You can now watch the online webinars given by the Physicians of Proliance Orthopaedics & Sports Medicine when it’s convenient for you! We record our live webinars, and you can watch them on-demand.
WEBINAR: Robotic Joint Replacement – The Future is Here
PRESENTER: Dr. Christopher Boone
Simply CLICK HERE and you’ll be able to view the webinar in its entirety at your convenience.
The transcript from the webinar is below:
Moderator: Welcome everyone. Thank you for joining us for today’s webinar on Robotic Joint Replacement with Dr. Boone from Proliance Orthopaedics & Sports Medicine. Please feel free to submit your questions for Dr. Boone in the private chat box on the right-hand side of your screen. These questions just go directly to Dr. Boone, and we will follow up with them at the end of the presentation. And if we don’t get to your question today, we will follow up with you directly after via email. And with that, I’m pleased to welcome Dr. Boone.
Dr. Boone: Hello, my name is Dr. Boone orthopedic surgeon at Bellevue Proliance Orthopaedics & Sports Medicine. I practice mainly at Overlake Hospital, Evergreen Hospital, and then I do some cases at Swedish as well too. Just a little bit about me. I grew up on the East side, so I grew up North of Spokane, went to medical school over here at the University of Washington.
Dr. Boone: I left the area, went to Michigan for residency, and then back to the West coast for my fellowship. And I’ve now been back in the area for about seven or eight years now. My whole family’s from here, my wife’s family’s from here. So I’ve been a native Washingtonian for a really long time. It was definitely the first time I’ve done, one of these things as webinars because of the COVID status.
Dr. Boone: So if you guys have any questions or anything send the question and I’m happy to try to answer it. Some of them may be good questions for everybody. So if it’s possible, I may repeat it without obviously disclosing any health information or anything like that. But my presentation is mainly going to be about where we are in joint replacement surgery. So hip and knee surgery, and specifically robotic assisted joint replacement, which is something I’ve been very interested in and done a lot of about over the last six or seven years.
Dr. Boone: I got into it pretty quickly when I got out of fellowship. This is just one of the things that we see, the Mako robot is something I use quite frequently for my hips and knees. It’s a robotic arm. So people always wonder, well, what’s the robot look like? I don’t press the button and then go have lunch. I do all the work, I’m the one who drives the arm. But it just helps precision for sure. So today we want to talk about just a little bit about the anatomy.
Dr. Boone: So we’ll talk about, what’s a hip joint, what’s a knee joint? We’ll talk about arthritis. So what causes arthritis? What are some of the symptoms? And then some of the treatment options obviously. I’m sure a lot of people who have arthritis, who’ve done the standard Advil, Tylenol, Aleve, activity modification, injections. There’s lots of stuff out there. And then we’ll concentrate on, okay, when that stuff doesn’t work, what do we do? And the replacement is what we’ll talk about a little bit.
Dr. Boone: So some improvements I’ve seen definitely for me, at least anterior for the total hip replacement, it seems to be a quicker recovery, less dislocation. And then again, with the hips and the knees, the robotic aspect of this is really improve my surgical time. And I think really helped decrease complications and help patients get back to quicker function. So just a couple of ideas, how many joint replacement, a couple of quick questions.
Dr. Boone: This just gets at the heart of arthritis, especially in the hip and the knees is one of the most common things we see. There’s hundreds of thousands in the United States alone of hip and knee replacements performed. And it’s the leading cause of disability in the United States. Speaking to the anatomy, the hip was very simply just a ball in a socket joint. So the ball is the femoral head and the socket is what we call the acetabulum or maybe a bowl that holds the socket.
Dr. Boone: And then you get all that motion in your hip from that. The knee is more of a hinge joint. So it bends and extends like that, and there’s not a lot of rotation that goes along with the knee, but there’s mainly flexion and extension with it. So a healthy joint, the ends of the joint are covered with cartilage. It’s the smooth gliding white surface. If you’ve seen the end of the chicken bone, that’s what cartilage looks like.
Dr. Boone: And so arthritis is not actually gaining something you don’t … We think of arthritis as a disease and people think, “Well, I got arthritis.” Arthritis is actually the loss of cartilage. And think of it like all of a sudden you have bone on bone where you have two rough surfaces, like two pieces of sandpaper that rub against each other. Very painful causes, popping and clicking and grinding. So, those of you who have knee arthritis know … Knee and hip arthritis know what I’m talking about.
Dr. Boone: So just some facts about arthritis again, just discussing how common this is. And once you have arthritis in one joint, I tell patients that you’re almost guaranteed to have it in another joint. Hands are another common spot, shoulders, but hip and knee are still definitely some of the most common places to have arthritis. And it’s probably because it’s a weight-bearing joint. You’re putting a lot of weight on that joint possibly one of the reasons that it can wear out.
Dr. Boone: We talked about this a little bit, it’s the loss of cartilage. So you lose that smooth gliding surface of the joint, you’re rubbing two pieces of sandpaper together. There’s multiple causes and people always ask me, “Well, why … What happened? Why did I get this? Or why did I lose my cartilage?” Age definitely, it’s one of those things that’s like the wheels on your car, they eventually wear out. We’ve noted that weight can be a factor in causing arthritis as well as other kinds of systemic diseases, just diabetes.
Dr. Boone: Things like smoking can also do it as well too. And then genetics, it’s really common in families. If your mom or dad had arthritis, good chance that you’re going to have it as well too. And then the final one is trauma. If you break your hip, or if you have a fracture in your knee, you’re going to have a higher chance of developing arthritis in that joint at some point in your life time. Some of the non-surgical stuff, which I’m sure a lot of people have heard, the standard non-narcotic medications, Tylenol very common.
Dr. Boone: Glucosomine is one of those plus or minus some people think it works well some people don’t. I tell everybody try it because the only risk is that it doesn’t work. There’s lots of creams and gels and then injections, steroid is a very common one. And then I’m sure people have heard of the chicken comb or the hyaluronic acid which is something that again can be tried. These are all things just to alleviate symptoms. It doesn’t grow new cartilage.
Dr. Boone: So if you go to somebody who … Some of the newer stuff STEM cells and PRP, they tell you they’re going to grow cartilage, that’s not true. But some of that stuff can work at least to help with symptoms for sure. So you go down the treatment pathway, get yourself eventually ready for surgery. We used to say, “Take it easy and rest.” That’s not true. You want to keep your weight down and keep your joints as mobile as you possibly can.
Dr. Boone: As much low impact exercise, aerobic, hiking, swimming, cycling, they’re really, really important to do. And then again, the standard Tylenol, Advil, Aleve, there’s even some prescription stuff like Mobic and Celebrex which people possibly have heard of. All plus or minus and no reason not to try it. Long-term that stuff is not good for your kidneys and it can cause some GI upset as well too. So when we talk about a hip replacement, very simply talking about replacing the ball and the socket.
Dr. Boone: So you remove the diseased head and you put in a new bearing service on the inside, and this is what a standard total hip would look like. Again, you see a good hip on the left, arthritis in the middle, and then the hip replacement on the right. And the idea is, is to restore your normal anatomy. So I want to make your hip that I put in look like the hip that you had in your twenties. I get a lot of questions what are they made of?
Dr. Boone: Hips or titanium, there’s no real stainless steel and titanium, unless you’ve had a metal on metal hip, which we don’t do anymore that was a while ago. We have the ceramic head, that’s what the pink ball looks like. And then most of the time it’s a Teflon or a Polyethylene, kind of a hard plastic liner. Knees are different, some knees have titanium, some have cobalt-chrome, some have something like oxinium. They’re all different, but the idea is the same and that you have a cap on the femur, a cap on the tibia and then a plastic liner in the middle. Same as you do on the hip up here.
Dr. Boone: The most common type of bearing options are metal … Excuse me, ceramic on plastic, that’s what the vast majority of this in the area and even in the United States use. Some use a ceramic on ceramic, there’s no more metal on metal. That was a very unfortunate incident where people had metalosis and had some problems with that. We don’t do that anymore. And then metal and plastic is still used occasionally. The heads can be all different sizes as well. And the larger, the head, the lower, the dislocation risk.
Dr. Boone: Typically some patients like to talk to me about their bearing surface, some just tell me to pick the one I think is best. I’d say 90, 95% of my hips now are ceramic on poly. I think that’s the best option to lower wear rate and a lower chance of any sort of a fracture or anything like that happening. I used to do more ceramic on ceramic, but any more with the newer … There’s a newer polyethylene that came out that lasts a lot longer.
Dr. Boone: I definitely don’t use as much ceramic on ceramic anymore. I don’t know if any of you have heard of a squeaking hip. That’s something that’s very rare, but that happened with a ceramic on ceramic hip. And I had one patient I signed when I was in fellowship, he said … He came in and he told us he felt like somebody was following him. And he’d walk and you could hear his hip squeak a little bit. It’s pretty rare, but if that happens to you it’s not a fun thing to go through.
Dr. Boone: So I definitely usually just use a ceramic on poly. I often times will get the question well, when should I have it done? And that’s when you’re ready. And some of the questions you want to ask yourself are, how bad does it hurt? Do you have pain on a daily basis? Do you have more bad days than good days? Do you have difficulty sleeping? And are you avoiding the things that you want to do?
Dr. Boone: If the answer to those is yes, then I consider those symptoms severe and you’re a good candidate for a replacement. I think one of the myths out there is we used to tell patients, “Wait, as long as you can, there’s a certain age.” And now the implants are so much better that I tell people why waste the best years of your life. If you have severe symptoms and a really bad joint, we can replace it. It will last a long time, and if we need to do another one, we can.
Dr. Boone: But there’s no reason to be miserable for a long period of time, just because of an age limit. In the end, there’s really no formula I say, talk to patients who’ve had a joint replacement. Really look at your ADL’s, ask your significant other. A lot of times, family members will say, “Yeah, you’re limping a lot and you don’t even notice it yourself.” All that stuff can help. And then it never hurts to get a second opinion.
Dr. Boone: I tell my patients that if you go to a doctor who tells you not to get a second opinion go to another doctor. There’s no reason not to get another appeal. So this is the cool part and this is what the robot looks like. So you can see the picture on the right, there is a picture of a reamer basket on the end of an arm. The picture on the left is what it looks like as far as the knee.
Dr. Boone: So that picture on the upper left, you can see the computer screen and the robotic part of the knee that I’m looking at on the screen there to help guide me through the surgery. This is what the robot looks like in surgery. It’s pretty large and you can see it’s obviously got the big arm on the side here. A lot of patients will ask me why robotics? I think it decreases surgical time, it decreases blood loss, and both of those things then decrease infection risk.
Dr. Boone: And infection in my opinion and a lot of people’s opinion is one of the worst things that can happen in a joint replacement. It’s one of those things that it does happen, it’s less than 1%, but when it does happen, it’s pretty a devastating complication. We can fix it and it’s something that you just have to go with other surgeries for it, but it’s something you want to avoid. I think there’s likely a more predictable recovery and possibly improved outcomes at least in my patients.
Dr. Boone: That being said, not everybody does well still, but I think it’s allowed me to have better and better outcomes long-term. And the other thing is, is that with computers you can dial things in with the increased degree of certainty that the human eye just can’t see. And so that that’s very helpful. I’m moving things by millimeters now. In the human eye you can’t see, you can’t do things by millimeter. So I think it’s been very helpful for me.
Dr. Boone: This is what the incision looks like, so for a knee it’s off the front of the knee. So if you help your … Feel your patella and your kneecap, it’s about two finger breadths above that. And then it goes down and it’s about three or four finger breadths underneath your kneecap. That’s where the incision sits for the total knee. For the hips there’s lots of approaches. I typically do an anterior, although I will do a posterior or a lateral in certain patients who may have a weird deformity or a fracture or something else that we have to deal with.
Dr. Boone: With the inter approach, I feel like there is a quicker recovery. We don’t cut any muscles, we move between points. But I will say that my posterior patients and my anterior patients at one year, if I don’t know where their incision is, the outcome is the same. So just because you have a posterior doesn’t mean you’re getting an inferior surgery.
Dr. Boone: In fact, that’s a really good surgery, and I’d rather have a surgeon who did a posterior who did a lot of them than an anterior surgeon who didn’t do very many, because it’s more important to get things correct. And so posterior is a very good approach. I do use it for some things, but for the majority of patients, I use an anterior. Here is just a picture of where it is. The interior approach you’re thinking about it off of your hip pointer.
Dr. Boone: So if you feel the front of your hip it goes down from there. And a posterior approach is more posterior in the buttock area. This is what the special table looks like. It looks a little bit like a torture device. But this is what allows us to make the incisions that we need to and help us expose things appropriately so we can work between the muscle planes. One of the things people say is that the anterior approach is a new approach it’s actually not.
Dr. Boone: It’s been around since the 40s. It was done in Europe a lot more, and the posterior approach is just more common here. And then finally made its way about 10 or 15 years ago to the United States. But it’s an approach that has been used for a very long time. So it’s not new, it’s got a long successful history. And it’s also one of those things I want to … A lot of people look for the newest thing, but new it isn’t always necessarily better.
Dr. Boone: And in this case, it’s been around for awhile and been a very good approach. Some people ask me why. For me, it’s a quicker recovery. I get better X-rays in surgery and a lower dislocation risk. It does have a steep learning curve, so if you go to a surgeon who does an anterior, you want to ask how many. And the answer should be a lot. This isn’t something that is done just a couple of times a year and people do well. You need to have somebody who does a lot of these.
Dr. Boone: It’s really important in my opinion. The incision is on the front of the hip until you can have some numbness on the thigh, which is one of the drawbacks, but there are no hip precautions or anything like that. What to expect after surgery, I get this question a lot. I think a lot of my patients go home the same day from surgery. I tell everybody by six weeks, you’re glad you had it done. You’re better than you were before.
Dr. Boone: And hopefully by six to nine months you forget you had it done. I allow you to go back to your hiking, tennis golf in about three months. A lot of people probably don’t listen to me and go back sooner, but like you got to heal and you want to make sure you don’t cause any damage. And so typically about the three month mark is when I tell people, “Okay, you can start to get back to doing the stuff you want to do.
Dr. Boone: I don’t tell anybody they can’t do anything I say … Yeah, I’ve got lots of hikers, bikers, skiers, swimmers, “You have a risk of fracture, but you also had a risk of fracture before surgery too.” Knee it’s kind of the same, except there’s more work with the knee. You got to get going on range of motion. Hips I just tell the patients get up and walk around and you recover pretty well with a very little physical therapy.
Dr. Boone: For the hip you’re … Or excuse me with the knee, you’re definitely pushing yourself and go on with lots of therapy a couple of times a week, just to get your motion back for sure. So here’s just a picture of what we get before surgery. And so a 3D image and the picture on the right is actually what the robot gives us. And you can see a dial in my length and my off center and all this stuff within millimeters.
Dr. Boone: So this is all preoperative planning before we even go to the OR which is very … It helps me restore your normal anatomy, because your hip is not like my hip. They’re all very different. And so I want to make your hip like it was previously. Some of the myths with the anterior approach just that people may have heard, or that I’ve heard over the years, they’re still paying with a total hip replacement for sure.
Dr. Boone: Patients do not do better longterm. Short term yes, but at one year the study show that the outcome is the same. So if you’ve had a posterior you did not have a bad surgery and I still actually do posterior. Questions.
Moderator: All right. Dr. Boone, if you want to look around the chat section on the right hand side, you’ll see all … There’s a flood of questions in there for you to take a peek at.
Dr. Boone: So a couple of questions I have here that I think everybody would probably benefit from. In your experience, how many total hips are being done anterior versus posterior these days? It’s very dependent on the area that you’re in. So Midwest, West coast, I would say, if you look at the numbers, it’s probably 25% anterior versus posterior. But there’s also some other approaches, there’s a lateral, there’s a super path, there’s a superior, there’s lots of different ones.
Dr. Boone: And so I would say that the gold standard is not necessarily the approach. The gold standard is somebody who does 50 a year or more. You know what I mean? I think the gold standard is dependent on where you are as far as where you are in the country. In residency I had five posterior guys and only one anterior guy. So it’s dependent I would say for sure. But definitely posterior is probably still more common in this area. But there’s a lot of anterior guys as well too.Dr.
Dr. Boone: Here’s another question, when talking about the robot highlight changes and how you operate between today and four years ago? That’s a great question. My approach is the same and that’s the key. What the robot does is it gives me all this preoperative information based on a CT scan that I didn’t have prior. And so it makes my decision-making in surgery quicker. And so I’m taking much … I take way fewer X-rays. I used to take probably 10 or 15 X-rays during a surgery now I take one.
Dr. Boone: And so it’s sped it up based mainly on all the information I get at pre-op. Do you have experience with the MELISA tests testing for heavy metal sensitivities? I don’t. I do know that metal sensitivity is a concern. I typically just do patch testing, and with a total hip, if it’s a total hip that’s titanium, and there’s never been really a documented allergy to titanium that I’ve seen. But that’s not something I’ve seen. And then a follow up question.
Dr. Boone: How long do they last? I tell patients so the best … One of the best studies we have looked at hips that were put in 30 years ago, 80% of those lasted 20 years. Well, we’ve got much better prosthesis now. I mean, I hope your hip lasts you for 25 years and possibly longer. Hip resurfacing, that’s a great question, it’s not something I actually had in the presentation. They are metal on metal, and there’s a very small percentage of patients who develop metalosis from a hip resurfacing.
Dr. Boone: But we think it’s from the position of the compass. So if the compass put in a bad position, then they high chance of metal on metal. But that device was developed such that the metal ion level with that device specifically is very low, but it can happen. Resurfacing is something I will do sometimes for younger patients. It’s pretty rare though. Additional precautions taken due to COVID. So everybody gets tested before surgery.
Dr. Boone: So in my center, when you come in, you get a COVID test. When you walk in the center, patient family members are limited to one and we bring that person in at the end of the case and you’re quarantined over in a certain area. So there’s lots of stuff we’re doing, we’re making sure that patients get out quicker. I’ve got a lot of patients who just aren’t waiting. And I think it’s very safe to do.
Dr. Boone: With that being said, waiting until next year is not a bad idea if it’s something you can do. I haven’t had a single patient or heard of a patient get COVID from coming into the hospital. The precautions we have are pretty stringent with all the testing and stuff we’re doing. For revisions I do use it occasionally, mainly for the CT scan and help for preoperative planning. So I will use robotics for revisions as well too.
Dr. Boone: Most of my revisions for hips just so you know, are through a posterior approach because you get better exposure for the femur. But you can use it for revisions as well. What type of anesthesia? Most of the time, it’s a spinal with a little sedation. Sometimes you’ve had a back surgery or you have bad arthritis in your spine and they can’t get the needle in the spinal and you just … You can go to sleep.
Dr. Boone: But most of the time we try to do spinals, you get less medication, less chance of nausea. But both are done, but typically at the centers I practice in, most people try to do a spinal if they can. Do I recommend therapy after surgery? Absolutely. My hip patients get less therapy, they just don’t need it as much. But we typically do a week of some home therapy. So a therapist comes and sees you in the house. Some people just go straight to therapy I let it, it’s up to them.
Dr. Boone: And then typically for about six weeks, we do therapy. You see me in the office and I tell my knee patients, they likely continue therapy and my hips I say, “It’s between you and your therapist. If you’re still getting something out of it and your therapist says you are, I’m not going to step in the way of that. In fact, I think it’s a good thing.” And so I leave it up to the patient and the therapist. But I absolutely prescribed therapy for every single joint replacement.
Dr. Boone: Does ceramic on ceramic still have a lower wear rate than ceramic on poly? The newer polyethylene, the highly cross-linked to wear properties are approaching ceramic on ceramic. Which is why I’ve switched from a ceramic on ceramic bearing to ceramic on polyethylene. If you’re in your thirties and forties, and I do a total hip, I will still sometimes use a ceramic on ceramic bearing, but you have a risk of fracture.
Dr. Boone: And if you fracture that ceramic, that’s a really bad problem to deal with. And so with the newer polyethylene, I just use that a lot more because the wear properties are really, really good. A question let’s see, can strength training prevent having knees replaced or exercise in general? So this is not a ligament or a muscle problem, this is a bone problem. So keeping your joints moving and keeping your weight down, and keeping active can improve your symptoms.
Dr. Boone: Again, this is a cartilage problem and so those things aren’t going to grow new cartilage. And so eventually if you want to stay that active, and if you have better arthritis, you will likely need a replacement. Can stave it off for a period? Yeah, it can absolutely. But if it’s bad, it’s typically a losing battle at some point if you want to stay that active. Current thinking for knee and hip replacement, running or jogging.
Dr. Boone: So with hips, I give patients no restrictions. I say, “Do what you want.” I’d say 20% returned to long distance running. The vast majority of people just don’t return to running. They get a little bit of pain and they find that they’d rather bike or do something else. So most people don’t, but I don’t tell them they can’t. With knees I had a patient send me a picture from the end of the half marathon.
Dr. Boone: It’s not something that you typically see, the running that typically happens with a hip or knee is more short distance stuff. So if you’re running for tennis or pickleball or something like that, but long distance running, typically not, I’m not sure why that is. Maybe other joints start to hurt. I really don’t know. But most of the time it’s not … I don’t tell people you can’t, but people just typically end up doing some other stuff. This is a great question.
Dr. Boone: Are there anything that I tell patients you shouldn’t do after a hip or knee? I tell people this is a mechanical part. If you treat it well, it will last longer. If you’re super aggressive and do box jumps or crazy things like that, you’re going to wear it out quicker and you’d have a risk of fracture. But I’m not going to tell you what to do. I’ve got lots of skiers, I’ve got hikers, bikers, swimmers, tennis players.
Dr. Boone: The goal is just to do the things you want to do. And I’m not going to tell you what those are. Long distance running and again, I tell people if that’s your goal, I just don’t know if that will happen. I’m not going to tell you no, but based on my patients and literature, it just usually doesn’t for whatever reason. So hip resurfacing versus total hipbone would I recommend one over the other?
Dr. Boone: So I used to do a lot of hip resurfacings in younger patients, but when the new polyethylene came out with the rare properties, I’ve done less and less of that. So I will still do a hip resurfacing if I’ve talked to the patient about pluses or minuses about that. If you wanted to return to long distance running, hip resurfacing might be a little better option for you. But I’ve skewed more towards total hips now just because they last just as long.
Dr. Boone: A total hip is actually a faster surgery, it’s less blood loss and people think of resurfacing is less, but it’s actually not, it’s more difficult. The total hip takes me about 45 minutes, resurfacing takes me a couple of hours. So it’s actually a bigger surgery through a bigger incision. But I will talk to patients about it. I’ve done a resurfacing and a 32 year old recently.
Moderator: We’re about at our time here, if we didn’t answer your questions, please feel free to send them in again and I’ll make sure that we capture them and we’ll follow up with you directly via email. You can check us out on Proliance Orthopaedics & Sports Medicine. Our website is www.POSM.com. There’s a lot of information on the website. And if you have any questions or if you would like to request an appointment and you can do so online. Or you can always call any of our offices. Thank you everybody for joining us today.
Dr. Boone: Thank you all very much!