Dr. David Fischer

Well, these would all be, you know, for the most part, these were all seniors, you know, they, they were probably in their, uh,

The exception would be the less common patient that had some sort of a problem beginning much earlier in their life.

But I would say they're all seniors, which is a bit of a concern as well because they're all higher risks for surgical procedures and the rehabilitation, all the things that go with a major operation.

I would say the majority were being their 70s.

Yeah, yeah, yeah.

Yeah.

Well, I think probably go through a series of, of, uh,

steps here you know it starts with you know we use physical therapy we use medication yeah that then injections and you use them in kind of a serial way and yeah as they fail to provide relief you go to the next step and and they you know everything is time limited for the most part and

Unfortunately, the worse the arthritis is, the less predictable all of those other methods are.

But for the most part, you go through them.

They do help people probably stretch a little more time out of their knees.

And also the current insurance situation, for example.

sometimes mandates that, you know, that before a patient is eligible for a knee replacement, have they failed a course of physical therapy?

Have they failed medication?

You know, those are steps to maybe not postpone the inevitable, but put it off at least satisfactorily.

And it also serves the other purpose that

I think when patients are ready for surgery, they understand that they've exhausted these other, other options that they, they just haven't helped.

And they're just a little more prepared for, for an operation.

Well, that was a good indication for it.

I mean, a trip to Europe involves almost always a lot of walking.

Part of a trip overseas.

And yeah, I mean,

I'm glad it helped.

And I remember the trip very well.

I mean, it's a place Andrea and I have always wanted to see as well.

We still haven't made that trip.

Well, they're almost all some form of arthritis.

You know, the most common is just wear and tear, what we call degenerative arthritis.

And the most common cause of that is probably an old injury of some sort, even an injury that the patient doesn't remember or recognize.

But over millions of cycles, that part of the knee just starts to wear out.

And it's usually the inside half of the knee.

uh that starts to wear out and then as it starts to wear out that you know you'll see people walking around like cowboys you know they start to get a bull legged well that's kind of a nutcracker you know it just increases the pressure on the inside of the knee it increases the wear there's there's always been some argument as to whether you can wear out a normal joint and uh you know you may not be able to wear out an absolutely normal joint so

People are either born with a malalignment of the joint, have an injury, or they have these other what we call metabolic conditions, the various forms of systemic arthritis, rheumatoid arthritis, psoriasis.

These that affect not only your joints, but other body organs as well, not isolated to just the knee.

But yeah, wear and tear, it's just like you're

Transmission in your automobile, you know.

Yeah, well, they're all basically metal and plastic.

And

The metals that are used are alloys.

There's only two alloys that are generally used in joint replacement for the metal part.

And it doesn't make any difference whether your implant is made in Asia or Europe or Canada or the US.

These are accepted international alloys.

And one is a chrome cobalt molybdenum alloy, and the other is a titanium alloy.

And they're used interchangeably.

But they all have a couple of common features that they don't rust out.

They're compatible in a saline solution like the body.

So they're completely inert, and they're not rejected by the body.

The other thing is that a second thing is that they're available at a reasonable cost.

There are elements that can be put into and milled and cast into shapes that are easy to do.

And the third thing is they both can be very highly polished.

They can be polished to a surface that doesn't create

microscopic debris.

And so those are the three metal, three metal alloys.

And there are three reasons or so for metal alloys.

The plastic is also all the same.

You know, it's a, it's a polyethylene plastic.

And now that's been improved over the years, that's changed.

not the basic plastic itself, but it's been reinforced.

The earlier forms of that plastic tended to wear and they created the microscopic debris in the joint over a long time, which caused inflammation in the joint and would cause some of these components to loosen and need to be revised.

But the new plastic is good.

And that

You know, that was discovered by accident by John Charnley in England.

Sir John Charnley, back in the 50s, he was orthopedic surgery in England, interested in one of his interests was in joint replacement.

And he was testing things.

He couldn't find a frictionless bearing surface.

And somebody brought a piece of this plastic in and he put it in one of his machines and

got up and looked at it a couple of days later and found out that the thing didn't wear it didn't seem to be and it was sort of a fortuitous now it was you know accidents happen to people that have more than just luck yeah you know it was an interest of his but he recognized that immediately and that changed that that was a big change in joint replacement because now there was a bearing surface that was essentially

friction-free or wouldn't wear.

And so that just went from then.

The design has always been a cooperative effort between industry and basic science, the engineers.

It's been the engineers studying the joints, studying their motion in the laboratory, and then trying to mimic that function in the body.

and that's changed over the years but boy over the past couple of decades there there really hasn't been you know i'd say over the past 25 or 30 years there there probably hasn't been any monumental you know changes we still we still don't know for example as good as these joints are how to put them into a professional athlete and have them

you know, it's not, it's not the million dollar man yet.

You know, and Stan, you mentioned it.

I mean, they're, they're good.

And they, they, they generally help a lot with the chief complaint, which is pain, but they are not normal.

They're, they're not normal needs.

I think it depends on how long you live, probably.

Golly, I think the survival rate now has got to be well over 90% for at least 20 years.

Yeah.

You know, it's really good.

You know, I think, and it's a combination of things.

You know, I think that failures probably can be, you know, common failures like an infection or, you know, some problems generally occur earlier, you know, in the first few years.

Hmm.

and then we all realize this i mean if it's if it's done in a senior that their activity your activity level continues to slowly decrease a little bit so as time goes on uh you're putting less stress on it than you probably had in those first four or five years so yeah so it's a combination of behavior as well as durability they're they're really quite remarkable so dr fisher i want to ask you a couple questions one is that um

probably up to an hour and a half.

It's probably that amount of time that that takes.

And we know now that because of techniques and just patient education, these are being done as an outpatient even today in both the hip and the knee in many patients.

20, 26 years.

And some patients that have been in the hospital afterwards

might have a hard time believing this that that you could actually just send people home a few hours after their operation but it's becoming fairly common in in selected patients but it's a combination of patient education preparation uh adequate care at home uh lots lots of things and uh and there's also been a state you know toward been a movement towards the uh

the short stay, which Tria really began in the Twin Cities, which was putting patients in a hotel, in Tria's case, in the Hilton across the street, and providing the physical therapy and the 24-hour nursing and everything in a hotel.

And that helped a lot because we were still able to provide the medical aspect of their care, but the hospitality aspect

uh being a patient was a lot better done by Hilton than by any uh any hospital I know of so that was that now when it comes to recovery the hip is generally faster you know the hip is a ball and socket joint it's a stable joint it's got all these big muscles around it uh it's quicker uh

I used to tell patients that I thought they should allow a minimum of six months to really start to feel like they made the right decision sometimes.

It takes that long to normalize the gait.

One of the problems in patients, particularly in the hip and the knee especially, is a bad gait pattern.

You've been limping around for a long time.

Sometimes you aren't even aware of how severe it is.

And your brain is used to that gait.

And it takes a long time sometimes to get back to a normal gait.

In the case of the knee, that's being able to straighten your knee out all the way.

Usually, as the knee gets stiff, it won't straighten out all the way.

And if it doesn't straighten out all the way, you limp.

And even after knee replacement, when the knee straightens out all the way on the operating table and everything else,

the brain doesn't quite, you know, it's not a, it's not a switch that the brain can turn off.

And so I think normalizing gait is what, what is kind of the last, you know, once your gait gets normal, then you start to, I think, appreciate fully.

But I, I, I, I don't, you know, I don't expect a miracle in the, in the first few months.

No, I think you both raise a good point.

You know, pain has always been a concern in terms of how to manage it.

And one thing we learned the hard way is that if we rely on these highly controlled medications to fight back pain, once it gets bad, in other words, you know, asking a patient, well, grade your pain on a one to 10.

And we like, we like say, well, it's not an eight yet.

You know, that doesn't work.

That doesn't work because

Those high-powered pain medications, which, of course, are really, really been subjected to restrict, you know, all kinds of restrictions.

Now, they're not just specific for pain.

They have all kinds of other side effects and emotional effects.

And we created a lot of trouble, you know, trying to medicate pain instead of getting in front of it, like you both talked with.

Less pain medication more frequently, I think, has been the key.

Stay in front of it.

We focused on the medical aspects of it, the surgical aspects of it.

I think what has really helped in the last 10 or 15 years is focusing on the patient expectations and

And education for the patient and what to expect.

That you're going to have these things happen to you.

And preparing for them seems to help a lot too.

The actual requirements that patients generally have in studies now is they don't seem to need as much pain medication as they did.

And I think a lot of that has to do with the psychological aspects of just being better prepared

for what you're going to experience, whether it's physical or as Clarence mentioned, whether it's concerns around your work or what is the whole impact of this procedure going to have on my life rather than just what is the impact of it on my knee?

And we've learned a lot of things the hard way and still have a long ways to go, I think, but we're better at it than we were when I first started.

Yeah.

Well, you know, I always, I always referred to, to,

my time around the professional athletes whether it was basketball or football or olympics just working in a human performance laboratory that that there were just a lot of things that you saw that you couldn't really explain i mean i could see some athletes with the worst looking feet and ankles in the world that could run like the wind uh people like adrian peterson that

didn't seem to get the inflammatory response.

You know, if they got injured or surgery, they didn't get a big swollen, bloody looking thing.

Their body just, you know, I hate to refer to it as, you know, some of the, we've genetically through the years, you know, we still have genetic underlying

issues that we just don't understand, you know, that, that why, why do these, why do these guys and women too, why do they not seem to be as disabled from a injury that you and I are, you know?

Yeah.

And, uh, you know, I saw that all the time and, and, uh, you know, they've got willpower, they've got motivation, they have all the other, of course, uh,

elements that drive them.

But at the same time, it's a natural selection process.

And some of it is a natural selection process physically.

Some of it's the natural selection process for some reason emotionally or psychologically.

But they're just interesting people to be around because you see

It makes you a little more conservative.

It made me a little more conservative as a surgeon often.

I would say that in that you just couldn't explain it.

It was an extraordinary experience.

At the same time, a lot of the techniques and the investigations that were used in these athletes became great benefit to ordinary patients.

I mean, I'm sure that probably some of the rehabilitation aspects of Adrian Pearson, Adrian's recovery, you know, it got you to thinking like, well, Kelly, maybe we could do some of these things a little bit earlier in the recovery of other patients, which we maybe have not done, thinking that it's probably too early to start running a little bit or it's maybe a little bit too early to start doing this.

And so it's forced us to kind of expand our barriers, you know, move them down the road a little bit.

And it's, I mean, even anterior cruciate, even his operation, when I first started doing these things, patients were in the hospital for five days after a ligament reconstruction.

Well, that's not only an out, you know, outpatient now.

I mean, they're up and walking.

It's amazing.

You're starting your recovery 24 hours later.

Yeah.

And the operation hasn't changed that much.

Well, what's changed?

Well, you make a good observation there, Clarence.

You know, we probably all, when we were young, played, you know, divided up teams on skins and shirts.

You know, and you'd pick a team.

One of those guys that show up for the first time you ever saw him with his shirt off, you'd say, I don't know him, but I'll take him.

Oh, close to, probably, rounded off to about 50, I suppose.

Wow.

You know, I have to, boy, when I think about something like this, I have to think about both inventions,

and probably the law, in that the computer changed all of our lives, but it really changed medicine, in that things like the CAT scan and the MRI, they were known for years.

I mean, the MRI was used in the 1940s in industry to evaluate blocks of plastic for

uh impurities in blocks of plastic the x-ray which is the foundation of the cat scan you know that was discovered in 1896 yeah long time ago yeah and with the computer it became possible to take the x-ray to take the mri and apply it to to

to humans.

We knew how to do these things, but we couldn't handle the amount of data that was created.

And so the computer changed that.

The MRI and the CAT scan totally changed the face of medicine, both of them.

In the case of the MRI, we could finally see under the skin.

We could finally see the soft tissues

which we really didn't have any way of seeing them or seeing an injury to them.

And then the arthroscope came along, of course, in orthopedics and changed the face of medicine as well as orthopedics.

So during my career, those inventions all happened and changed the face of medicine.

When I look at the law, I look at

I look at three federal acts.

I don't want to get into too much of a discussion here.

But the Civil Rights Act in 1964, Title IX in 1972, and the Americans with Disabilities Act after that opened the door for people to be more active, to participate in society

to a greater extent.

It made us all, I think, better people, better doctors.

I think it's slowly, slowly over generations beginning to generate a larger sense of community.

I'm optimistic, but those are the things, when I look back on 50 years that have happened in my lifetime, I think those are all things that happened

that have changed not only my career and my patients' health, but my personal life.

Not to get into too much philosophy here, but they all go together.

You have to have meaningful work if you're going to have a meaningful life.

And that's important for everybody.

Yeah, my pleasure.

Well, thank you.

I'm glad Andrea isn't listening to this because she wouldn't want to talk to me for

For weeks after hearing this.

She said, get your head back in the room there, Dan.

That's a, that's a good question, Stan.

I, you know, it's kind of, it's hard to say whether the incidence of these things is increasing.

Yeah.

Changed over the, over the course of your treatment and my career is, is the choices that we have for treating them.

So it's not, I mean, I remember my father had a terrible knee and, you know, it was just something you adjusted your life to and, and, uh,

you know, we've been able to treat people, whether it's arthroscopy in their younger years, you know, and I might mention to everybody that you had one of the most rare and unusual conditions I've ever seen in the knee.

In fact, and it was so early in my career that it kind of dumbfounded me at the time, but in fact,

I've only seen it in two patients in my whole career, and we actually wrote you up, you know, and published that congenital condition that you had.

But getting back to your question, it's possible that the increasing activity level that we're seeing in youths, you know, there's more and more kids that are starting in organized programs, and they're single specialty kids.

kids, they're competing and stressing their bodies at a much higher level in earlier years, more of them.

There are more patients and there's better treatment.

It's all led to a condition where we've stretched the indications for it.

30 years ago, the indications to do a knee replacement were quite a bit different than they are today.

We just didn't have the

the techniques, we didn't have the implants, we didn't have the confidence.

And so the whole spectrum of application of joint replacement has definitely increased.

Well, that was a, that was a remarkable invention and it was invented, uh, by a British, uh,

Professor, actually, not a surgeon, but a professor.

And it was the application of fiber optics.

And what fiber optics allowed us to do was to both shine light through it as well as see through it.

So we could not only put a light inside a joint, but we could actually see through the same small bore implement.

And that changed the whole thing.

And then when we could begin to see what was going on inside the knee or the hip or the shoulder or just about any area of the body now, in orthopedics, we could figure out how to treat it if we could see it.

And, you know, that's an element of any kind of surgery, whether it's orthopedics or general surgery or heart surgery, is that

the first thing you have to be able to do is you have to be able to see what's wrong.

If you can see what's wrong, you can figure out a way to treat it.

And the arthroscope had a great application in orthopedics, but my goodness, it's probably had a broader application in other areas of medicine, you know, gallbladders and appendixes and all these things now are

for the most part, handled the same way with a few little incisions and small tools.

It's been a remarkable invention because it's basically allowed us to see what's going on inside a joint.

Very good recovery.

I mean, you know, a gallbladder is a good example of general surgery where that used to be, that used to be a tough operation.

You were in the hospital for days.

You had this big incision in your abdomen.

Well, that's another one.

That's an outpatient procedure.

It's just like a lot of other things.

Well, not everybody does, Clarence.

No, that might have something to do with you.

You might put up with these things longer than a lot of people do.

But I think

I think sometimes you feel like, well, it's going to get better.

Maybe somehow things are going to get better.

But what you mentioned is often the key.

And when people start having pain at night and they start losing sleep and it starts interfering with their whole life, I mean, they're fatigued the next day.

A lot of times that's the last straw.

That brings people into the office and they say, well, you know, the aspirin or the Tylenol or the ibuprofen, it's not helping anymore.

And I just generally feel awful and my knees killing me.

Well, it's the unknown, too, in that whether it's a medical condition or a social condition, sometimes you could be in a bad situation

but you know what it's going to be like.

And the unknown is more of a detriment to making a decision at that point.

And I think it's scary when you think about going into surgery and maybe under an anesthetic where you lose total control.

Your life is in somebody else's hands completely.

And everybody knows somebody that's done really, really well

you know, from church or something, you know, they tell you, well, I had this operation done and I was playing tennis in two weeks.

Well, that's a lie, you know, but, but, but they weren't playing very well.

No, that's what their memory does to them.

But then, you know, if you go into rehab and I'm sure Stan has seen this, you go into talk to you and you see a rehab, you see some people don't do very well and they struggle.

And, and, and so the expectations are, you know, we can't say this is what's going to happen a hundred percent of the time.

Yeah.

And thank goodness it happens most of the time, but no, there's a fair amount of anxiety with, with any surgery, I think.