there any particular tests that you have to do to be considered for the outpatient ahead of time?

>> I know you had mentioned some of the factors so there's not really a specific tasks like like I said, we do have our kind of old algorithm.

We put patients through to see if they'd be a candidate for our patient and if they are then then we consider it for that reason.

I'd say the biggest difference is all the work is done ahead of time now.

So it used to be that you'd come you'd get your surgery done, you get admitted then the therapist would see you afterwards and you figure out you know, are you going home or rehab ?

I used to be the old take notes are you staying or going home typically OK and instead of doing that we're having patients see the therapist before surgery so they're doing a one time visit with the therapist before surgery.

So they have an idea of how what's going to be like getting around on one leg after surgery.

We do a class before the operation.

We do all our teaching ahead of time.

So really when they hit the door on the day of the operation, hopefully they know everything that's coming their way, you know, helps them get through the process because it can be a relatively quick process.

Some people are you know, in and out of the door within, you know, five five to six hours and you know, so it's obviously way so you get the biggest difference I'd say is is making sure all that work is done ahead of time so patients are well prepared come to have surgery.

>> Yeah, I know a lot of I've seen at the doctor's office a lot there's a lot of brochures and things now.

You know they they definitely do a good job of informing you.

I feel like if you're going to be going through some kind of procedure at least give you a heads up as to what to expect.

So we do have that call that came in but it was someone who wanted me to ask the question for them was Walter who called and he wants to know.

Dr. Lynch, are there any new procedures for shoulder joint replacement if you are a seventy five year old?

>> Yeah, sure.

So there is, you know, a couple of shoulder replacement options.

I don't do them specifically but I do know enough tried to answer the question.

So in the in the past a lot of times people get what's called rotator cuff or through apathy where you basically we get a really bad rotator cuff tear and you'd get a very degenerative arthritic joint secondary to that and you couldn't really do a shoulder replacement because the original shoulder the standard shoulder replacement total shoulder replacement relies on your rotator cuff to hold the joint replacement in place.

There's a newer one called a reverse total shoulder which has been a game changer for shoulder replacement.

Basically it switches around the ball and socket.

It's very hard to kind of understand or explain but by doing that you don't need the rotator cuff muscles anymore and it's able to function in the absence of those muscles.

So it's essentially able to treat very difficult conditions and patients that may have advanced rotator cuff disease it's based off the age that you're asking would be something in consideration.

So the short answer would be reverse.

Total shoulder is part of the newest shoulder procedure that has certainly been a game changer for those difficult situations.

>> All right.

Well, we appreciate Walter calling in with that question a great question and I want to encourage anyone else watching.

There's really almost nothing that's really free anymore.

But you can ask Dr. Lynch a question for free.

So why don't you take advantage of that and give us a call?

It's (969) to seven to zero again, we've been talking about outpatient joint replacement but Dr. Lynch said if it was anything else orthopedic related you'd be more than happy to help you out.

>> So give us a call.

Do you ever come into I wondered if you ever come into a case where somebody is prepared to do this on an outpatient basis but maybe something changes once you're in the procedure or afterward and then they have to stay overnight or there's some, you know, unforeseen factors that can occur.

>> Yeah, absolutely.

I mean I'd say the most common is like hypertension after surgery is pretty common thing to see and sometimes the blood pressure can drop enough to want to just be on the safe side and keep them overnight.

That's the most common thing we see.

So I think kind of going back into kind of the algorithmic approach, you know, when you see a patient, you know, their medical comorbidities coming in and kind of can anticipate it, those are patients that you more want to do in a hospital setting at least because in the hospital setting you have the ability to then keep them overnight whereas a lot of surgeries are done in an ambulatory surgery center now to see a lot of the downside of that is you don't have admitting capabilities if something does come up or you can't keep them.

So like you know, depends on the practitioner and like I'm fortunate to be in a practice where we have both options available so we're able to kind of triage patients appropriately but so I think that's the bit that goes in mind for like any surgeon if you're going to take a patient to ambulatory surgery center, it's going to be someone that you have a very low likelihood of needing to keep them overnight.

>> OK, yeah, I didn't think about that.

I'm assuming everybody would have this done would need physical therapy for a while afterward.

You kind of talked a little bit about that.

So I I make it a requirement that everybody see a therapist before surgery just to get baseline you know, some baseline exercises for rehab and some idea of what to do afterwards after hip replacement.

Right now it's sometimes utilized it's not always utilized because there's been some studies to show that just going about the exercise program and walking gains back the ultimate strength that you're out whether they do therapy or not in knee replacement.

It's no doubt for almost every surgeon a critical part of recovery because without therapy to really regain that motion the knee can get very stiff which is you know, is very detrimental to the outcome.

So therapy for all knees after surgery is is very important and typically starts two to three days after surgery.

>> And if you have this done outpatient, does that necessarily mean your restrictions are going to be lifted sooner as I mean yeah.

Or is it kind of the same no matter what your situation is?

>> Yes, it's the same as OK. And if you would typically if it didn't have to I don't know would it be less invasive necessarily at an ambulatory or it's the same thing yes.

Exact same thing.

So that's one thing that's kind of you know talked about at our meetings and things like when you when you are doing patients outpatient you have to consider a lot of the factors at play in terms of what could hold you up or what could, you know, lead the patient staying the night or being ready to address those.

But in the end the message is we're doing the same operation.

We're not doing anything differently.

But yeah, considering you know, considering surgeries that are going to be more amenable to our patients, obviously we're not doing typically like revision surgeries or surgeries where you're going to have more blood loss and things like that.

>> But a standard typically a standard total hip and total knee no matter what approach is done like there's not necessarily a less invasive approach.

You know, you could do any approach to the hip and and those are considered outpatient procedures now.

>> So all right.

Yeah, we have a hip that always shocks me when they say those patients are up walking that night that that just seems amazing.

But I know I know many of your colleagues have said that's just how they do.

Yeah, I believe it used to be like a week in my hospital.

Yeah.

Years ago.

Yeah.

So get them walking right away.

It's amazing and I think that's been a huge benefit especially for like blood clots because bookless you might be worry and I think you know we really look I mean we're basically for most people we're doing baby aspirin twice a day now.

So like at the start of the show we talked to everyone got Coumadin.

It's you know, I was right now we're trying to get everybody off coming in and people are on Coumadin.

We're trying to get them on a different oral anticoagulant that's less risky in terms of bleeding.

Yeah.

And so people aren't on a blood thinner medication like that.

>> We're typically just doing a baby aspirin twice a day so.

Right.

Yeah, yeah.

That's we've come a long way.

So we had another gentleman calling wanted me to ask the question for him.

So he is this is Brian who wants to know how long does it take to recover from a total hip replacement and to be able to walk normal again?

Yeah so I know they get you up that usually within hours of the surgery but I'm assuming you're maybe I don't know do you maybe have some kind of assistance with a walker at that point?

Yeah.

So I mean total hips you know I typically tell patients by six weeks or 90 percent recovered but most people are six weeks compared to where they started are typically ecstatic.

I mean compared to what they were they feel like one hundred percent better per say but the less you know, the recovery of like the muscles and your biomechanics and your takes really a full year.

Oh, but for most people it's about two weeks of using some sort of assistive device whether it be a walker or a cane and then some people are off it sooner than that.

I mean realistically within a couple of weeks people are I mean people are right away better than what they were because of the pain they had there is gone.

But the surgical pain in the muscle tends to linger for the first few weeks after that.

>> After that by six weeks I'd say 90 percent recovered.

That's pretty big.

I mean in the grand scheme of things I'm sure when you're in the thick of it it seems like forever.

But when you look at the big picture, you know, a whole calendar year, six weeks isn't you always, you know, impasto as I've said the same hips always a little easier to recover from than the knee.

There's a lot of people that from from what they tell me they're experiencing going through a hip replacement from like day one even they say their pains sometimes and this doesn't go for everyone but for some people like the pain is actually less within the first few days even just because the pain can be so excruciating from the arthritis is a different pain.

Obviously I always counsel patients expect the pain to be worse for at least a couple of few weeks but I set the bar a little bit low for a lot of people it could be a relatively rewarding procedure pretty instantly which is nice.

>> I was going to say sometimes if those people if it's bone on bone, you know you have a situation.

Yeah, yeah.

If it's interfered with your everyday life I would think that would be a big change just right.

>> But it's mind boggling even for the surgeon to go the day after and have patients have no pain and this is not it's not a non invasive surgery, you know.

>> Yeah.

So that's nice to see people bounce back quickly.

>> Wow.

Yeah I'm sure just there's got to be a different you know there's surgery pain but then the pain that they were used to living longer every day that's probably a nice break.

We have a lot of folks tonight I'm sorry nobody's calling in line but I still I'm glad you're calling in so this is from a woman named Jun and she wants to know when would you know when it's time to get a hip replacement.

>> She's wondering like is there a certain type of pain level that you would notice and when you have to go to the doctor or is this one of those things where you say to the patient it's up to you the patient to decide a little bit so so how I always run it?

>> June is typically we'll get an X-ray of the hip and from my standpoint if there's still some good joint space in your hip like it's not completely eroded through the cartilage or there's still a little bit of joint space left, then we'll typically talk about doing conservative measures whether it's anti inflammatories, physical therapy, stretching or consideration of a cortisone shot in the hip once he gets bone on bone where there's absolutely no joint space left.

That's where I throw out the option of surgery and that's when I say that, you know, ultimately it's up to you when you're at the point in your life where you can no longer don't want to live with this pain anymore.

I can predictably tell you that you'll do well with surgery because there's no cartilage left there.

So you know it is it's only up to the patient when it gets to that point truly being born on bone before being bone on bone I really counsel hard against you know, just not not everybody that comes in with hip pain needs a hip replacement.

That's not going to certainly be the right thing for everyone.

So some people come in, you know, requesting a total of when you don't need it.

But once his bone on bone and you're miserable those are the patients that very predictably are going to do quite well.

So it really depends on the the progression of the disease along with your symptoms I'd say yeah, I've heard that I know about Nees that that usually is left up to the patient like you know the physician will say well you tell me when when is it to the point where it's interfering with your everyday activities.

Exactly.

So but I guess because it is you know, it's an elective surgery and by elective yeah.

Being up to the patient it's not emergent doesn't have to be done but obviously something that's not covered by insurance.

>> So what I'm just curious is the hardware different that you use in these replacements depending on what it is?

>> Are they all made out of the same material?

So typically for like total hips it's a titanium always the newest one.

So the reason of that is it's a very similar stiffness to bone.

So OK, older materials were made out of cobalt chromium or stainless steel and they were too stiff and so people would notice it because the where the the implant contacted the bone there was a transition of modulus sakal but essentially it became too stiff and you're more likely to notice that.

So the titanium is very close to bone in terms of its elasticity properties.

So the hip implants are made of titanium.

The bone actually grows to those implants and the articulation where the cartilage used to be is ceramic on polyethylene typically sometimes it's ceramic on sometimes it's ceramic on ceramic.

That's what used to be metal on metal and you heard metal on metal.

That's where the ball was touching metal socket.

But those ones unfortunately found had some of them not all of them but some had issues were no longer putting those in sometimes sometimes having to revise those.

OK, so that's that's material on the hip side the knee it's a cobalt chromium implant poly I can't remember was you or one of your colleagues brought in the the hardware for the knee and I was shocked by how heavy it was.

>> Yeah it was pretty quite a bit it was one of my colleagues down there about that and but yeah it is yeah yeah it was it was just heavier than I thought.

>> Yeah.

Some people and I think they did it some studies that show that actually what you take out and is pretty similar to what we put in because some people ask like how much weight do I get.

So if you hold it it's not like super light I guess but that is that the titanium for the it's actually cobalt chromium on the femur and the tibia is titanium and the plastics polyethylene and so those are the three most common materials and it's usually a one and done right.

>> I mean yeah I normally wouldn't anticipate having to repeat.

>> Yeah.

So especially on the hip side the biggest improvement that has been made is actually on polyethylene so original hips were cemented in and we still cement some hips in especially in poor bone but most of them are press fit where the bone actually grows to the implant.

So people used to think that there was problems with the cement and they and because the cement was actually the plastic was wearing out very quickly.

And so they've reinvented the way that the plastic sterilize and process wears out very low.

So we expect hips to have a very good longevity like right now the longevity is about ninety five percent at twenty years which is pretty good.

>> That's twenty years ago but the ones today we expect to last a long, long time so people are in their teens and 20s getting hip replacements because they obviously they need it but it used to be we got to just make you wait until you're at little a little older but why make someone suffer if we can fix them now?

>> Yeah, I actually this last summer I met a young girl, a high school age girl who had to have a hip replacement but so there are some kids you have didn't think there's a fourteen year old not by me but someone else I saw fourteen year last we got a hip replacement did great.

>> So crazy kids all right.

Yeah we have a couple I know if we can squeeze a couple of these in can you just quickly give us a TED call.

>> They want to know the definition of arthritis.

Yeah very good question.

So there's different kinds of arthritis.

The two most common we see is osteoarthritis in rheumatoid arthritis the majority of joint replacements are osteoarthritis and it has to do with loss of cartilage at the joint and then kind of destruction of the capsule's and contraction of the ligaments around the joints.

So the underlying factor though is basically the loss of cartilage at the joint is what osteoarthritis is rheumatoid arthritis is a completely different type.

It's an inflammatory arthritis so it actually has to do with a auto immune response around the joint.

So it's actually inflammation of the lining around the joints of the lining is attacked first in the cartilage is is actually second to go in the disease.

But those are kind of the two most common forms of arthritis and for osteoarthritis it's a bit of a misnomer because it's actually not an inflammatory process because itis it means inflammation but um but nonetheless.

>> All right.

And I know if we could squeeze this other one in really quickly, Susan wanted to know how soon do you start physical therapy after head of knee replacement typically two days after so usually work at you in the therapist's office two days after because we want that I want that knee starting to move and we want to avoid any scar tissue from forming so usually to date we say I mean we say two to four business days depending on your surgeries done because I'm sure it might not be till Monday but yeah.

>> And then I we can't use the name of this.

She wanted a certain I think certain type of a drug because we can't promote anything in particular.

>> But do they use some kind of a block.

Yeah I know the block is it's called a cryotherapy or kronur or lysis we're basically freezing nerve's around the knee and it's becoming more popularized.

It's not yet approved by all payers yet I look forward to the day when it is because there's been some studies to show that it does decrease narcotic use and helps with nerve pain after surgery which I think is a lot of the pain we experience.

So if it's something that is covered by insurers, I usually advocate for it.

We usually try and get it done.

But essentially I think what she's referring to is kind of freezing of the nerves before surgery is done within a couple of weeks of surgery and I think it is showing some promise and benefit.

>> All right.

To be continued.

So all right.

Thank you so much.

Wow.

You're inundated with questions which is a good thing.

So again, this is Dr. Jonathan Lynch and we're so grateful you were with us tonight.

Thank you so much.

Thank you for having me.

Well, thanks.

And our time is up unfortunately go so fast.

I'm Jennifer Blomqvist.

Take care everybody especially there's me some severe weather tomorrow.

So keep keep yourselves alert for that and be safe and we'll see you next week here on HealthLine.

>> Take care.

Bye bye.