Barry Waldman, MD, practices with OrthoMaryland and serves as the director of the Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopaedics. He also serves as the president of the medical staff at Sinai Hospital and a clinical instructor of orthopedic surgery at Johns Hopkins School of Medicine, both in Baltimore. Dr. Waldman completed a fellowship in surgical arthritis surgery at Hospital for Special Surgery in New York. He has developed a minimally invasive hip and knee systems, as well as a minimally invasive hip replacement approach.
Dr. Waldman discusses the specialization of orthopedics, benefits customized implants and the question of osteoarthritis.
Q: How has orthopedic surgery changed since you first began to practice?
Dr. Barry Waldman: It's getting more and more specialized. We used to be able to treat many, many conditions with the various technologies available. Now it's getting to the point where we really have to specialize in just one area of orthopedics, in my case it's arthritis, in order to keep up with all the treatment options available.
We've also come a long way in terms of the technology used in orthopedic surgery – of particular note are knee replacement surgeries. Beforehand, knee replacements were off-the-shelf, and they had to be fit to somebody's knee kind of like a shoe. And as we all know, shoes don't always fit perfectly. Now, by scanning the knee we're able to make an exact copy of what that patient's knee should look like. Not even the deformity that they often have from arthritis, but exactly their knee as it should look without any deformity. And when we put these implants into the patient, they fit perfectly, which is not the case we had in the past.
Q: How do customized implants affect patient recovery?
BW: Customized implants actually have quite an impact on recovery. With patients, they will eventually result in less pain following surgery. Today we're finding that 20 percent of patients are not happy with their knee replacements. Part of that can be attributed to off-the-shelf implants.
What I'm seeing with customized implants is that patients are recovering faster, whereas a traditional knee replacement may require three months of recovery, patients who receive a customized knee are feeling better in six to eight weeks. It's a huge difference. Physical therapy is easier, and once they've recovered, the knee itself feels more natural and there is less pain.
Q: How do customized implants affect operating room flow?
BW: Regarding OR flow, customized implants have a huge impact. With traditional, off-the-shelf knee replacements, we had to have every size and every combination of different sizes available. And for most implants, that involved eight really heavy trays that had to be opened up, had to be sterilized, had to be processed correctly and all open in the operating room. Each tray probably cost in excess of $100 to prepare.
When we receive the ConforMIS customized implant, it's literally just a little black box with all the parts in it, and all the customized implants and customized instruments that we used to put the parts in – pre-sterilized. Then we need one tray of metal instruments that we use for retractors and for a few other more generalized things that are related to the knee. And that's it. And our operating room staff loves it, the surgical techs love it.
Q: What are a few of the biggest unanswered questions in orthopedics?
BW: The number one question is: "Why do people get osteoarthritis?" Of those afflicted by arthritis, 90 percent, or 27 million Americans, have OA and we don't fully know why. In fact, the lifetime risk of developing OA of the knee is about 46 percent, according to the Johnston County Osteoarthritis Project, and nearly one in two people may develop symptomatic knee OA by age 85.
We know that genetics, level of activity (for instance, two in three people who are obese may develop symptomatic knee OA in their lifetime ) and anatomy are all factors, but we don't know to what specific extent. If we could treat it sooner, we could probably prevent joint replacement. Impressive, especially when you consider that there are 600,000 knee replacements are performed annually, costing about $9 billion per year!
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[1] Arthritis Rheum 2008;58(1):26–35. [Data Source: NHANES]
[2] Arthritis Rheum 2008;59(9):1207–1213. abstract [Data Source: 1999-2003 Johnston County Osteoarthritis Project data]
[3] Agency for Healthcare Research and Quality
[4] Journal of the American Medical Association