When Should You Get a Knee Replacement?

In this episode, we delve into the advances, myths, and realities of knee and joint replacement with Dr. David William Fabi, a board-certified, fellowship-trained joint replacement specialist and internationally recognized pioneer in the field. 

Darleen, the host,  engages Dr. Fabi in a dynamic conversation about why the frequency of knee replacements is increasing, the influence of the baby boomer generation on current trends, and why more people are opting for surgery at younger ages. Listeners will uncover the intricacies of elective joint replacement—why “need” isn’t always the right word, the value of conservative management, and the sometimes murky results around popular treatments like PRP and stem cell therapies.

Dr. Fabi sheds light on major advances in surgical approaches, including smaller incisions, improved implant design, and the integration of robotics and computer technology, which have significantly improved outcomes, shortened recovery times, and reduced dissatisfaction rates. He shares invaluable tips for patients: from what questions to ask surgeons about technology and technique, to the importance of mental health and motivation in post-surgical recovery. We also tackle the nuances of online research, patient-doctor trust, and the evolving landscape of telemedicine and AI in orthopedic care.

The episode wraps up with a forward-looking discussion on the future of joint replacement—touching on artificial intelligence, augmented reality, and even 3D printing—as well as advice for those considering surgery to prioritize quality of life, seek second opinions, and connect with relatable, authentic care providers.

If you—or someone you love—is considering a knee replacement or just curious about how technology is reshaping the field of orthopedics, this episode offers must-hear insights and takeaways from a leading expert.

San Diego Orthopedic Institute. Our phone number is 619-299-8500

 https://www.sandiegohipandkneedoc.com/

https://discsurgerycenter.com/physician/david-william-fabi-md/

SeniorLivingGuide.com Podcast sponsored by LivDry Incontinence Products & TerraBella Senior Living
 

The background music is written, performed and produced exclusively by purple-planet.com.
https://www.purple-planet.com/

*SeniorLivingGuide.com Webinars and Podcast represents the opinions and expertise of our guests. The content here is for informational and educational purposes. It does not necessarily represent the views, recommendations, opinions or advice of Fairfax Publishing/SeniorLivingGuide.com or its employees

Transcript

Darleen Mahoney [00:00:09]:

Today we are joined by Dr. Fabi. He is a board certified, internationally renowned, fellowship trained joint replacement specialist and innovative pioneer in the field. He trained at the prestigious Rush University, a world renowned joint replacement center with where he mastered cutting edge techniques for treating complex joint disorders. As an early adopter and recognized expert in robotic joint replacement, Dr. Fabi has contributed extensively to the field through published articles, book chapters and national lectures. His expertise and commitment to advancing joint replacement surgery has made him a leading authority in delivering exceptional patient care. I'm so elated to have you join us today.

Dr. Fabi [00:00:58]:

Well, thanks for having me. Really appreciate this opportunity. I'm really excited for it. You know, I'm all about education and, you know, spreading awareness, spreading the word out. Because, hey, the more that we know can really help, help our health, particularly joint health.

Darleen Mahoney [00:01:17]:

Yeah, yeah, yeah. And I know that one of the reasons why I really want to talk about this subject is because I have some friends and they're slightly different age groups, but had knee replacements all around the same time. And it kind of seems like it was the tale of three different knee replacements. So I really thought. And one was very, very difficult recovery and one, all of a sudden it's just snippity snap getting the other one done, happy as a clam. So I think it's an important subject because people are getting knee replacements. I mean, much more significantly, it feels like anyway, or maybe it's just my age more often than they used to.

Dr. Fabi [00:01:57]:

Yeah, yeah. And so the amount of joint replacements that we're doing in, in the United States each year continues to grow, and it's growing at an exponential rate. I don't know what the exact numbers are, but by 2030, it's going to be pretty significant. So. Yeah, that's why we're seeing a lot of higher volume in terms of what we do in regards to knee replacements. Furthermore, people are getting intervention earlier than in the past. You know, it used to be like, wait till you're this age of 65 or 70 before you get a joint replacement. You know, wait till you're on a cane or a walker. But these days, you know, we're. It's about quality life. And, you know, people don't want to wait to get to that point. You know, there are certain sports that they're not able to do and that's important to their quality of life and they want to get back to that. So. Yeah, yeah.

Darleen Mahoney [00:02:50]:

And even just the baby.

Dr. Fabi [00:02:52]:

Yeah, Sorry, sorry, go ahead.

Darleen Mahoney [00:02:53]:

I was gonna say, even just walking around, I think that, you know, people that are experiencing pain. They're less likely to, to just do the everyday things of like exercising, bike riding, going on vacations where you're, you're walking a city. I mean, you're miserable if you're doing all that. So do you think that it's. So they're starting to do knee surge or knee replacements earlier than they used to? They used to wait till it was severely deteriorated before they started making those decisions to move forward.

Dr. Fabi [00:03:20]:

I think, I think, I think that's a part of it, you know. You know, when I first started residency, about 20 years ago now. Crazy. A little over 20 years ago, you know. Yeah, we were kind of a little more gun shy than we are to offer joint replacements. But I think also a big part of that is that the baby boomer population, the largest generation that we've seen, is now entering that demographic and that age group where they've tried everything and they're candidates and considering knee replacement surgery. So it's multifactorial, but I think probably the largest factor is that generation that I just alluded to.

Darleen Mahoney [00:04:01]:

Right, right. So why would someone need a knee replacement? Is it because they've used and abused those knees or is it just arthritis or deterioration through the years or bone on bone? I mean, I don't really know what caus. I'm sure there's a variety, but just in general.

Dr. Fabi [00:04:18]:

Yeah, well, you know, I hear a lot of surgeons and you know, I don't like, for me, I don't like to use the word need a knee replacement. I tell my patients that it's like you can live with arthritis. You know, this is not one of those surgeries like cardiac surgery or you know, God forbid for that patient, anything, intervention with regards to cancer, because you need those surgeries. Yeah, it's an elective surgery, it's an option. But patients that are candidates, usually, you know, we always want to offer, and we want to start with conservative management, you know, because I tell all my patients, you'll know when you're ready for surgery. I'm not one that pushes surgery because people can get by with physical therapy, with taking anti inflammatory medications, injections, whether it's cortisone injections or what we call hyaluronic acid injections, which is essentially a gel that you do, you put inject into the knee joint to lubricate the joint. And now you have other inventions, interventions that are kind of getting more and more, quote unquote popular. I don't know if popular is the word, but like mainstream, more considered is like PRP or platelet rich plasma and stem cell injections, which right now the literature is controversial on whether they work or not. Issue with that, it's that it's a cash pay thing. Insurance doesn't cover it. You know, not something that I believe in right now because in my experience, you know, the results are. Are not that great. So I'm not one that likes to get cash for the sake of getting cash, you know, but there are doctors that I tell my patients, if they're interested in it, you know, do your research, you know, find people that say they have good results, get some referrals, but just know that you're spending that money and, you know, there's a good chance it won't work.

Darleen Mahoney [00:06:10]:

Yeah, I mean, you have to always do your due diligence anytime you do any kind of medical procedure, regardless if it's cash or not. But if it is cash and your insurance isn't paying for it, you really need to do some due diligence because absolutely nobody wants to throw their money in a black hole. So.

Dr. Fabi [00:06:24]:

No, especially, especially these days.

Darleen Mahoney [00:06:26]:

100%. 100%. Um, so I feel like one of the things that I remember way back in the days, I had someone that I knew that had a knee replacement. He was like, in his 30s. He had like a. I guess a really bad football injury. And I remember him coming into work with like a huge contraption on his knee. And then the recovery was like six months. And it was. We've come a long way. Yes, absolutely, is what I'm getting to.

Dr. Fabi [00:06:56]:

No doubt.

Darleen Mahoney [00:06:58]:

So what do you think as far as, like, technology advancements that have really made knee surgeries with a shorter time frame, less pain or whatever the case may be. And are there different procedures? Because I know that they have different cuts, per se, that might be less painful, more painful, that kind of thing.

Dr. Fabi [00:07:16]:

Well, let me. I forgot. Sorry, I forgot to finish that last question. With regards to people that are candidates for joint replacements, you know, it gets to a point. I tell my patients, like I said, you'll know when. And that means a lot of different things to a lot of different people. You know, some people will actually wait till they're almost wheelchair bound. And I get that, you know, surgery is a. Is a big decision, you know, and it can be. Can be scary, especially if you've never had surgery before. I mean, you know, a lot of people haven't had knee replacement surgery before, so it's that fear of the unknown. But once their quality of life gets compromised, you know, I have, I have people that it can be as something as like, I can't play golf anymore and that's their indication to undergo surgery. And people just know when they get to a point where like, all right, enough is enough. I've tried all this non surgical treatment options and I'm like, you know, my quality of life is not where I want it. And yeah, I want, I want to get, I want to get a more permanent, more permanent solution. So those are patients that are, that are candidates and going back to age group, you know, I do have, we do have people that get joint replacements in their 30s, 40s, 50s is, you know, not, not heresy like it used to be because these are some of the more active years of your life, you know, and you know, to say wait 30 years or 20, 30 years to prevent a surgery, a second surgery, doesn't really, doesn't really fly anymore because what are you going to do? You're going to suffer for 20, 30 years. And philosophically, not to sound morbid, there's no guarantee we make it to that age. Right. So it's like, it's like live your best life. Exactly.

Darleen Mahoney [00:09:01]:

So, yeah, I think the kids call that yolo.

Dr. Fabi [00:09:04]:

Exactly. I was just going to say that. Yeah. So going back to what you said about technology, there's a lot, a lot of work, both industry and surgeons, to really improve what we're doing with regards to knee replacements. You know, classically there's been a 20 up to a 20 dissatisfaction rate and a lot of that. Yeah, yeah, yeah. But, you know, we really kind of brought down those numbers. You know, we saw a big thing that we saw is that, and you may know hip replacements tend to recover a lot quicker than knee replacements and the satisfaction rate's higher.

Darleen Mahoney [00:09:42]:

Yeah, you shared that with me. I was so shocked by that. And that's, that's amazing. Especially for our senior population who, who struggles in that area. Yeah.

Dr. Fabi [00:09:50]:

So, you know, you know, being that we're like type A personalities, we want to kind of, you know, 20% dissatisfaction is what, like B minus work? You know, because you're 80, you're hitting 80%. You know, we want to get in the A plus range, so we really want to kind of bring that delta, delta down. So. And you know, so a lot goes into that. Number one, you know, I trained an institution there was one of my mentors, Dr. Richard Berger. He started doing outpatient joint replacements probably over 25 years ago, meaning going home the same day.

Darleen Mahoney [00:10:26]:

Wow.

Dr. Fabi [00:10:27]:

And initially that was thought as heresy, but, you know, he Saw it was true visionary. He saw there's really not much that we were doing for these patients and in the hospital. So a lot of it's mental. It's kind of planting that seed, you know, because if you tell a patient, you know, you got to stay in bed for two or three days, you have to go to skilled nursing facility, they're going to believe it. Whereas if you tell a patient we're going to get you up the same day, you're going to go home the same day, that really sets the bar for their recovery. Meaning, oh, I can do this day one. You know, this should be a lot quicker than, than, than say in the past where it's going to be months. So a lot of that, you know, 95 of the recovery. Recovery is mental, particularly when it comes to knee replacements. You know, us surgeons, we can do a great job, but it's a two way street. You know, that patient has got to do their work, they got to do their rehab, you know, and that's makes for the best formula. The people that are motivated to do their exercises do the therapy tend to recover quicker.

Darleen Mahoney [00:11:27]:

Yeah.

Dr. Fabi [00:11:27]:

Also our technique with regards to how we dissect down to the hip, to the knee, to the knee joint, our incisions used to be a lot longer. So what does that mean? There's more collateral damage to the soft tissues that we get in there. So now our incisions are smaller than in the past and that means, you know, less, less soft tissue that has to heal. And our implants, our design of our implants are significantly, a lot better than they were even five, 10 years ago as a whole. Because the knee is considered a hinge joint. Right. And a hinge just goes like this. But actually the true hinge philosophy goes like this. But actually a normal knee doesn't just do this, it kind of rotates as he goes back. So that's always been a conundrum in our industry as to how we reproduce that motion. But now finally with implant technology, we're able to recreate that motion. So at the end of the day, taking it back to the basics, we want to recreate normal. So before we were not recreating normal, we were actually recreating abnormal. And that can lead to dissatisfaction rate. But now that we're able to hit that range of motion, our recovery has been a lot, lot better. And then we also have computer technology that we can utilize at the time of the operation. Robotics has really come to the forefront. And what that does is it's a game of Millimeters. A game of degrees, you know, in. In joint replacement surgery. And if you're off by a few degrees, if you're off by even a few millimeters, that can lend itself to a poor result. So now with these new. These new technologies that we're having, we're able to hit that target zone. There's been studies that show just naturally, there's human error. Right. You know, if you do it with standard, just regular instruments, you can hit precision, accuracy rate of max 90%. And I'm not talking that we're going way off the reservation with our alignment or with, you know, our angles and stuff like that. But now with these new technologies, we're hitting 98 and 99%, which is huge. We don't have any as many outliers. So kind of doing the math, say you do 1000 knee replacements a year. I don't do that many, but I know there's some people that do. You know, if you're hitting 90%, those are 100 patients that you're like, okay, this could have gone better. That's a lot of patience. And, you know, I have a conscience, and that kind of will kind of keep me up at night.

Darleen Mahoney [00:14:09]:

Yeah.

Dr. Fabi [00:14:10]:

Whereas if you're hitting 98, 90, 99, you're bringing that total down to 10 to 20%. So it's up to 10x improvement in terms of decreasing our outliers. So. And then. Sorry, go ahead.

Darleen Mahoney [00:14:23]:

I was gonna say I wanted to ask you this question. So when, if anyone's just listening that might need a knee replacement or know someone that does, do they. When they're talking to the person that may or may not be performing that knee replacement, asking about the type of robotics and technology that they use, I think would be something. Do. Do you recommend that, or is that standard protocol to use the technology?

Dr. Fabi [00:14:49]:

Well, you know, I think, you know, the way. I think it's great that patients come in more educated than they have in the past. Now it's up to us as the doctors how to help that patient interpret the data. That education that they're getting. We used to have the Google doctors come in, you know, meaning

Darleen Mahoney [00:15:12]:

WebMD. Stay away from WebMD. Yes.

Dr. Fabi [00:15:15]:

And they come in all knowledgeable. Now, actually, maybe I'm coining this term, I don't know. We have the chat GPT doctors. You know, I'm.

Darleen Mahoney [00:15:23]:

Oh, yeah.

Dr. Fabi [00:15:24]:

Impressed about, you know, the elderly population. They've been really hardcore on the chat GPT.

Darleen Mahoney [00:15:31]:

Yeah.

Dr. Fabi [00:15:31]:

And they're coming in with questions that I haven't gotten in the past, you know, So I think I will say

Darleen Mahoney [00:15:37]:

this on Chat GPT. Chat GPT I found to be wrong.

Dr. Fabi [00:15:41]:

Yes, absolutely.

Darleen Mahoney [00:15:42]:

Yes. So, I mean, that's just a little food for thought. If you get something out of Chat GPT and it's not a guarantee. Yeah, yeah.

Dr. Fabi [00:15:48]:

Claude may be better, but that's a topic for another.

Darleen Mahoney [00:15:51]:

I was gonna say this another whole other episode.

Dr. Fabi [00:15:56]:

Yeah. I mean, I think at the end of the day, it's, you know, whatever the surgeon needs to get their best results possible, you know, because if you're a higher volume surgeon, naturally it's kind of time on task. The more that you're able to, you know, you get better at it. Right. And your accuracy rate, your precision rate, your results get better. Now, if that surgeon is comfortable going standard instrumentations and they're really good at it, they get good results, I think that's great, you know, but I think just adding another layer to improving our results I think is hugely important, you know, So a lot of that comes down to the technology that that surgeon uses. So I think it's a great question for a patient to come in and ask be like, what type of technology are you utilizing? Because at the end of the day, that patient has to be comfortable with that surgeon, you know, because that's a huge privilege, a huge relationship, a huge trust factor that goes into getting surgery done, you know, because, I mean, I've never had surgery, but I think that's kind of very comforting, very reassuring for that patient because there's. There's always a level of, I think whether small or large, there has to be a level of anxiety that a person goes through going into surgery. And if they know that that surgeon, you know, utilizes all the tools at their disposal to get the best results possible, I think that's very comfor. Very comforting to the patient.

Darleen Mahoney [00:17:40]:

Yeah, yeah. And I think even maybe get referrals from someone that's worked with, you know, I think that that's always amazing. Any, Anytime that you do that, you need some kind of a, you know, referral from someone that, you know, that's had it done or even going online and looking at the credentials or anything like that as well, I think because all that stuff is at our fingertips right now. So. Yeah, that's a good one.

Dr. Fabi [00:18:01]:

I mean, I think a person, it would, it would benefit a surgeon to have a. A large online profile, you know, because word of mouth is still kind of our bread and butter. Right. But now people are coupling that word of mouth, from what they're seeing Online.

Darleen Mahoney [00:18:17]:

Yeah.

Dr. Fabi [00:18:18]:

And patients should take that with a grain of salt also, because sometimes online presence is not entirely representative of, you know, that surgeon or that orthopedic group that they're going through, I think, by and large. Yeah, I mean, it's very close, very accurate, of course. But, you know, just like any industry, you know, there may be kind of some bad actors out there, so. And I welcome all my patients, the people that come see me, you know, get a second opinion, get a third opinion. You know, this is. This is a huge day in your life. You know, you need to be comfortable with whoever you go to.

Darleen Mahoney [00:18:58]:

Yeah. So, yeah, no, I appreciate that. And one thing that I always think about back to, like, the boomer generation, sometimes they don't want to get second opinions or they don't want to question because that's how they were raised. They raised, you know, it's out of the mouth of the doctors. Like out of the mouth of God.

Dr. Fabi [00:19:18]:

Exactly.

Darleen Mahoney [00:19:18]:

To some folks. But I think that a doctor that's really well worth his reputation is going to welcome any additional questions and want to be able to answer those questions to relieve that anxiety, et cetera. And then if they want to get a second opinion, I think that that should be something completely that you're in favor of, just to give them that relief.

Dr. Fabi [00:19:42]:

Yeah, absolutely.

Darleen Mahoney [00:19:43]:

Absolutely.

Dr. Fabi [00:19:43]:

And I think it's important, again, to have an online presence because, you know, we only spend a certain. A finite amount of time with. With these people and with. With the people that come see us, you know, and I like, for me, you know, because, you know, with Google reviews, you know, with social media, it's a way for people to kind of get to know me, not just on a professional level, but on a personal level, you know, because on my social media profile, and then that filters into what they're seeing on Google, you know, they. They kind of get a sense of, you know, who I am as a person beyond just. Beyond just being a surgeon. And I think. I think that's important, you know, because I don't want. Certainly there's. There's. I don't want them to put me on a pedestal. Pedestal, so to speak. You know, I want it to be kind of more level because, you know, we're all human beings here, you know, and if they find that I feel. To really establish an important connection with that person on a kind of more level basis, I think that increases the trust factor and that mentally, because I think 95% of the recovery is mental. That kind of really helps their recovery.

Darleen Mahoney [00:21:11]:

Yeah. Yeah. And I do think also there's that huge level of comfort when you are meeting with a physician where you don't feel nervous or don't feel inferior, where you do feel like you. You're relatable. I think being relatable, I love the idea of that, so. Because you don't always get that.

Dr. Fabi [00:21:27]:

No, no, unfortunately, you know, so. And everybody has their own personalities, you know.

Darleen Mahoney [00:21:32]:

Sure.

Dr. Fabi [00:21:32]:

You know, I'm not, you know, hey, you know, whatever. Whatever works, works, you know, And I just. I think I believe in authenticity and I just like to be myself, you know, and I think that's. That goes a long way.

Darleen Mahoney [00:21:49]:

Yeah, no, I absolutely appreciate that, and I hope our listeners will as well. I do want to kind of switch topic a little bit regarding, like, are there different types of incisions that are. There's, like, I think that there's multi. And correct me if I'm wrong, because I actually don't even know the answer to this. Different types of incisions that could affect. In different ways. So what are those different kind of options and the outcomes of those.

Dr. Fabi [00:22:17]:

Yeah, so incisions as it. As it relates to knee replacements, I would say primarily there's two. You know, there's. I think most common is that they. The incision down to the knee. I got a model right here. Let's get all. Let's get all. Let's get all fancy, you know. So this is up and down here.

Darleen Mahoney [00:22:41]:

Okay.

Dr. Fabi [00:22:41]:

This is your femur, your thigh bone. This is your kneecap right here. This is your quadriceps tendon. This is your quad muscle, and this is your tibia down here. So I think, you know, most people do an incision that goes straight down here. Okay.

Darleen Mahoney [00:22:56]:

Okay. So because. Because this is an audio, for the most part, podcast and not visual, we will have shorts and reels if anyone's listening. But. So they can see the. The video. But it's basically just a cut, like right from the top of your knee to below the knee.

Dr. Fabi [00:23:12]:

Exactly. So, yes, it's going straight over the kneecap. And whereas the way I was taught, I go to the kind of. Kind of more to the side. And, you know, it's not like one is better than the other in terms of incision. I just was taught that going to the side, you can make that incision smaller. And I'm not saying small incisions is the end. All. Be all. I think at the end of the day, you want to put in that knee replacement, that implant as accurately and as precisely as possible, regardless of what incision that you use, I think the incision kind of more comes into play as to how quickly they're going to recover. So doing one straight down the kneecap, number one, I think, and it doesn't happen all the time, but that incision going straight over the kneecap can make it a little more difficult because you can have a painful scar there and make it a little more difficult for. For patients to kneel once all the recovery is done. Which is a common question that I ask is like, you know, can you kneel in the joint replacements? And that answer is absolutely yes. Whereas going to the side, you know, I'm not doing that incision over the kneecap. So that means we don't have to worry about that factor of a painful scar getting in the way of their ability to kneel. So that's incision. And then there's more to the just incision. It's how you dissect the deep tissues down to the joints. Okay. Some people will, you know, kind of cut a little bit through the quadriceps tendon, whereas other people will kind of not do that. Now, it's controversial whether is one better than the other. Honestly, we don't know. But I don't like to cut the quadriceps tendon. And some studies show that leads to a quicker recovery. And also another thing is to get good exposure, to get visualization of the knee joint. You can either put the kneecap, slide it to the side, or you can kind of flip it, what we call evert the patella. And that makes the surgery, you know, you get a little more exposure, a little more ability to see if you flip the kneecap. But if you think about it, that can really stretch the tendons. You know, your patellar tendon, which attaches your kneecap to your tibia, your shin bone, and your quadriceps tendon, which attaches, you know, your kneecap to your quadriceps muscle. Just imagine that kind of being stretched out when you flip the kneecap. And that can lend itself to a longer recovery. But honestly, I think at the end of the day, regardless of your incision, as long as you do a well done, accurate, precise, good implant knee replacement surgery, I think the results become a little more equivocal. But I think the large, as we, as we talked about before, the larger that your incision, potentially there's more scar tissue that can develop if your incision is a little longer and your dissection is a little bigger. Going down to the knee joint.

Darleen Mahoney [00:26:26]:

Yeah, yeah. The other Question I had, and I was going to ask it in the beginning and then we got busy talking about something different is if you do wait longer and it deteriorates more, does that make for. I mean, to me, I always think get on top of it before it gets too bad and don't procrastinate. But is that, Is that a good practice, a knee replacement, or does it.

Dr. Fabi [00:26:45]:

I think there's two sides to that coin. I think it's rare in this country that patient will finally get to the point where they're ready for surgery and their knee is so, so damaged, you know, that it's gonna make the surgery extremely more complex than we like to. People will get intervention prior to that. But yeah, there are certain times where the knee is so damaged and makes the surgery a little more difficult and it can possibly lead to suboptimal results. But I think when technology has really kind of, kind of intervened, we've been able to improve upon that. On the other side of the coin, you know, those people, in terms of the severity and in terms of their function, are starting down here, whereas someone who has less disease, they're starting up here. And if you do a knee replacement, you know, you're getting them to here. So that is a big improvement there. So those are people often, I think, that will notice a difference quicker than patients that have less disease. So, you know, those are ones where honestly you're like. And not