June 24, 2023 • 48 mins
Are you tired of suffering from hip pain and searching for a solution? We're excited to welcome Dr. Victor Ortiz, a board-certified, fellowship-trained orthopaedic surgeon at the Kayal Orthopaedic Center, to share his expertise on revolutionary advancements in hip replacement surgery. Discover how the cutting-edge Mako robotic arm assisted total hip arthroplasty, and minimally invasive direct anterior total hip replacement techniques are transforming the field and offering life-changing relief for patients.
In our conversation, we unravel the complexities of arthritis, its various types, and the symptoms you should be aware of. Dr. Ortiz will guide us through the critical role that the labrum, joint fluid, and articular cartilage play in hip health, and how these components can be damaged by arthritis. We'll also discuss the importance of consulting an orthopaedic surgeon for any musculoskeletal issues.
Lastly, Dr. Ortiz compares the traditional posterior approach in hip replacement surgery to the minimally invasive anterior approach, which results in less pain and better functional outcomes for patients. Learn about the crucial role of the MAKO robotic system in ensuring proper implant positioning and sizing, as well as its impact on procedure efficiency and patient outcomes. Don't miss out on this fascinating exploration of the future of hip replacement surgery with Dr. Victor Ortiz.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is June 22nd 2023, andI'm very privileged to have our
very own Dr Victor Ortiz with ustoday.
Dr Victor Ortiz is a boardcertified, fellowship trained
orthopedic surgeon at the KaleOrthopedic Center.
Dr Ortiz has completed twofellowships one in the area of
(00:23):
sports medicine and arthroscopyand the second in the area of
hip preservation.
His focus is going to be allabout how Dr Ortiz introduced
two cutting edge technologies tothe Kale Orthopedic Center in
the field of hip replacementsurgery.
The first is the introductionof the Mako robotic arm assisted
(00:44):
total hip arthroplasty and thesecond is the introduction of
the minimally invasive directanterior total hip replacement
through the front in a veryminimally invasive manner.
So we're so honored, privilegedand pleased to have Dr Victor
Ortiz with us today.
Welcome to the podcast, drOrtiz.
Victor Ortiz, MD (01:02):
Thank you so much, Dr Kale, for having me
today and look forward todiscussing hip replacement and
robotic surgery So happy to haveyou.
Robert A. Kayal, MD, FAAOS (01:09):
So before we get started, why don't
you just tell the audience alittle bit about yourself?
Victor Ortiz, MD (01:15):
Dr Ortiz.
So I grew up in Puerto Rico,born and raised.
I came back to the Statesapproximately seven years ago
with the whole family.
We were probably never lookingto do the move, but luckily we
came to New York.
My wife is also a healthcareprovider So while she was doing
her training I was practicing inanother New York City And so
(01:39):
far we love everything.
We've been a very happyadaptation to the whole family
and we're excited about it.
Robert A. Kayal, MD, FAAOS (01:45):
And we're very excited to have you.
It's also a little bit aboutyour professional education as
well.
Victor Ortiz, MD (01:50):
So I did my medical school in the School of
Medicine in Balamond, puertoRico.
After I finished my medicalschool, i went on to orthopedic
surgery and I did my residencyin orthopedic surgery in the
University of Puerto RicoMedical Science Campus.
After I was done with residency, my next goal was to do a
sub-specialty in sports medicineAnd I went to Chicago.
(02:13):
I did the University ofIllinois, chicago, where I
trained in sports medicinemainly arthroscopic procedures
of the shoulder and knee Duringmy fellowship.
I always had an interest indoing hypertroscopy.
So I met one of my mentors atthat time and he invited me to
join his fellowship called theAmerican Hip Institute in hip
(02:35):
preservation surgery And duringthat year I was really able to
focus on two main things that Ireally want was the
hypertroscopic procedure, butalso the direct anterior
approach.
So I did a second year inChicago doing these two
outstanding procedures that Ithink have really changed my
practice.
(02:55):
Also, it is interesting becauseduring training during
residency, i always said that Iwould never do hip replacement
And now it's part of my practiceis what really has allowed me
to build up a practice andreputation in the area.
But the long story short,during my fellowship in sports
(03:16):
medicine, i said I really wantto improve my skills in
hypertroscopy.
So when I decided to do thesecond fellowship, the downside
for me at the time was well, youhave to learn anterior approach
and robotic surgery.
So I said, okay, let's do it.
Long story short, i went inthere.
I love the approach, i love theoutcomes of the patients and
(03:37):
now it is probably the majorityof my practice And I'm
passionate about it.
I love the direct anteriorapproach, the robotic surgery.
I do everything that way.
I don't have the robot underthe surgery And it's been really
a game changer for my career.
Robert A. Kayal, MD, FAAOS (03:53):
Wow, dr Ortiz and I have been great
friends and colleagues for manyyears now, and this is the first
time I'm actually hearing thatstory, so that's something I
didn't know about you, dr Ortiz.
It's very interesting.
Well, thank God, you did receivethat training from one of the
finest institutions, not only inthe United States of America
but in the world.
That fellowship is very muchconsidered a thought leader in
(04:18):
this area of hip replacement andhip preservation technology,
and we're just so privilegedthat you learned from a master
surgeon and were able to bringthat technology to Northern New
Jersey and the tri-state areaand introduce it for our
patients and our community tobenefit from.
You certainly have become, andare now, a master surgeon in the
(04:41):
area of hip arthroscopy and hipreplacement surgeries, so we're
very fortunate to have thattechnology, especially with us
at the Kaila Orthopedic Centerbecause of Dr Ortiz.
Before we continue ourdiscussion regarding what that
technology is and why it's sobeneficial to our patients, i
think we need to start with thebasics, the fundamentals, and
(05:01):
let's just even talk aboutarthritis.
What is arthritis?
What types of arthritis existand why do they exist and how do
they present?
What are the symptoms that areassociated with arthritis, and
which types of patients wouldultimately benefit from your
expertise?
Victor Ortiz, MD (05:19):
So I think there are multiple types of
arthritis that affect the hip.
I always think that when Iexplain to the patients, the
common denominator here is thatthe patients are losing a
cartilage in the joint.
It's like the wear and tear,the bone and bone, and it can
happen in different ways ormodalities.
The one that we know, the wearand tear of the hip, or
(05:40):
osteoarthritis, is the mostcommon one, the one that a lot
of the patients have And theypresent with this bone and bone
disease, stiffness, difficulty,like pain along the groin,
difficulty getting in and out ofthe car, really difficulty with
prolonged walking and affectingreally their daily life
activities It's hard to put yoursocks and shoes and it's really
hard to do the things that theyenjoy, like playing golf,
(06:03):
playing tennis So simple thingsthat the elderly population want
to enjoy is being reallyaffected.
There are other types ofarthritis and, for example,
inflammatory arthritis that cansee in patients with chronic
autoimmune disease, likerheumatoid arthritis, like lupus
, for example, where the immunesystem creates a response
against the hip joint, causingthe same wear and tear.
(06:28):
There's another arthritis, likepost-traumatic patients that
have car accidents, where theyhave acetabular fractures or
fractures in the socket.
They can have fractures in thefemoral head that can lead to a
bands or progressive wear of thejoint, where they subsequently
need a procedure.
There's also infectious processor septic arthritis, where an
(06:51):
infection creates inflammationof the hip joint, causing the
same common denominator of wearand tear And, interesting, with
the septic arthritis you can seethe damage as soon as eight
hours after the infectiousprocess.
So we in orthopedic surgery arevery aggressive in treating
them because we know the sequalaand what can happen in patients
(07:11):
with possible infections.
There's also osteonecrosis orabascular necrosis, where
there's a blood supply insult tothe hip joint.
Where the patient develops lotsof blood supply or circulation
to the femoral head, theydevelop necrotic bone and
subsequently end up with havingwear of the joint that might
need surgical intervention.
Robert A. Kayal, MD, FAAOS (07:33):
Yeah , so you mentioned.
We've mentioned the termarthritis right.
So to break that down for ourviewing audience, arthro means
joint and itis meansinflammation.
We've talked in the past thatinflammation can be associated
with redness, warmth, swellingand pain, and then arthro
represents the fact that thejoint is involved.
(07:54):
So arthritis is inflammation ofthe joint, so you can get
redness, warmth, swelling andpain in that joint, as Dr Ortiz
alluded to.
That arthritis, or inflammationand pain, is associated witha
destruction of the joint for awhole myriad of different
reasons.
The most common, he said, wasthe typical wear and tear,
(08:16):
degenerative osteoarthritis.
But there are other types, allof which can definitely benefit
from treatment, ultimately, withDr Ortiz, with a hip
replacement.
The worst of those that wasdescribed was the septic
arthritis, because that's whereyou have an infection in a joint
And certainly that becomes very, very complicated because you'd
(08:36):
never really want to put animplant in the presence of
infection.
But for the most part, all theothers osteoarthritis,
inflammatory arthritis,avascular necrosis those would
benefit tremendously ultimatelyfrom a hip replacement.
So we talked about some of thedefinition of arthritis and some
(08:58):
of the classic presentationsymptoms groin pain, difficulty
getting in and out of cars,difficulty putting on socks and
shoes, restricted range ofmotion and a limp.
But there are changes going oninside the joint that are very
characteristic of that arthritis.
Dr Ortiz mentioned essentiallybone on bone, wear and tear of
(09:20):
the cartilage.
There's other changes, right,dr Ortiz, going on with respect
to possibly the labrum, thefibrocartilaginous labrum, and
also the fluid inside the jointas well.
But before you even answer thatquestion, just for our viewing
audience, what are the differenttypes of joints Like?
what kind of joint is a hipjoint as compared to, say, a
(09:41):
knee joint?
Victor Ortiz, MD (09:42):
So the hip joint is a ball and socket joint
similar to the shouldercompared to the hinge joint of
the knee, so every joint is madedifferent and has special roles
.
I think when we have a ball andsocket joint there are multiple
things.
I think for me the mostimportant one is that the hip
joint is a joint that is madeball and socket with the
(10:04):
extension of the labrum.
So the labrum is an extensionof the socket, creates a suction
seal mechanism to first providestability but also allow the
function or mechanics of the hipto function correctly, you know
, to be able to you haveadequate mobility, that the
properties of the synovial fluid, of the cartilage are protected
to decrease the inflammation,because at the end of the day,
(10:26):
inflammation is what causes painand is what causes the damage.
So our goal really with thetreatment of are any type of
arthritis is really to bringthat inflammation down, to
decrease the chances of havingsubsequent or more damage in the
hip joint right.
Robert A. Kayal, MD, FAAOS (10:42):
Yeah , it's interesting you mentioned
the labrum and, by the way, wewill allude to the labrum in the
future.
Doctor Ortiz, as I mentioned,is a master Hip arthroscopist as
well as a hip replacementsurgeon.
In a subsequent podcast we willbe interviewing doctor Ortiz on
the subject of hip preservation, where he addresses labral
(11:03):
tears.
So stay tuned for that.
But with respect to the hiparthritis and the role of the
labrum and the joint fluid, whatwe call the synovial fluid in
the joint, i often give thepatients the analogy of a gasket
on a car engine.
Right, because we have a carengine, we have the cylinders,
(11:23):
we have the pistons going up anddown and the most important
thing in there is the oil, theengine oil that's lubricating
that mechanical construct.
Right, if there's a gasket leakand that fluid can leak out the
oil, can you can you can freezeup a piston in a cylinder and
it can jam and cause enginefailure.
The same analogy I give whenI'm talking about labral tears
(11:47):
and referring patients to youfor that.
When There's a labral tear in,that fluid can see about and you
lose those mechanicalproperties inside that ball and
socket joint, that seal fromthat labrum that helps to keep
that fluid in there and providethose mechanical properties.
But again, we're digressing alittle bit because it's also
very, very important in the areaof hip preservation Where we're
(12:10):
actually referring patients todoctor or a tease to fix and
repair the labrum so ultimatelythey hopefully do not end up
needing a hip replacement.
So that's, that's anotherpodcast, but for now I think
it's important to justunderstand the anatomy, the fact
that the hip is a ball andsocket joint.
You have this big round ballsitting inside a big bony cup
(12:34):
and around that cup is a labrum,a fibro cartilage labrum that
basically seals that joint, thatconstruct to allow that fluid,
the synovial fluid inside thejoint, to stay inside the joint,
just like that car enginegasket we talked about, to
provide those mechanicalproperties to that ball and
(12:56):
socket joint so that thepatients like doctor or T said,
less inflammation.
So now you understand thefunction of that fibro
cartilaginous ring of tissuethat seal.
Are there other anatomicalstructures that come into play
in a healthy, non arthritic hipjoint?
Vic, Absolutely.
Victor Ortiz, MD (13:18):
I think one of the most besides the label and
the most one of the mostimportant structures is the
articular cartilage, and we knowthat our ticket or cartilage in
every joint is a little bitmore smooth than the label is a
collagen type two And it reallygives some of the properties of
the joint, like load bearing,and when we start losing that,
(13:38):
that's when we as you mentionedbefore with the gasket and it,
that's when we develop problemsand that's when you know about
inflammation And pain right.
Robert A. Kayal, MD, FAAOS (13:47):
So what?
what you're essentially sayingis that this articular cartilage
is essentially different fromthe cartilage in the labrum
right, the labrum There's.
There's something calledcollagen that we have in our
body in different areas, but inorthopedics is relevant
primarily in the area of boneand cartilage.
Okay, in bone that's type onecollagen, but in the meniscus
(14:10):
and in the labrum and in theinter vertebral disc of the
spine that's also type onecollagen, but in the healthy
joint there's a different typeof collagen in what we call the
articular cartilage, thecartilage that is essentially
stuck to the end of the bone.
So if you have a hinge kneejoint of the knee, that type two
collagen makes up articularcartilage, the cushion on the
spine, and the same thingapplies in the hip to right in
(14:32):
the ball and socket joint youhave that type two collagen,
highland articular cartilage onthe end of the bone, different
from the cartilage That's in thelabrum right.
So you're saying that witharthritis that can wear down,
correct and become thin, verythin, to the point where
sometimes bone can be exposedright and that knee Normal
(15:00):
smooth surface is now sort oferoded and it's not smooth
anymore.
It's bumpy like potholes in aroad right.
And then what about the jointfluid, the synovial fluid inside
a bone socket joint?
we talked about the labrum thatcontains it, but what about the
fluid itself?
So the synovial fluid provideslubrication to the joint, helps
in the low distribution.
Victor Ortiz, MD (15:23):
Has a good amount of proteins that, when we
have our triad, is the, forexample.
The high loronic acid getsdiluted.
So those properties are not thesame.
Right and all that, itcontributes to the whole
spectrum of hip pain.
Right, it's a whole downwardspiral.
Robert A. Kayal, MD, FAA (15:35):
You're wearing the articular cartilage
, you're tearing the labrum andnow the synovial fluid is
markedly diluted over the entirespine Right, and that's why the
the FDA has approved some whatwe call intraarticular
injections of high loronic acid.
But it's only FDA approved forthe knee, where we can inject
(15:59):
these products, such as sin viscand ortho visc and others, into
the joint to try to restore thenormal concentration of high
loronic acid into the joint.
Unfortunately it's not FDAapproved yet for the hip, but
maybe someday.
Thank you so much, doctor Ortiz, for that very elaborate and
and thorough explanation aboutarthritis.
(16:19):
How does arthritis typicallypresent?
besides the pains you'retalking about, are there other
symptoms that are commonlyassociated with arthritis?
Victor Ortiz, MD (16:33):
I think the main comment besides pain, which
absolutely is one of the firstsigns that patients feel
limitation in range of motion.
So patients feel stiff, theyfeel that they are limping, that
they need to use a cane to movearound because they cannot
really stand on that feed, andthen there's difficulties in
(16:54):
their activities of daily life.
Right, the most common one islike this is I want to go to New
York City, i want to couplewalk for a couple blocks and I
have to stop every block becauseI don't feel comfortable.
And that's usually the.
What brings into the office isbecause they are really trying
to do things that they enjoy andthey're not able to.
And another thing for example,if we go to sports and we know a
(17:16):
lot of our patients, you knowthey like to play golf, they
like to play pickleball which isthe new thing out there And
they have limitations and theysay, like I cannot perform, you
know I get pain during the,during playing.
At the end I'm miserable for acouple days.
So those are usually the typeof signs or symptoms that
patients are feeling them.
Bring them to our practice tolook for care.
Robert A. Kayal, MD, FAAO (17:38):
Right And I noticed over the years
that it's often the familymembers that finally get them to
come in right.
They're sick of them seeingthem limp like this and not
participate in family events Andthey really strongly encourage
them to just get it taken careof so they can restore their
quality of life.
So thank God for those familymembers, because a lot of times
(18:00):
patients just opt to live withthings and or don't even know
that options exist that we canactually get them out of that
pain and restore that quality oflife.
And that's one of the reasonsfor this podcast to try to
educate our community ofpatients that you don't have to
live like this anymore.
There's a lot of things thatcan be done to help you, which
we'll get to in a minute.
(18:20):
But besides the pain loss ofmotion, stiffness, instability
sometimes their joints canbuckle and give way Besides that
, do they sometimes have pain inother areas and not the hip,
even though it might be comingfrom?
Victor Ortiz, MD (18:41):
the hip Right.
There are two main places whenI look at that.
I think the first one will bethe knee And we have had a good
amount of patients that theyjust come to the office with
knee pain.
You look at the x-rayeverything looks perfect In the
knee, the x-ray looks perfect Inthe knee.
Robert A. Kayal, MD, FAAOS (18:54):
it's perfect.
Victor Ortiz, MD (18:55):
You do an examination, it feels pretty
good And then you start feelingthe hip.
If the hip feels stiff, andthen you get x-rays and out of
the blue it's bone on bone Andit's not uncommon to see that
that you have radiating pain.
I think one of the reasonsbeing is that there's a small
nerve under the hip joint thatcan get irritated and cause pain
(19:15):
going down the knee, but it'sreally coming from the hip joint
.
Robert A. Kayal, MD, FAAOS (19:18):
I think that other one it's very
common, By the way, not tointerrupt you, but on that note
I mean sometimes it's hard toconvince patients that the
problem is the hip.
Not that we get in argumentswith our patients, but sometimes
they don't believe us.
They say there's nothing wrongwith my hip, My pain is in the
knee, And that is oftensometimes the only presentation
(19:42):
Because the patient's havingpain in the knee.
We evaluate the knee, We takethe patient's word for it, We
get an x-ray of the knee butthere's nothing wrong with the
knee And the only thingsometimes that is wrong is the
hip, And I've done many hipreplacements over the years for
a chief complaint of knee pain.
It's interesting Ultimately thepatients concede because they
(20:07):
understand we're the experts inthat regard But it is hard for
them to believe that the problemis stemming from the hip and
not the knee And where else.
Victor Ortiz, MD (20:16):
And I think the other one which would be one
of the most commonly missed iswhen something that I described
to the patients as a hip spinesyndrome, where patients are
constantly told the pain is fromthe back, we can do anything
else, and a lot of timespatients with hip pathology can
present with posterior hip pain.
It gets confused.
It might take two or threeoffice visits for them to well.
(20:40):
the problem is the hip.
Robert A. Kayal, MD, FAAOS (20:41):
When he says post-do your hip pain
he's talking about in the butt.
Is that the head In thebuttocks, like where possibly
sciatica may present?
Victor Ortiz, MD (20:49):
And usually they'll go to the primary care
doctor, they'll go to thechiropractor or physical
therapist and they're told well,is the back, is the back?
keep working the back and outof the blue, same as the knee,
you start looking at the hip.
you maybe sometimes do aninjection and they are whoa like
everything changed.
Robert A. Kayal, MD, FAAOS (21:04):
We see that all the time.
We see it all the time And it'simportant that patients see an
expert and get a physicalexamination by an expert
orthopedic surgeon with atremendous amount of experience,
because we tend not to havetunnel vision When we listen to
our patients.
We know the potentialetiologies of pain in certain
(21:27):
areas.
Oftentimes patients don'tunderstand that the hip to the
orthopedic surgeon is not theoutside of the hip, it's the
groin.
So the hip joint for theorthopedic surgeon is the groin.
There can be pain, like DrOrtiz is describing, in the area
of the buttocks.
That's still the hip, butusually pain in the buttocks is
(21:49):
coming from the back.
Pain on the outside of the hipis coming typically from soft
tissues around the hip joint butnot the hip joint itself.
But pain in the hip and pain inthe groin can very often be
stemming from the hip jointitself.
Now that we've described hiparthritis and we've described
the symptoms that are oftenassociated with hip arthritis,
(22:14):
does everyone with hip arthritisget a hip replacement?
Victor Ortiz, MD (22:17):
No?
I think that the answer is no.
I think that is a very commonthing for patients to come to or
not want to come to theorthopedic surgeon because, as
the word says, it's a surgeonand they don't want to have
surgery.
But I think that the first lineof treatment and for almost
every orthopedic problem, is aconservative approach And we do
(22:40):
that with our patients.
We try two or three months ofconservative treatment, which
includes a gamma of treatmentthat includes diet and
exercising good weight in ourpatients, physical therapy,
where there's 70 muscles goingaround the hip joint.
So if we work around thosemuscles the load to the hip
(23:02):
joint can be less and thepatients can have a significant
amount of relief.
We try anti-inflammatorymedications, sometimes combined
with pain medication, andsometimes it's being shown that
cortisol injections as ashort-term pain relief can
provide significant relief.
And one of the things how Iincorporate these injections in
(23:23):
my practice is that when thepatient comes to the office,
when they decide to come,they're in pain, they need
something, and that's where thatinjection really plays an
important role brings theinflammation down, allows our
therapies to work with thepatient in a better way.
Sometimes these patients willgo through physical therapy,
they'll flex the hip and they'renot able to finish the session.
The cortisol injection allowsthem to do that, allows them to
(23:48):
be comfortable, allow thetherapies to really do a better
work and they come back aftersix 12 weeks and they have
significant improvement ofsymptoms.
Robert A. Kayal, MD, FAAOS (23:56):
Just to elaborate on what you were
just discussing, vic.
There is a common misconceptionthat, just because patients are
coming to an orthopedic surgeon, that that's all we do.
Like you only come to us whenyou need surgery.
Nothing could really be furtherfrom the truth.
Right?
If we see a hundred patients,we'll probably end up just
(24:17):
scheduling five of thosepatients, right?
Most of those patients arebeing seen for physical therapy
prescriptions.
We just do a physical exam.
They might need a cortisoneinjection, they might need an
X-ray and told nothing's wrong.
Most of what we do is primarycare and non-operative
orthopedics, right, so you don'thave to be scared to see us.
(24:39):
Okay, don't be scared to getassessed by an orthopedic
surgeon, because I've always andI say this during every podcast
for the most part, most of whatwe do is non-operative.
We should be your first callwhen you have anything wrong
with your musculoskeletal system, because you're being evaluated
(24:59):
by an expert in the field oforthopedic surgery, where we can
assess and do a physicalexamination.
We can interpret x-rays andMRIs and cat scans.
We can write prescriptions formedications, anti-inflammatories
, give trigger point injectionsto help alleviate some of your
(25:20):
pain.
Order physical therapy,chiropractic, acupuncture,
massage therapy.
Again, most of what we do isnot operative, so you should
really rely on us to helpquarterback your care and then
ultimately, if you do needsurgery, we can do that too, but
most of what we do is notoperative, so I did want to
(25:42):
drive that point home.
Also, you mentioned that youoffer it Cortisone injections.
Right, and that dovetails offthe fact that osteoarthritis is
associated with inflammation ofthe joint and there's no better
or more potent anti-inflammatorythan what we call an
intraarticular injection of acorticosteroid.
(26:05):
You know, arthritis,inflammation of the joint,
inflammation is associated withredness, warmth, swelling and
pain, and when we give you acortisone injection, it very
often alleviates that.
For instance, what's been yourexperience when a patient is
coming in To the office insevere pain with a horrific limp
(26:29):
and you lie him down on thefluoroscopy table in our
procedure room and give him acortisone injection into the
joint?
what's been your experienceimmediately thereafter?
Victor Ortiz, MD (26:41):
So you know I think that we also put some
light of hand in there thatusually a lot of times when you
put the needle in you get somefluid out, so that fluid
immediately decreases thepressure of the joint.
So they feel sometimesimmediate relief.
And then when the joint is numb, it's like when you go to the
dentist right, you know thejoint, they're like, wow, my hip
feels great.
And when they come for followup, you know the amount of
(27:03):
relief that these patients get,how happy they are.
Robert A. Kayal, MD, FAAOS (27:06):
It's unbelievable yeah, i can't tell
you how many patients havegotten off that table just gave
me a huge hug and thank me.
I don't think there's anythingthat's more rewarding than that
injection.
When patients are limping andsuffering in pain and you give
them that injection, they'rejust so thrilled and after I
experienced that with them I sayguess what?
(27:27):
that's exactly how you're goingto feel after Dr Ortiz does
your hip replacement.
I always tell patients that ofall the conditions we treat in
the field of orthopedic surgery,i don't think there's any
operation or any disease entitythat does better postoperatively
then hip replacement surgery.
(27:47):
It is probably the mostrewarding operation.
We do that, and probably carpaltunnel release as well.
They're just incredibly,incredibly successful operations
.
So now that we've spent a lotof time talking about all of
this, let's get to the focus ofthe of the podcast, and that is
(28:07):
the fact that you brought to thepatients of the tri state area
here this incredible technologyto incredible technology
simultaneously, and those are,just to reiterate, the Mako
robotic arm assisted total hiparthroplasty combined with the
minimally invasive directanterior approach.
(28:28):
There were some surgeons thatwere doing the direct anterior
approach.
There were some surgeons thatdid robotic surgery, but Dr
Ortiz, really pioneered thesetwo cutting edge technologies
simultaneously in our area andhas done hundreds of different
types of surgeries And hundredsand hundreds, if not thousands,
(28:50):
of these operations over thepast few years.
Just a master surgeon.
So let's, let's talk about oneat a time.
Ok, so the let's first talkabout the technology of the Mako
robotic arm assisted total hipreplacement.
Just what is that?
First of all, even before weget there, what is a hip
(29:11):
replacement?
Can you compare and contrastfor us the difference between
the traditional posteriorapproach that everyone's
familiar with, and compare andcontrast that with this new
technology that you are bringingto the table, that you've
brought to the table, you know,about five years ago now, in the
(29:32):
area of hip replacement surgery?
that pertains to the minimallyinvasive, direct anterior
approach.
Victor Ortiz, MD (29:39):
So the conventional approach, which is
the posterior approach with, asyou mentioned, has been, has
been a very successful procedurein the surgery and is the most
of the surgeons in the countryperforms that approach.
But I think that we alwaysnever satisfied.
We're never satisfied inorthopedics, we always want to
see how we can make a greatprocedure even better And I
(30:02):
think that's where the approach,with the direct anterior
approach, we have been able toachieve that.
When we do the posteriorapproach The main you know, to
get into the hip joint we haveto cut through normal anatomy So
that a lot of the timestranslates to having either
either temporary or permanentlimitations or restrictions
(30:23):
where patients are not reallyable to flex the hip too much to
cross their legs.
They have to sleep with apillow between the legs, they
might need a bathroom mold or,you know, they spend some time
to recovery.
The functional recovery is alittle bit longer in the acute
phase.
When we do the anteriorapproach, the biggest benefit of
(30:44):
the approach is a minimallyinvasive technique where instead
of having to detach normalanatomy, we go between the
muscles, so we go into front ofthe hip, you separate the
muscles and right there you'rein the hip joint.
I always tell the patients youknow the biggest difference when
we look at the ball and socketand we'll do it later with the
model The hip, the socket isalways looking to the front of
(31:05):
the patient.
So when you go to a house youwant to knock the door to the
front, not to the back.
It's harder to get in.
So when we do the anteriorapproach we separate the muscles
, open the joint and we can seethe socket in front of us.
I think if you make a pole, alot of the orthopedic surgeons
(31:26):
would say I would never do areplacement because I'm not
comfortable doing the socket.
And I can tell you, with theanterior approach the socket
becomes the easy part of theprocedure And I think those are
the biggest difference betweenapproach.
I think we look at evidencebased medicine.
It's been clear that in thefirst three months in that acute
recovery that the patientsremember forever, the pain is
(31:49):
less and the functional outcomesthe functionality of the
patients is is much better And Ihave had a lot of patients that
I do their their hips when theyhad the other side done through
a posterior approach And theyalways say it's a night and day
experience.
If I knew about this.
I will only do it through theanterior approach And I think
it's really been a game changerfor my practice as being a game
(32:11):
changer for the patients, it isallowing patients to be more
comfortable doing our patienttotal joint replacement, which
is the future of medicine andorthopedics And, you know, i
think that is the way to go.
Yeah, definitely, we've seen itin in our practice.
Robert A. Kayal, MD, FAAOS (32:30):
It's really revolutionized the way
that we do hip replacements inour practice and the outcomes.
Like you said, our night andday.
Patients have been able tocompare and contrast with the
patient.
Patients have been able tocompare and contrast posterior
approaches to anteriorapproaches and it's it's much
more rewarding early on,especially Through that
(32:50):
posterior approach.
You know you can do that in aminimally invasive manner.
But it does not change the fact.
Even if the incision is small,it does not change the fact that
surgeons are taking downimportant tendons and structures
, detaching them in order togain exposure and then
(33:12):
reattaching them at the end toprovide stability.
So that is really a majorconcern.
The sciatic nerve is rightthere as well.
There's a concern, patient.
There's a concern possiblyabout causing some iatrogenic
injury potentially to thatsciatic nerve.
There have been patients in theliterature that have woken up
with foot drops because ofinjury to that sciatic nerve
(33:34):
through the posterior approach.
Clearly there's a higherdislocation rate because you're
taking down those soft tissuesand that's a problem.
And so now that can, for themost part, all be avoided
through this minimally invasive,direct anterior approach.
This minimally invasive, directanterior approach is often done
through an incision.
How big?
(33:55):
would you say this, this, yeah,about that, about this big?
I mean to do the operationroutinely.
This has allowed us to, for themost part, really pioneer
outpatient hip replacementsurgery in the area.
You know these are routinelydone as an outpatient.
Patients are now walking thesame day on this hip and home in
(34:18):
the comfort of their homeWithin, often four hours after
surgery.
So much less pain, much lessinvasive.
Essentially, you don't evenrestrict the patients after
surgery at all.
Right, with the posteriorapproach, our training is that
some surgeons say for six weeksyou can't cross your legs, you
(34:40):
can't sit, bend your hip morethan 90 degrees, you can't
internally rotate your leg morethan 20 degrees For six weeks.
Some people say for life.
With the direct anteriorapproach, there's no
restrictions.
You know, after the posteriorsurgery, patients would always
get either a neomobilizer orthat big blue foam pillow
(35:01):
between their legs And they'resitting like this or trying to,
you know, go to sleep like thisand with this big foam pillow
between their legs.
For six weeks you don't havethat at all.
Right, you don't use the pillow, you don't restrict them from
sitting in a sofa, sitting on asoft sofa or a toilet seat.
You don't make them use aelevated toilet seat.
(35:24):
Nothing like that, right?
Nothing like that.
Those are the beautifuladvantages of this minimally
invasive approach, but itdoesn't stop there, right?
You didn't just introduce thisminimally invasive, direct
anterior approach.
You combine that with thesecond technology, and what is
that?
Victor Ortiz, MD (35:42):
So that we combine the direct anterior
approach with the medicalrobotic guidance, and that's
been amazing.
I think that right now, as Imentioned initially, if I don't
have the robot, i'm not doingthe surgery, and that's how
confident I feel that the robotis a compliment to what we're
doing.
And the biggest things that weget with the robot is two things
(36:05):
.
I think that we do a CT scan onthe patient before the
procedure.
That allows us to customize theimplants.
We can design the implants toevery patient's need.
Robert A. Kayal, MD, FAAOS (36:15):
And let me make something clear.
Dr Ortiz mentioned he's notdoing the operation if he
doesn't have the robot, notbecause he can't do it without
the robot, but because he relieson the accuracy and precision
of the robot.
You see, he's designed thesehip replacements on a computer
before surgery And the robotensures that he doesn't
(36:35):
inadvertently deviate from thatpreoperative design.
So, for instance, if heinadvertently were to angle his
arm or his hand one way or theother, the robot would shut off
and not allow him to proceed.
Because the robot ensures theprecision of installation of the
hip replacement to beconsistent with his preoperative
(36:57):
design on the computer and onthe proprietary software program
.
Victor Ortiz, MD (37:04):
So before we start the procedure, we have the
computer and we design theimplants the way we want it to
have a right tension, the rightsizing of the implants.
So once we go into theprocedure we can reproduce that
to the patient's anatomy.
And this is, for example, anexample of the socket.
So if we look at this, thiswill be the cop.
(37:26):
So after we prepare the areawhere we rim the whatever is
left of cartilage, we haveadequate bleeding bone because
these implants grow into thebone, grows into the implant.
That's part of what we call ingrowth, bone in growth, which is
an important characteristic ofthis implants to incorporate
into the hip replacement.
So what that means is that thebone grows into the implant to
(37:49):
avoid any movement or looseningof these devices.
So that when I'm looking at thecop and when I'm looking at the
CT scan from a three-dimensionstandpoint, we wanna make sure
that the cop is exactly flushAnd you can see how there's no
prominence, the cop is not toodeep, that we don't remove too
much bone, that it's not a copthat is too small.
(38:12):
Those are things that are veryimportant.
Sometimes we look at copstarted too big And when we have
a cop that is too big, thatcreates problem in the soft
tissues around.
We don't want any soft tissueto be irritated because we have
a prominent cop.
Then when we have cops that arenot in the right position, we
make patients.
Patients can be prone todislocation, as we mentioned
(38:34):
initially, but also when thedistribution of load in the hip
is not even my belief is thatwe're gonna load over one area
of the implant more and thatimplant will wear faster.
So robotic has allowed us toput this implant where the
patient needs And we incorporatethe balance of the spine, we
(38:54):
incorporate the rotation ofdifferent bones to make sure
that the patient doesn't haveimpingement that doesn't
dislocate, to get the patient ahip that resembles the native
hip.
And one of the things that Ilike to tell the patients is my
goal with this procedure, withthe direct anterior approach,
with the robotic surgery, isthat three to six months later
(39:14):
you forget that you have areplacement, that you think this
is my normal hip.
So the MAKO robot has reallyallowed us to work with the
socket to make this procedurethat doesn't have that.
The patients resemble itself Soand then we go ahead and we do
the stem.
Robert A. Kayal, MD, FAAOS (39:34):
So essentially what you're saying
you're installing that cupperfectly each and every time.
You're trying to restore thenormal anatomy of the patient.
So if the cup is too big, itcan result in some impingement
of some soft tissues and somepain.
If it's improperly positionedin a certain plane, it can
result in instability as well.
(39:55):
And so that's where the benefitof the robot comes in, where
you design the precise placementon the computer and then the
robot ensures that you put it inexactly that way, so it's
perfectly sized, positioned andaligned each and every time.
Victor Ortiz, MD (40:13):
Correct.
so I think that the firstimportant interoperative role of
the robot As it pertains to thecup.
Robert A. Kayal, MD, FAAOS (40:21):
As you mentioned, many orthopedic
surgeons in this country willnot even attempt hip replacement
for fear of the acetabulum,right?
I don't.
I wanna make sure we emphasizethat point, because with this
minimally invasive, directanterior approach, you're
staring right at that acetabulumso you can see it so perfectly,
(40:42):
and then now with the robot,the robot will put in that cup
exactly in the right positionand angulation that you designed
on the computer.
So it essentially eliminatesthat fear of taking on the
acetabulum right.
It's ensuring that it's perfecteach and every time, and that
(41:06):
has traditionally been the mostchallenging part of this
operation that has typicallydissuaded so many orthopedic
surgeons from even doing hipreplacements.
And let me just drive home oneother point, and that is that Dr
Ortiz is doing the surgery.
It's not the robot doing thesurgery.
The robot just ensures that hedoes the surgery exactly the way
(41:30):
he designed the surgery, and ifhe doesn't, for whatever reason
, it just shuts off, it stops.
And so one of the otheradvantages of using this robot
as a pertain to the acetabulumis that it becomes a much more
efficient surgery, right?
You're doing the surgery morerapidly, and that's important to
(41:50):
get patients off the table,right?
Traditionally we used to preparethe acetabulum in a sequential
manner.
If we were reaming, to say, asize 52 cup, we would maybe
start at a 48 and then go to a50 and then go to a 51, and then
you know gradually.
This is a one-time ream for themost part, right?
(42:12):
The robot knows exactly theangle, the depth, and it's a
one-time shot and it makes itperfect every time.
So the robot comes in, dr Ortizis guiding the robot, he sets
the angle for that robot to reamand the size It's a one-stop
shop And then boom, you put thecup in, you're done And you're
(42:36):
moving on now to the stem.
Right, correct?
So let's talk about the stem.
Victor Ortiz, MD (42:40):
And then we will do the stem in a
traditional manual way.
So we have a.
This is a sample of the stem.
This is a titanium stem with aceramic head.
So what we do is that we firstprepare the canal to the size of
the patient.
That was already planned withthe CT scan And then we impact
the implant.
And same way as there's boneingruth in the acetabulum or the
(43:01):
socket, there's bone ingruth inthe femur.
The bone will grow into theimplant and will become part of
it.
So once we have the right stemthat we need, we go ahead and we
do something we call trialing.
And when we're trialing, we aremaking sure that we have a
balanced hip.
And that's where the secondfunction of the robot comes into
(43:23):
play.
As I mentioned, we want torecreate this hip to be as the
hip, the native hip, the hipthat you have before.
That was functional.
Robert A. Kayal, MD, FAAOS (43:31):
So And we talk about offset and leg
length, right, right.
Victor Ortiz, MD (43:35):
So that's where we put the joint together.
And when we have the jointtogether, we can look at the
robot and we can make sure fourimportant things And then it's
gonna be that the leg is not toolong or too short And that the
tension in the gluteus or the ABdoctors or the muscles in the
side is adequate, that they arenot too tight, that they are not
(43:57):
too loose.
So those are the things thatreally allows the patients to
feel better when you have theright tension and the right
length And it's a hip that isstable.
We test the hip in differentrange of motion modalities and
the hip stays in the socket.
That's when this not too tight,when it's not too short.
Those are the most commoncomplaints of patients When they
(44:18):
have trouble my leg is too long, i feel so tight.
And those are the things thatthe Mako has really allow us to
perfection.
It Just the bouncing of thesoft tissues around the hip that
are very important, and notonly in the acute process, in
the acute rehab of patients, butalong the road.
Robert A. Kayal, MD, FAAO (44:40):
Maybe even more important, right It's
.
You know we say with kneereplacements it's a soft tissue
operation And same thing withhip replacements.
It's so important The softtissues have to feel good.
Right, it's one thing toresurface or replace a joint,
but it's the soft tissues thathave to feel good and have to
provide stability and properstability.
(45:01):
Right, if the soft tissueenvelope is too lax, you might
have an unstable hip.
If it's too tight, you mighthave a long leg length
inequality or a painful hipbecause the soft tissues are
just too stretched and too tightor limited motion.
So both hip replacement, kneereplacement and you can probably
(45:21):
extrapolate to shoulders andankles they're soft tissue
operations And that's where thisincredible software technology
allows us to tension the softtissue envelope, with me for
knees and with you for hips, tomake it perfect.
So not only are we putting inimplants perfectly, perfectly
aligned, sized, positioned, butnow the soft tissues are also
(45:46):
happy.
You know, i'm sure you canelaborate on patients that
you've seen over the years wherethe doctor might have done a
beautiful job on X-ray.
Right, the X-ray looks perfect.
We're looking at an X-raydoctor's telling the patient I
don't see anything wrong, it'sperfect.
Just take some more Advil anddo physical therapy, but really
(46:06):
the soft tissues are notproperly tensioned in one
capacity or another.
Same thing with knees Like theX-ray could be perfect but the
knee might not be balanced andthe knee might be tight or stiff
or unstable.
The soft tissues are very, very, very important And unless
you're a high volume surgeon,you may not know how to handle
(46:29):
the soft tissues as well as thehigh volume surgeons, right?
The literature is clear on that.
The American Academy ofOrthopedic Surgeons makes it
clear that high volume surgeonshave the best outcomes.
So you really want to go to asurgeon that's highly skilled,
trained and experienced in hisor her area of expertise,
because you know it's just likeany other thing, right?
(46:50):
You want a good plumber, youwant to get electrician, you
want a good, you know, you nameit profession.
You know High volume surgeonsreally have the best outcomes.
We've seen it all, we'vehandled it all and I think
that's just important for ourviewing audience to know and
appreciate.
And there's never anythingwrong with getting a second
opinion, because it's veryimportant that you know what's
(47:14):
out there and to get the latestand greatest technologies.
And that's really what we prideourselves on at our practice
right.
We're always trying to offerour patients the latest and
greatest technologies in thearea, and I think that's
important to emphasize.
Victor Ortiz, MD (47:32):
And what I was preparing for.
Today.
I was reading about a studyfrom Cleveland Clinic and they
were saying that by 2030, theywere expecting, they were
projecting that 60% of thepatients will be having
robotic-assistant hipreplacements.
I think that is something thatwe have brought to the practice,
where almost I do 100% of them.
Robert A. Kayal, MD, FAAOS (47:53):
So, Dr Ortiz, this has been a
fantastic conversation with you.
I really appreciate your time.
Victor Ortiz, MD (47:59):
We went over a lot of things today and I'm
very grateful.
Thank you so much, dr Kale, forhaving me today.
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is June 22nd 2023, andI'm very privileged to have our
very own Dr Victor Ortiz with ustoday.
Dr Victor Ortiz is a boardcertified, fellowship trained
orthopedic surgeon at the KaleOrthopedic Center.
Dr Ortiz has completed twofellowships one in the area of
(00:23):
sports medicine and arthroscopyand the second in the area of
hip preservation.
His focus is going to be allabout how Dr Ortiz introduced
two cutting edge technologies tothe Kale Orthopedic Center in
the field of hip replacementsurgery.
The first is the introductionof the Mako robotic arm assisted
(00:44):
total hip arthroplasty and thesecond is the introduction of
the minimally invasive directanterior total hip replacement
through the front in a veryminimally invasive manner.
So we're so honored, privilegedand pleased to have Dr Victor
Ortiz with us today.
Welcome to the podcast, drOrtiz.
Victor Ortiz, MD (01:02):
Thank you so much, Dr Kale, for having me
today and look forward todiscussing hip replacement and
robotic surgery So happy to haveyou.
Robert A. Kayal, MD, FAAOS (01:09):
So before we get started, why don't
you just tell the audience alittle bit about yourself?
Victor Ortiz, MD (01:15):
Dr Ortiz.
So I grew up in Puerto Rico,born and raised.
I came back to the Statesapproximately seven years ago
with the whole family.
We were probably never lookingto do the move, but luckily we
came to New York.
My wife is also a healthcareprovider So while she was doing
her training I was practicing inanother New York City And so
(01:39):
far we love everything.
We've been a very happyadaptation to the whole family
and we're excited about it.
Robert A. Kayal, MD, FAAOS (01:45):
And we're very excited to have you.
It's also a little bit aboutyour professional education as
well.
Victor Ortiz, MD (01:50):
So I did my medical school in the School of
Medicine in Balamond, puertoRico.
After I finished my medicalschool, i went on to orthopedic
surgery and I did my residencyin orthopedic surgery in the
University of Puerto RicoMedical Science Campus.
After I was done with residency, my next goal was to do a
sub-specialty in sports medicineAnd I went to Chicago.
(02:13):
I did the University ofIllinois, chicago, where I
trained in sports medicinemainly arthroscopic procedures
of the shoulder and knee Duringmy fellowship.
I always had an interest indoing hypertroscopy.
So I met one of my mentors atthat time and he invited me to
join his fellowship called theAmerican Hip Institute in hip
(02:35):
preservation surgery And duringthat year I was really able to
focus on two main things that Ireally want was the
hypertroscopic procedure, butalso the direct anterior
approach.
So I did a second year inChicago doing these two
outstanding procedures that Ithink have really changed my
practice.
(02:55):
Also, it is interesting becauseduring training during
residency, i always said that Iwould never do hip replacement
And now it's part of my practiceis what really has allowed me
to build up a practice andreputation in the area.
But the long story short,during my fellowship in sports
(03:16):
medicine, i said I really wantto improve my skills in
hypertroscopy.
So when I decided to do thesecond fellowship, the downside
for me at the time was well, youhave to learn anterior approach
and robotic surgery.
So I said, okay, let's do it.
Long story short, i went inthere.
I love the approach, i love theoutcomes of the patients and
(03:37):
now it is probably the majorityof my practice And I'm
passionate about it.
I love the direct anteriorapproach, the robotic surgery.
I do everything that way.
I don't have the robot underthe surgery And it's been really
a game changer for my career.
Robert A. Kayal, MD, FAAOS (03:53):
Wow, dr Ortiz and I have been great
friends and colleagues for manyyears now, and this is the first
time I'm actually hearing thatstory, so that's something I
didn't know about you, dr Ortiz.
It's very interesting.
Well, thank God, you did receivethat training from one of the
finest institutions, not only inthe United States of America
but in the world.
That fellowship is very muchconsidered a thought leader in
(04:18):
this area of hip replacement andhip preservation technology,
and we're just so privilegedthat you learned from a master
surgeon and were able to bringthat technology to Northern New
Jersey and the tri-state areaand introduce it for our
patients and our community tobenefit from.
You certainly have become, andare now, a master surgeon in the
(04:41):
area of hip arthroscopy and hipreplacement surgeries, so we're
very fortunate to have thattechnology, especially with us
at the Kaila Orthopedic Centerbecause of Dr Ortiz.
Before we continue ourdiscussion regarding what that
technology is and why it's sobeneficial to our patients, i
think we need to start with thebasics, the fundamentals, and
(05:01):
let's just even talk aboutarthritis.
What is arthritis?
What types of arthritis existand why do they exist and how do
they present?
What are the symptoms that areassociated with arthritis, and
which types of patients wouldultimately benefit from your
expertise?
Victor Ortiz, MD (05:19):
So I think there are multiple types of
arthritis that affect the hip.
I always think that when Iexplain to the patients, the
common denominator here is thatthe patients are losing a
cartilage in the joint.
It's like the wear and tear,the bone and bone, and it can
happen in different ways ormodalities.
The one that we know, the wearand tear of the hip, or
(05:40):
osteoarthritis, is the mostcommon one, the one that a lot
of the patients have And theypresent with this bone and bone
disease, stiffness, difficulty,like pain along the groin,
difficulty getting in and out ofthe car, really difficulty with
prolonged walking and affectingreally their daily life
activities It's hard to put yoursocks and shoes and it's really
hard to do the things that theyenjoy, like playing golf,
(06:03):
playing tennis So simple thingsthat the elderly population want
to enjoy is being reallyaffected.
There are other types ofarthritis and, for example,
inflammatory arthritis that cansee in patients with chronic
autoimmune disease, likerheumatoid arthritis, like lupus
, for example, where the immunesystem creates a response
against the hip joint, causingthe same wear and tear.
(06:28):
There's another arthritis, likepost-traumatic patients that
have car accidents, where theyhave acetabular fractures or
fractures in the socket.
They can have fractures in thefemoral head that can lead to a
bands or progressive wear of thejoint, where they subsequently
need a procedure.
There's also infectious processor septic arthritis, where an
(06:51):
infection creates inflammationof the hip joint, causing the
same common denominator of wearand tear And, interesting, with
the septic arthritis you can seethe damage as soon as eight
hours after the infectiousprocess.
So we in orthopedic surgery arevery aggressive in treating
them because we know the sequalaand what can happen in patients
(07:11):
with possible infections.
There's also osteonecrosis orabascular necrosis, where
there's a blood supply insult tothe hip joint.
Where the patient develops lotsof blood supply or circulation
to the femoral head, theydevelop necrotic bone and
subsequently end up with havingwear of the joint that might
need surgical intervention.
Robert A. Kayal, MD, FAAOS (07:33):
Yeah , so you mentioned.
We've mentioned the termarthritis right.
So to break that down for ourviewing audience, arthro means
joint and itis meansinflammation.
We've talked in the past thatinflammation can be associated
with redness, warmth, swellingand pain, and then arthro
represents the fact that thejoint is involved.
(07:54):
So arthritis is inflammation ofthe joint, so you can get
redness, warmth, swelling andpain in that joint, as Dr Ortiz
alluded to.
That arthritis, or inflammationand pain, is associated witha
destruction of the joint for awhole myriad of different
reasons.
The most common, he said, wasthe typical wear and tear,
(08:16):
degenerative osteoarthritis.
But there are other types, allof which can definitely benefit
from treatment, ultimately, withDr Ortiz, with a hip
replacement.
The worst of those that wasdescribed was the septic
arthritis, because that's whereyou have an infection in a joint
And certainly that becomes very, very complicated because you'd
(08:36):
never really want to put animplant in the presence of
infection.
But for the most part, all theothers osteoarthritis,
inflammatory arthritis,avascular necrosis those would
benefit tremendously ultimatelyfrom a hip replacement.
So we talked about some of thedefinition of arthritis and some
(08:58):
of the classic presentationsymptoms groin pain, difficulty
getting in and out of cars,difficulty putting on socks and
shoes, restricted range ofmotion and a limp.
But there are changes going oninside the joint that are very
characteristic of that arthritis.
Dr Ortiz mentioned essentiallybone on bone, wear and tear of
(09:20):
the cartilage.
There's other changes, right,dr Ortiz, going on with respect
to possibly the labrum, thefibrocartilaginous labrum, and
also the fluid inside the jointas well.
But before you even answer thatquestion, just for our viewing
audience, what are the differenttypes of joints Like?
what kind of joint is a hipjoint as compared to, say, a
(09:41):
knee joint?
Victor Ortiz, MD (09:42):
So the hip joint is a ball and socket joint
similar to the shouldercompared to the hinge joint of
the knee, so every joint is madedifferent and has special roles
.
I think when we have a ball andsocket joint there are multiple
things.
I think for me the mostimportant one is that the hip
joint is a joint that is madeball and socket with the
(10:04):
extension of the labrum.
So the labrum is an extensionof the socket, creates a suction
seal mechanism to first providestability but also allow the
function or mechanics of the hipto function correctly, you know
, to be able to you haveadequate mobility, that the
properties of the synovial fluid, of the cartilage are protected
to decrease the inflammation,because at the end of the day,
(10:26):
inflammation is what causes painand is what causes the damage.
So our goal really with thetreatment of are any type of
arthritis is really to bringthat inflammation down, to
decrease the chances of havingsubsequent or more damage in the
hip joint right.
Robert A. Kayal, MD, FAAOS (10:42):
Yeah , it's interesting you mentioned
the labrum and, by the way, wewill allude to the labrum in the
future.
Doctor Ortiz, as I mentioned,is a master Hip arthroscopist as
well as a hip replacementsurgeon.
In a subsequent podcast we willbe interviewing doctor Ortiz on
the subject of hip preservation, where he addresses labral
(11:03):
tears.
So stay tuned for that.
But with respect to the hiparthritis and the role of the
labrum and the joint fluid, whatwe call the synovial fluid in
the joint, i often give thepatients the analogy of a gasket
on a car engine.
Right, because we have a carengine, we have the cylinders,
(11:23):
we have the pistons going up anddown and the most important
thing in there is the oil, theengine oil that's lubricating
that mechanical construct.
Right, if there's a gasket leakand that fluid can leak out the
oil, can you can you can freezeup a piston in a cylinder and
it can jam and cause enginefailure.
The same analogy I give whenI'm talking about labral tears
(11:47):
and referring patients to youfor that.
When There's a labral tear in,that fluid can see about and you
lose those mechanicalproperties inside that ball and
socket joint, that seal fromthat labrum that helps to keep
that fluid in there and providethose mechanical properties.
But again, we're digressing alittle bit because it's also
very, very important in the areaof hip preservation Where we're
(12:10):
actually referring patients todoctor or a tease to fix and
repair the labrum so ultimatelythey hopefully do not end up
needing a hip replacement.
So that's, that's anotherpodcast, but for now I think
it's important to justunderstand the anatomy, the fact
that the hip is a ball andsocket joint.
You have this big round ballsitting inside a big bony cup
(12:34):
and around that cup is a labrum,a fibro cartilage labrum that
basically seals that joint, thatconstruct to allow that fluid,
the synovial fluid inside thejoint, to stay inside the joint,
just like that car enginegasket we talked about, to
provide those mechanicalproperties to that ball and
(12:56):
socket joint so that thepatients like doctor or T said,
less inflammation.
So now you understand thefunction of that fibro
cartilaginous ring of tissuethat seal.
Are there other anatomicalstructures that come into play
in a healthy, non arthritic hipjoint?
Vic, Absolutely.
Victor Ortiz, MD (13:18):
I think one of the most besides the label and
the most one of the mostimportant structures is the
articular cartilage, and we knowthat our ticket or cartilage in
every joint is a little bitmore smooth than the label is a
collagen type two And it reallygives some of the properties of
the joint, like load bearing,and when we start losing that,
(13:38):
that's when we as you mentionedbefore with the gasket and it,
that's when we develop problemsand that's when you know about
inflammation And pain right.
Robert A. Kayal, MD, FAAOS (13:47):
So what?
what you're essentially sayingis that this articular cartilage
is essentially different fromthe cartilage in the labrum
right, the labrum There's.
There's something calledcollagen that we have in our
body in different areas, but inorthopedics is relevant
primarily in the area of boneand cartilage.
Okay, in bone that's type onecollagen, but in the meniscus
(14:10):
and in the labrum and in theinter vertebral disc of the
spine that's also type onecollagen, but in the healthy
joint there's a different typeof collagen in what we call the
articular cartilage, thecartilage that is essentially
stuck to the end of the bone.
So if you have a hinge kneejoint of the knee, that type two
collagen makes up articularcartilage, the cushion on the
spine, and the same thingapplies in the hip to right in
(14:32):
the ball and socket joint youhave that type two collagen,
highland articular cartilage onthe end of the bone, different
from the cartilage That's in thelabrum right.
So you're saying that witharthritis that can wear down,
correct and become thin, verythin, to the point where
sometimes bone can be exposedright and that knee Normal
(15:00):
smooth surface is now sort oferoded and it's not smooth
anymore.
It's bumpy like potholes in aroad right.
And then what about the jointfluid, the synovial fluid inside
a bone socket joint?
we talked about the labrum thatcontains it, but what about the
fluid itself?
So the synovial fluid provideslubrication to the joint, helps
in the low distribution.
Victor Ortiz, MD (15:23):
Has a good amount of proteins that, when we
have our triad, is the, forexample.
The high loronic acid getsdiluted.
So those properties are not thesame.
Right and all that, itcontributes to the whole
spectrum of hip pain.
Right, it's a whole downwardspiral.
Robert A. Kayal, MD, FAA (15:35):
You're wearing the articular cartilage
, you're tearing the labrum andnow the synovial fluid is
markedly diluted over the entirespine Right, and that's why the
the FDA has approved some whatwe call intraarticular
injections of high loronic acid.
But it's only FDA approved forthe knee, where we can inject
(15:59):
these products, such as sin viscand ortho visc and others, into
the joint to try to restore thenormal concentration of high
loronic acid into the joint.
Unfortunately it's not FDAapproved yet for the hip, but
maybe someday.
Thank you so much, doctor Ortiz, for that very elaborate and
and thorough explanation aboutarthritis.
(16:19):
How does arthritis typicallypresent?
besides the pains you'retalking about, are there other
symptoms that are commonlyassociated with arthritis?
Victor Ortiz, MD (16:33):
I think the main comment besides pain, which
absolutely is one of the firstsigns that patients feel
limitation in range of motion.
So patients feel stiff, theyfeel that they are limping, that
they need to use a cane to movearound because they cannot
really stand on that feed, andthen there's difficulties in
(16:54):
their activities of daily life.
Right, the most common one islike this is I want to go to New
York City, i want to couplewalk for a couple blocks and I
have to stop every block becauseI don't feel comfortable.
And that's usually the.
What brings into the office isbecause they are really trying
to do things that they enjoy andthey're not able to.
And another thing for example,if we go to sports and we know a
(17:16):
lot of our patients, you knowthey like to play golf, they
like to play pickleball which isthe new thing out there And
they have limitations and theysay, like I cannot perform, you
know I get pain during the,during playing.
At the end I'm miserable for acouple days.
So those are usually the typeof signs or symptoms that
patients are feeling them.
Bring them to our practice tolook for care.
Robert A. Kayal, MD, FAAO (17:38):
Right And I noticed over the years
that it's often the familymembers that finally get them to
come in right.
They're sick of them seeingthem limp like this and not
participate in family events Andthey really strongly encourage
them to just get it taken careof so they can restore their
quality of life.
So thank God for those familymembers, because a lot of times
(18:00):
patients just opt to live withthings and or don't even know
that options exist that we canactually get them out of that
pain and restore that quality oflife.
And that's one of the reasonsfor this podcast to try to
educate our community ofpatients that you don't have to
live like this anymore.
There's a lot of things thatcan be done to help you, which
we'll get to in a minute.
(18:20):
But besides the pain loss ofmotion, stiffness, instability
sometimes their joints canbuckle and give way Besides that
, do they sometimes have pain inother areas and not the hip,
even though it might be comingfrom?
Victor Ortiz, MD (18:41):
the hip Right.
There are two main places whenI look at that.
I think the first one will bethe knee And we have had a good
amount of patients that theyjust come to the office with
knee pain.
You look at the x-rayeverything looks perfect In the
knee, the x-ray looks perfect Inthe knee.
Robert A. Kayal, MD, FAAOS (18:54):
it's perfect.
Victor Ortiz, MD (18:55):
You do an examination, it feels pretty
good And then you start feelingthe hip.
If the hip feels stiff, andthen you get x-rays and out of
the blue it's bone on bone Andit's not uncommon to see that
that you have radiating pain.
I think one of the reasonsbeing is that there's a small
nerve under the hip joint thatcan get irritated and cause pain
(19:15):
going down the knee, but it'sreally coming from the hip joint
.
Robert A. Kayal, MD, FAAOS (19:18):
I think that other one it's very
common, By the way, not tointerrupt you, but on that note
I mean sometimes it's hard toconvince patients that the
problem is the hip.
Not that we get in argumentswith our patients, but sometimes
they don't believe us.
They say there's nothing wrongwith my hip, My pain is in the
knee, And that is oftensometimes the only presentation
(19:42):
Because the patient's havingpain in the knee.
We evaluate the knee, We takethe patient's word for it, We
get an x-ray of the knee butthere's nothing wrong with the
knee And the only thingsometimes that is wrong is the
hip, And I've done many hipreplacements over the years for
a chief complaint of knee pain.
It's interesting Ultimately thepatients concede because they
(20:07):
understand we're the experts inthat regard But it is hard for
them to believe that the problemis stemming from the hip and
not the knee And where else.
Victor Ortiz, MD (20:16):
And I think the other one which would be one
of the most commonly missed iswhen something that I described
to the patients as a hip spinesyndrome, where patients are
constantly told the pain is fromthe back, we can do anything
else, and a lot of timespatients with hip pathology can
present with posterior hip pain.
It gets confused.
It might take two or threeoffice visits for them to well.
(20:40):
the problem is the hip.
Robert A. Kayal, MD, FAAOS (20:41):
When he says post-do your hip pain
he's talking about in the butt.
Is that the head In thebuttocks, like where possibly
sciatica may present?
Victor Ortiz, MD (20:49):
And usually they'll go to the primary care
doctor, they'll go to thechiropractor or physical
therapist and they're told well,is the back, is the back?
keep working the back and outof the blue, same as the knee,
you start looking at the hip.
you maybe sometimes do aninjection and they are whoa like
everything changed.
Robert A. Kayal, MD, FAAOS (21:04):
We see that all the time.
We see it all the time And it'simportant that patients see an
expert and get a physicalexamination by an expert
orthopedic surgeon with atremendous amount of experience,
because we tend not to havetunnel vision When we listen to
our patients.
We know the potentialetiologies of pain in certain
(21:27):
areas.
Oftentimes patients don'tunderstand that the hip to the
orthopedic surgeon is not theoutside of the hip, it's the
groin.
So the hip joint for theorthopedic surgeon is the groin.
There can be pain, like DrOrtiz is describing, in the area
of the buttocks.
That's still the hip, butusually pain in the buttocks is
(21:49):
coming from the back.
Pain on the outside of the hipis coming typically from soft
tissues around the hip joint butnot the hip joint itself.
But pain in the hip and pain inthe groin can very often be
stemming from the hip jointitself.
Now that we've described hiparthritis and we've described
the symptoms that are oftenassociated with hip arthritis,
(22:14):
does everyone with hip arthritisget a hip replacement?
Victor Ortiz, MD (22:17):
No?
I think that the answer is no.
I think that is a very commonthing for patients to come to or
not want to come to theorthopedic surgeon because, as
the word says, it's a surgeonand they don't want to have
surgery.
But I think that the first lineof treatment and for almost
every orthopedic problem, is aconservative approach And we do
(22:40):
that with our patients.
We try two or three months ofconservative treatment, which
includes a gamma of treatmentthat includes diet and
exercising good weight in ourpatients, physical therapy,
where there's 70 muscles goingaround the hip joint.
So if we work around thosemuscles the load to the hip
(23:02):
joint can be less and thepatients can have a significant
amount of relief.
We try anti-inflammatorymedications, sometimes combined
with pain medication, andsometimes it's being shown that
cortisol injections as ashort-term pain relief can
provide significant relief.
And one of the things how Iincorporate these injections in
(23:23):
my practice is that when thepatient comes to the office,
when they decide to come,they're in pain, they need
something, and that's where thatinjection really plays an
important role brings theinflammation down, allows our
therapies to work with thepatient in a better way.
Sometimes these patients willgo through physical therapy,
they'll flex the hip and they'renot able to finish the session.
The cortisol injection allowsthem to do that, allows them to
(23:48):
be comfortable, allow thetherapies to really do a better
work and they come back aftersix 12 weeks and they have
significant improvement ofsymptoms.
Robert A. Kayal, MD, FAAOS (23:56):
Just to elaborate on what you were
just discussing, vic.
There is a common misconceptionthat, just because patients are
coming to an orthopedic surgeon, that that's all we do.
Like you only come to us whenyou need surgery.
Nothing could really be furtherfrom the truth.
Right?
If we see a hundred patients,we'll probably end up just
(24:17):
scheduling five of thosepatients, right?
Most of those patients arebeing seen for physical therapy
prescriptions.
We just do a physical exam.
They might need a cortisoneinjection, they might need an
X-ray and told nothing's wrong.
Most of what we do is primarycare and non-operative
orthopedics, right, so you don'thave to be scared to see us.
(24:39):
Okay, don't be scared to getassessed by an orthopedic
surgeon, because I've always andI say this during every podcast
for the most part, most of whatwe do is non-operative.
We should be your first callwhen you have anything wrong
with your musculoskeletal system, because you're being evaluated
(24:59):
by an expert in the field oforthopedic surgery, where we can
assess and do a physicalexamination.
We can interpret x-rays andMRIs and cat scans.
We can write prescriptions formedications, anti-inflammatories
, give trigger point injectionsto help alleviate some of your
(25:20):
pain.
Order physical therapy,chiropractic, acupuncture,
massage therapy.
Again, most of what we do isnot operative, so you should
really rely on us to helpquarterback your care and then
ultimately, if you do needsurgery, we can do that too, but
most of what we do is notoperative, so I did want to
(25:42):
drive that point home.
Also, you mentioned that youoffer it Cortisone injections.
Right, and that dovetails offthe fact that osteoarthritis is
associated with inflammation ofthe joint and there's no better
or more potent anti-inflammatorythan what we call an
intraarticular injection of acorticosteroid.
(26:05):
You know, arthritis,inflammation of the joint,
inflammation is associated withredness, warmth, swelling and
pain, and when we give you acortisone injection, it very
often alleviates that.
For instance, what's been yourexperience when a patient is
coming in To the office insevere pain with a horrific limp
(26:29):
and you lie him down on thefluoroscopy table in our
procedure room and give him acortisone injection into the
joint?
what's been your experienceimmediately thereafter?
Victor Ortiz, MD (26:41):
So you know I think that we also put some
light of hand in there thatusually a lot of times when you
put the needle in you get somefluid out, so that fluid
immediately decreases thepressure of the joint.
So they feel sometimesimmediate relief.
And then when the joint is numb, it's like when you go to the
dentist right, you know thejoint, they're like, wow, my hip
feels great.
And when they come for followup, you know the amount of
(27:03):
relief that these patients get,how happy they are.
Robert A. Kayal, MD, FAAOS (27:06):
It's unbelievable yeah, i can't tell
you how many patients havegotten off that table just gave
me a huge hug and thank me.
I don't think there's anythingthat's more rewarding than that
injection.
When patients are limping andsuffering in pain and you give
them that injection, they'rejust so thrilled and after I
experienced that with them I sayguess what?
(27:27):
that's exactly how you're goingto feel after Dr Ortiz does
your hip replacement.
I always tell patients that ofall the conditions we treat in
the field of orthopedic surgery,i don't think there's any
operation or any disease entitythat does better postoperatively
then hip replacement surgery.
(27:47):
It is probably the mostrewarding operation.
We do that, and probably carpaltunnel release as well.
They're just incredibly,incredibly successful operations
.
So now that we've spent a lotof time talking about all of
this, let's get to the focus ofthe of the podcast, and that is
(28:07):
the fact that you brought to thepatients of the tri state area
here this incredible technologyto incredible technology
simultaneously, and those are,just to reiterate, the Mako
robotic arm assisted total hiparthroplasty combined with the
minimally invasive directanterior approach.
(28:28):
There were some surgeons thatwere doing the direct anterior
approach.
There were some surgeons thatdid robotic surgery, but Dr
Ortiz, really pioneered thesetwo cutting edge technologies
simultaneously in our area andhas done hundreds of different
types of surgeries And hundredsand hundreds, if not thousands,
(28:50):
of these operations over thepast few years.
Just a master surgeon.
So let's, let's talk about oneat a time.
Ok, so the let's first talkabout the technology of the Mako
robotic arm assisted total hipreplacement.
Just what is that?
First of all, even before weget there, what is a hip
(29:11):
replacement?
Can you compare and contrastfor us the difference between
the traditional posteriorapproach that everyone's
familiar with, and compare andcontrast that with this new
technology that you are bringingto the table, that you've
brought to the table, you know,about five years ago now, in the
(29:32):
area of hip replacement surgery?
that pertains to the minimallyinvasive, direct anterior
approach.
Victor Ortiz, MD (29:39):
So the conventional approach, which is
the posterior approach with, asyou mentioned, has been, has
been a very successful procedurein the surgery and is the most
of the surgeons in the countryperforms that approach.
But I think that we alwaysnever satisfied.
We're never satisfied inorthopedics, we always want to
see how we can make a greatprocedure even better And I
(30:02):
think that's where the approach,with the direct anterior
approach, we have been able toachieve that.
When we do the posteriorapproach The main you know, to
get into the hip joint we haveto cut through normal anatomy So
that a lot of the timestranslates to having either
either temporary or permanentlimitations or restrictions
(30:23):
where patients are not reallyable to flex the hip too much to
cross their legs.
They have to sleep with apillow between the legs, they
might need a bathroom mold or,you know, they spend some time
to recovery.
The functional recovery is alittle bit longer in the acute
phase.
When we do the anteriorapproach, the biggest benefit of
(30:44):
the approach is a minimallyinvasive technique where instead
of having to detach normalanatomy, we go between the
muscles, so we go into front ofthe hip, you separate the
muscles and right there you'rein the hip joint.
I always tell the patients youknow the biggest difference when
we look at the ball and socketand we'll do it later with the
model The hip, the socket isalways looking to the front of
(31:05):
the patient.
So when you go to a house youwant to knock the door to the
front, not to the back.
It's harder to get in.
So when we do the anteriorapproach we separate the muscles
, open the joint and we can seethe socket in front of us.
I think if you make a pole, alot of the orthopedic surgeons
(31:26):
would say I would never do areplacement because I'm not
comfortable doing the socket.
And I can tell you, with theanterior approach the socket
becomes the easy part of theprocedure And I think those are
the biggest difference betweenapproach.
I think we look at evidencebased medicine.
It's been clear that in thefirst three months in that acute
recovery that the patientsremember forever, the pain is
(31:49):
less and the functional outcomesthe functionality of the
patients is is much better And Ihave had a lot of patients that
I do their their hips when theyhad the other side done through
a posterior approach And theyalways say it's a night and day
experience.
If I knew about this.
I will only do it through theanterior approach And I think
it's really been a game changerfor my practice as being a game
(32:11):
changer for the patients, it isallowing patients to be more
comfortable doing our patienttotal joint replacement, which
is the future of medicine andorthopedics And, you know, i
think that is the way to go.
Yeah, definitely, we've seen itin in our practice.
Robert A. Kayal, MD, FAAOS (32:30):
It's really revolutionized the way
that we do hip replacements inour practice and the outcomes.
Like you said, our night andday.
Patients have been able tocompare and contrast with the
patient.
Patients have been able tocompare and contrast posterior
approaches to anteriorapproaches and it's it's much
more rewarding early on,especially Through that
(32:50):
posterior approach.
You know you can do that in aminimally invasive manner.
But it does not change the fact.
Even if the incision is small,it does not change the fact that
surgeons are taking downimportant tendons and structures
, detaching them in order togain exposure and then
(33:12):
reattaching them at the end toprovide stability.
So that is really a majorconcern.
The sciatic nerve is rightthere as well.
There's a concern, patient.
There's a concern possiblyabout causing some iatrogenic
injury potentially to thatsciatic nerve.
There have been patients in theliterature that have woken up
with foot drops because ofinjury to that sciatic nerve
(33:34):
through the posterior approach.
Clearly there's a higherdislocation rate because you're
taking down those soft tissuesand that's a problem.
And so now that can, for themost part, all be avoided
through this minimally invasive,direct anterior approach.
This minimally invasive, directanterior approach is often done
through an incision.
How big?
(33:55):
would you say this, this, yeah,about that, about this big?
I mean to do the operationroutinely.
This has allowed us to, for themost part, really pioneer
outpatient hip replacementsurgery in the area.
You know these are routinelydone as an outpatient.
Patients are now walking thesame day on this hip and home in
(34:18):
the comfort of their homeWithin, often four hours after
surgery.
So much less pain, much lessinvasive.
Essentially, you don't evenrestrict the patients after
surgery at all.
Right, with the posteriorapproach, our training is that
some surgeons say for six weeksyou can't cross your legs, you
(34:40):
can't sit, bend your hip morethan 90 degrees, you can't
internally rotate your leg morethan 20 degrees For six weeks.
Some people say for life.
With the direct anteriorapproach, there's no
restrictions.
You know, after the posteriorsurgery, patients would always
get either a neomobilizer orthat big blue foam pillow
(35:01):
between their legs And they'resitting like this or trying to,
you know, go to sleep like thisand with this big foam pillow
between their legs.
For six weeks you don't havethat at all.
Right, you don't use the pillow, you don't restrict them from
sitting in a sofa, sitting on asoft sofa or a toilet seat.
You don't make them use aelevated toilet seat.
(35:24):
Nothing like that, right?
Nothing like that.
Those are the beautifuladvantages of this minimally
invasive approach, but itdoesn't stop there, right?
You didn't just introduce thisminimally invasive, direct
anterior approach.
You combine that with thesecond technology, and what is
that?
Victor Ortiz, MD (35:42):
So that we combine the direct anterior
approach with the medicalrobotic guidance, and that's
been amazing.
I think that right now, as Imentioned initially, if I don't
have the robot, i'm not doingthe surgery, and that's how
confident I feel that the robotis a compliment to what we're
doing.
And the biggest things that weget with the robot is two things
(36:05):
.
I think that we do a CT scan onthe patient before the
procedure.
That allows us to customize theimplants.
We can design the implants toevery patient's need.
Robert A. Kayal, MD, FAAOS (36:15):
And let me make something clear.
Dr Ortiz mentioned he's notdoing the operation if he
doesn't have the robot, notbecause he can't do it without
the robot, but because he relieson the accuracy and precision
of the robot.
You see, he's designed thesehip replacements on a computer
before surgery And the robotensures that he doesn't
(36:35):
inadvertently deviate from thatpreoperative design.
So, for instance, if heinadvertently were to angle his
arm or his hand one way or theother, the robot would shut off
and not allow him to proceed.
Because the robot ensures theprecision of installation of the
hip replacement to beconsistent with his preoperative
(36:57):
design on the computer and onthe proprietary software program
.
Victor Ortiz, MD (37:04):
So before we start the procedure, we have the
computer and we design theimplants the way we want it to
have a right tension, the rightsizing of the implants.
So once we go into theprocedure we can reproduce that
to the patient's anatomy.
And this is, for example, anexample of the socket.
So if we look at this, thiswill be the cop.
(37:26):
So after we prepare the areawhere we rim the whatever is
left of cartilage, we haveadequate bleeding bone because
these implants grow into thebone, grows into the implant.
That's part of what we call ingrowth, bone in growth, which is
an important characteristic ofthis implants to incorporate
into the hip replacement.
So what that means is that thebone grows into the implant to
(37:49):
avoid any movement or looseningof these devices.
So that when I'm looking at thecop and when I'm looking at the
CT scan from a three-dimensionstandpoint, we wanna make sure
that the cop is exactly flushAnd you can see how there's no
prominence, the cop is not toodeep, that we don't remove too
much bone, that it's not a copthat is too small.
(38:12):
Those are things that are veryimportant.
Sometimes we look at copstarted too big And when we have
a cop that is too big, thatcreates problem in the soft
tissues around.
We don't want any soft tissueto be irritated because we have
a prominent cop.
Then when we have cops that arenot in the right position, we
make patients.
Patients can be prone todislocation, as we mentioned
(38:34):
initially, but also when thedistribution of load in the hip
is not even my belief is thatwe're gonna load over one area
of the implant more and thatimplant will wear faster.
So robotic has allowed us toput this implant where the
patient needs And we incorporatethe balance of the spine, we
(38:54):
incorporate the rotation ofdifferent bones to make sure
that the patient doesn't haveimpingement that doesn't
dislocate, to get the patient ahip that resembles the native
hip.
And one of the things that Ilike to tell the patients is my
goal with this procedure, withthe direct anterior approach,
with the robotic surgery, isthat three to six months later
(39:14):
you forget that you have areplacement, that you think this
is my normal hip.
So the MAKO robot has reallyallowed us to work with the
socket to make this procedurethat doesn't have that.
The patients resemble itself Soand then we go ahead and we do
the stem.
Robert A. Kayal, MD, FAAOS (39:34):
So essentially what you're saying
you're installing that cupperfectly each and every time.
You're trying to restore thenormal anatomy of the patient.
So if the cup is too big, itcan result in some impingement
of some soft tissues and somepain.
If it's improperly positionedin a certain plane, it can
result in instability as well.
(39:55):
And so that's where the benefitof the robot comes in, where
you design the precise placementon the computer and then the
robot ensures that you put it inexactly that way, so it's
perfectly sized, positioned andaligned each and every time.
Victor Ortiz, MD (40:13):
Correct.
so I think that the firstimportant interoperative role of
the robot As it pertains to thecup.
Robert A. Kayal, MD, FAAOS (40:21):
As you mentioned, many orthopedic
surgeons in this country willnot even attempt hip replacement
for fear of the acetabulum,right?
I don't.
I wanna make sure we emphasizethat point, because with this
minimally invasive, directanterior approach, you're
staring right at that acetabulumso you can see it so perfectly,
(40:42):
and then now with the robot,the robot will put in that cup
exactly in the right positionand angulation that you designed
on the computer.
So it essentially eliminatesthat fear of taking on the
acetabulum right.
It's ensuring that it's perfecteach and every time, and that
(41:06):
has traditionally been the mostchallenging part of this
operation that has typicallydissuaded so many orthopedic
surgeons from even doing hipreplacements.
And let me just drive home oneother point, and that is that Dr
Ortiz is doing the surgery.
It's not the robot doing thesurgery.
The robot just ensures that hedoes the surgery exactly the way
(41:30):
he designed the surgery, and ifhe doesn't, for whatever reason
, it just shuts off, it stops.
And so one of the otheradvantages of using this robot
as a pertain to the acetabulumis that it becomes a much more
efficient surgery, right?
You're doing the surgery morerapidly, and that's important to
(41:50):
get patients off the table,right?
Traditionally we used to preparethe acetabulum in a sequential
manner.
If we were reaming, to say, asize 52 cup, we would maybe
start at a 48 and then go to a50 and then go to a 51, and then
you know gradually.
This is a one-time ream for themost part, right?
(42:12):
The robot knows exactly theangle, the depth, and it's a
one-time shot and it makes itperfect every time.
So the robot comes in, dr Ortizis guiding the robot, he sets
the angle for that robot to reamand the size It's a one-stop
shop And then boom, you put thecup in, you're done And you're
(42:36):
moving on now to the stem.
Right, correct?
So let's talk about the stem.
Victor Ortiz, MD (42:40):
And then we will do the stem in a
traditional manual way.
So we have a.
This is a sample of the stem.
This is a titanium stem with aceramic head.
So what we do is that we firstprepare the canal to the size of
the patient.
That was already planned withthe CT scan And then we impact
the implant.
And same way as there's boneingruth in the acetabulum or the
(43:01):
socket, there's bone ingruth inthe femur.
The bone will grow into theimplant and will become part of
it.
So once we have the right stemthat we need, we go ahead and we
do something we call trialing.
And when we're trialing, we aremaking sure that we have a
balanced hip.
And that's where the secondfunction of the robot comes into
(43:23):
play.
As I mentioned, we want torecreate this hip to be as the
hip, the native hip, the hipthat you have before.
That was functional.
Robert A. Kayal, MD, FAAOS (43:31):
So And we talk about offset and leg
length, right, right.
Victor Ortiz, MD (43:35):
So that's where we put the joint together.
And when we have the jointtogether, we can look at the
robot and we can make sure fourimportant things And then it's
gonna be that the leg is not toolong or too short And that the
tension in the gluteus or the ABdoctors or the muscles in the
side is adequate, that they arenot too tight, that they are not
(43:57):
too loose.
So those are the things thatreally allows the patients to
feel better when you have theright tension and the right
length And it's a hip that isstable.
We test the hip in differentrange of motion modalities and
the hip stays in the socket.
That's when this not too tight,when it's not too short.
Those are the most commoncomplaints of patients When they
(44:18):
have trouble my leg is too long, i feel so tight.
And those are the things thatthe Mako has really allow us to
perfection.
It Just the bouncing of thesoft tissues around the hip that
are very important, and notonly in the acute process, in
the acute rehab of patients, butalong the road.
Robert A. Kayal, MD, FAAO (44:40):
Maybe even more important, right It's
.
You know we say with kneereplacements it's a soft tissue
operation And same thing withhip replacements.
It's so important The softtissues have to feel good.
Right, it's one thing toresurface or replace a joint,
but it's the soft tissues thathave to feel good and have to
provide stability and properstability.
(45:01):
Right, if the soft tissueenvelope is too lax, you might
have an unstable hip.
If it's too tight, you mighthave a long leg length
inequality or a painful hipbecause the soft tissues are
just too stretched and too tightor limited motion.
So both hip replacement, kneereplacement and you can probably
(45:21):
extrapolate to shoulders andankles they're soft tissue
operations And that's where thisincredible software technology
allows us to tension the softtissue envelope, with me for
knees and with you for hips, tomake it perfect.
So not only are we putting inimplants perfectly, perfectly
aligned, sized, positioned, butnow the soft tissues are also
(45:46):
happy.
You know, i'm sure you canelaborate on patients that
you've seen over the years wherethe doctor might have done a
beautiful job on X-ray.
Right, the X-ray looks perfect.
We're looking at an X-raydoctor's telling the patient I
don't see anything wrong, it'sperfect.
Just take some more Advil anddo physical therapy, but really
(46:06):
the soft tissues are notproperly tensioned in one
capacity or another.
Same thing with knees Like theX-ray could be perfect but the
knee might not be balanced andthe knee might be tight or stiff
or unstable.
The soft tissues are very, very, very important And unless
you're a high volume surgeon,you may not know how to handle
(46:29):
the soft tissues as well as thehigh volume surgeons, right?
The literature is clear on that.
The American Academy ofOrthopedic Surgeons makes it
clear that high volume surgeonshave the best outcomes.
So you really want to go to asurgeon that's highly skilled,
trained and experienced in hisor her area of expertise,
because you know it's just likeany other thing, right?
(46:50):
You want a good plumber, youwant to get electrician, you
want a good, you know, you nameit profession.
You know High volume surgeonsreally have the best outcomes.
We've seen it all, we'vehandled it all and I think
that's just important for ourviewing audience to know and
appreciate.
And there's never anythingwrong with getting a second
opinion, because it's veryimportant that you know what's
(47:14):
out there and to get the latestand greatest technologies.
And that's really what we prideourselves on at our practice
right.
We're always trying to offerour patients the latest and
greatest technologies in thearea, and I think that's
important to emphasize.
Victor Ortiz, MD (47:32):
And what I was preparing for.
Today.
I was reading about a studyfrom Cleveland Clinic and they
were saying that by 2030, theywere expecting, they were
projecting that 60% of thepatients will be having
robotic-assistant hipreplacements.
I think that is something thatwe have brought to the practice,
where almost I do 100% of them.
Robert A. Kayal, MD, FAAOS (47:53):
So, Dr Ortiz, this has been a
fantastic conversation with you.
I really appreciate your time.
Victor Ortiz, MD (47:59):
We went over a lot of things today and I'm
very grateful.
Thank you so much, dr Kale, forhaving me today.
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