Restoring Quality of Life Through Joint Replacements

June 22, 2019

 

Alexander Sah, MD currently serves as Director of the Outpatient Joint Replacement Program and as Co-Director of the Institute for Joint Restoration and Research at Washington Hospital in Fremont, CA. He was born at Washington Hospital and raised in Fremont. He earned his medical degree, graduating Magna Cum Laude, from Thomas Jefferson Medical College in PA. He then went on to complete his residency at the Harvard Combined Orthopaedic Program and then a joint reconstruction fellowship at Rush University Medical Center in Chicago. Dr. Sah specializes in total knee and total hip replacement, and developed the outpatient program in Fremont in 2014. He is the only surgeon performing anterior hip replacement at IJRR. He has expertise in partial knee replacement and is the United States Lead Investigator for one of the newest partial knee prosthesis. He teaches courses and lectures on this procedure, as well as on advanced pain management techniques and outpatient joint replacement. Dr. Sah is a member of leadership committees for the American Academy of Orthopedic Surgeons, the California Orthopedic Association, and the American Association of Hip and Knee Surgeons. In 2016, he was selected as 1 of 10 orthopedic surgeons in the nation to the prestigious AAOS Leadership Fellows Program. He is a multi-year recipient of the “Best of Fremont” Doctor and Orthopedic Surgeon Awards and named a California Top 10 Orthopedic Surgeon, among many other honors. He also serves as a reviewer for Clinical Orthopedics and Related Research and an editor forTechniques in Orthopaedics. Dr. Sah is widely published and is an esteemed speaker, having presented at more than 50 meetings and conventions across the United States.

Bio Source: whhs.com

 

Alan 

So just for the listeners, I've had personal experience with you. You're my surgeon who helped you do a partial knee replacement. And thank you very much. But for the listeners here, can you give us the background of how did you get into deciding to be a surgeon and bring us up to what you do specifically today?

 

Dr. Sah 

Well thank you again for having me here. It's a great privilege to be part of this show. And, and again, thank you it's, it's a look, I've been looking forward to it. I have a long history in the medical field. I have a grandfather who was a physician, two uncles who are physicians, and my father was a physician. So I grew up around medicine. My father was actually a head and neck surgeon here at Washington Hospital here in Fremont. He did that for nearly 40 years. He was Chief of Staff, he was on the board of the hospital. And he continues to volunteer at that hospital today after retirement. And my mom has volunteered there as well, for close to 40 years. I was born in that hospital. So I actually was born in Washington hospital, and then did my training out east and then came back in 2008 to practice orthopedic surgery. So I've had a long history in this community, and obviously a long history in that hospital of locally. So I had a strong feeling I would go into medicine ever since my childhood. And I've just been fortunate to be able to come back to the community where I was raised. So that's what makes our story somewhat special in the fact that we get to give back to the community that raised us and we grew up in and we know so many of the community members. So it's been a great privilege that many of my father's patients are now my patients, or some of my patients will tell me that their children were patients that my father, so it's great to see that even though we're in different disciplines. It's been a great honor to take care of those same community members.

 

Alan 

Where did you intern at on the East Coast?

 

Dr. Sah 

So again, grew up here, went to local elementary schools, we were talking about Parkmont Elementary, and then Centerville Junior High. I went to high school up in Oakland, actually, but then I went to college out east in Philadelphia, Haverford College, which is a small liberal arts college. Actually, my father and my sister went there before I did so a little bit of a family legacy there as well. I did my medical training in Philadelphia, at Jefferson Medical College, and then my orthopedic residency and training at Massachusetts General Hospital in Boston. So after finishing the Harvard orthopedic program, went to Chicago for a one year fellowship in minimally invasive hip and knee surgery. And that  concluded in 2008, when I returned home,

 

Alan 

This minimally invasive surgery that you do is very unique. Can you go into a little bit more detail about who you trained under there?

 

Dr. Sah 

Sure. So I was fortunate in that both at Harvard and at Rush, where I was in Chicago for fellowship, I had some excellent mentors. And so during that time was really the revolution of joint replacement and changing from four or five day lengths days down to two day lengths days. And a lot of that was built upon better surgical techniques, minimally invasive surgery, better pain management. And so learning from great mentors, I was fortunate to pick up on a lot of their techniques, things have advanced even beyond that, so that now people after joint replacement are going home the next day, routinely or even the same day in some cases. So things have continued to evolve. But in my training, as you had mentioned, I was very fortunate to learn from people that really started that revolution in joint replacement recovery.

 

Alan 

The minimally invasive. I know when I went through You had me walking stairs the same day. Is that a typical case?

 

Dr. Sah 

so things really have changed. So when I was in training back in the 2000's, after total joint replacement hip and knee replacement, it was not uncommon for patients to lie in bed for a day or two. And to be in the hospital for four or five days, the majority of we're going to rehab centers, where they're being taken care of on walkers for six weeks, so a much slower recovery. But then we gradually learned with this more rapid recovery after joint replacement and minimally invasive surgery that people could ambulate sooner, could recover faster. And what we once thought would cause more pain and swelling such as walking just hours after surgery like you did. It actually had the opposite effect, people recovering faster, they had less pain, they were more ambulatory. And so that's why with modern day techniques, people can walk just a few hours after surgery and even go home in many cases.

 

Alan 

Typically, how many surgeries will you do in the morning?

 

Dr. Sah 

Sure. So I'm fortunate in that I work at a center for job placement with a robust program where myself, my anesthesiologist, the surgical teams, the physical therapist, all we do is joint replacement care. And so because of that, we can be very efficient. And we can have very great outcomes as shown by various measures such as health grades or other consumer report and things like that, What you'll find is that when you do a high volume of surgery, both the hospital and the surgeon when they are high volume, they tend to have better outcomes. And so since I've been here, my practice has been focused strictly on hip and knee replacement surgery. With that we typically do eight joint replacements, if not more in a single day. And that's because we can be efficient. And because all the team members are focused on that care. With that we can improve our outcomes and our protocols to really optimize it so people can recover as quickly as possible. As we mentioned before, people traditionally went to the hospital for many days and had slow recoveries, but people now days want to return to work sooner, they want to get back to their life sooner they want to travel, they want to take care of their families sooner. And so with more rapid recovery after your replacement with minimally invasive surgery, people are able to do so. And that's what's lend itself to outpatient joint replacement. I've been fortunate that I've been able to lecture at our national hip and knee society meetings on outpatients, joint replacement surgery, also have published articles on how to achieve successful programs. Because it's not just the surgery, it's not just the pain management. It's not just the therapy, it's really a combination of all of these things where we have to pick the right patient, educate the patient well, make sure they're set up with appropriate care afterwards. And of course, have good surgery and good pain management. But all of these things have to be working well, to give you that good end product of an outpatient joint replacement. So that's what I lecture to other surgeons, that's what I teach when I educate others and really emphasize the entire package so that people can have the best outcome,

 

Alan 

How does a person know when they need to have the surgery?

 

Dr. Sah 

So that's a great question. That's what I've often asked. And joint replacement is an elective surgery. So it's not like other diagnoses, where once you find out you have it, you have to have a surgery, you have to have a treatment, this is really a quality of life surgery, meaning when patients start to have their life that's impacted, they can't do the work they want to do, they can't walk the way they want to they're modifying their activities because of their hip or knee pain. That's typically when they need to have some sort of intervention. They of course, can start with over the counter medications like Advil or Tylenol, they can use a knee brace, for example, a walking stick, they can try injections. But at some point with an arthritic hip or knee it gets it gets to the point where they can't have the symptoms controlled anymore and they need surgical intervention when their quality of life has impact to the point that they need to have surgery.

 

Alan 

What process do you walk a person through before you qualify them for the surgery?

 

Dr. Sah 

So I love to do surgery, of course, and as a surgeon, we want to be in the operating room. However, I always tell patients, as good as these joint replacements are, it's never as good as having your own joint. So if I can do anything to help preserve that we of course will try. So, we want to make sure people have exhausted all their non operative treatments first. And so as mentioned, the medications, the injections, the physical therapy, the bracing, all these things can be tried. But arthritis unfortunately only progresses, it only gets worse with time. All the modalities I just mentioned really help treat the symptoms. None of them are curative, meaning the pain the limitations will progress at some point. And it's at that point that you decide to undergo the surgery.

 

Alan 

Typically how long does a knee replacement last?

 

Dr. Sah 

It's a great question Alan, and I get that question a lot. Because previously, historically, patients would ask how long we last. And we would tell patients you should wait as long as you possibly can. And because they may only last 10 or 15 years. But those numbers are really more historic, these implants now have much better durability, they're being advanced all of the time, the materials are getting better and better. And so what you'll find is that patients actually are having surgery earlier and earlier mainly because they want to maintain their active lifestyle. Life isn't guaranteed, waiting 10 years to have your joint replacement may greatly affect their quality of life, whereas they could have their joint fixed and have a great quality of life right away. So the average age for joint replacement is decreasing. Because people are more active people are living longer, and they want to have a good quality of life. That being said these materials we expect can last decades, we would hope we have seen trauma placements last 20, 30 years even. It's important to monitor patients after your replacement to make sure that they're not wearing or having an unforeseen complication of ware or loosening. But for the majority of joint replacements they should last many, many years, if not decades.

 

Alan 

What's your oldest patient that you've done a replacement on?

 

Dr. Sah 

That's a great question too many times when I give lectures to communities or other they will ask, is there an age that's too old or someone that's too young? Really the youngest patient I've had has been in their 40's. And that's because they really require the surgery they could have hardly walking sometimes you have to do it. For the oldest patient. I actually had a 96 year old man who walked in with a cane. He was not the healthiest person in the world. But he said, look, if I can't walk, I would rather not live. And so we had him medically optimized, did his surgery, and he loved it. Two years later at 98. He came back and had his other knee done. So age is really a number. It's about quality of life, some 90 year olds are healthier than some 70 year olds, this patient did bring us 100 year old sister to see me but I did have to say we have to draw the line somewhere. But age really is just a number. It's more important at what their physiologic age is rather than their chronological age.

 

Alan 

What's your opinion on stem cells?

 

Dr. Sah 

Stem cells is certainly a very hot topic. It sounds very intriguing. And that's where the future may lie. It's interesting in that it has so much promise, but the data there is just nonexistent to be frank. People are working on it. The reason stem cells has such attraction is because people believe that we can direct those cells to become a certain type of cell. In our field of work. Obviously, we're talking about cartilage cells. But unfortunately, stem cells or PRP injections, that's where you draw someone's blood and spin it down and inject it back in the knee. Some athletes are doing those kind of things, these biologic interventions, the data is just lacking. So, people are trying it. It's available. But the reason no insurance covers it is because there's been no data to prove it. The reason it's an out of pocket expenses. Because these things really are mostly experimental, we don't have good data to show that it will regrow a cartilage cell for example, or withstand the forces the moment you start to walk on that arthritic hip or knee. So, it's still being investigated. I caution my patients to do their research and no harm will really be done, it's just they have to understand that they may not get a benefit and because these things are very expensive. They need to weigh the pros and cons.

 

Alan 

It's probably not to be the first one in the pool trying to experimental lab research too. I went through my knee replacement. And even today, I'm trying to figure out with my knee, where the appliances I you know, I can't feel screws- how you attach these things?

 

Dr. Sah 

So, these joint replacements are meant to resurface that joint or replace that joint. So, in the hip, it's a new ball and socket. In the knee, it's really resurfacing the ends of the bone. So, knee replacements sounds a little awkward, it's not cutting out the entire nice really resurfacing the ends of the knee so where cartilage is missing, now you don't have bone rubbing on bone in the arthritic knee, it's metal on a plastic surface. So that bearing will not cause pain, but they're really just a few millimeters thick in the knee. And it's just the idea is that it's going to recover and reshape the ends of the bone. And the idea is that it's the same shape and size of your knee when you had cartilage. So, no bigger, no smaller just to really recreate your natural anatomy. And that's why you don't notice it and you don't feel it as much. Similarly in the hip, the hip ball and socket joint go exactly where the native ball and socket were. So typically people say it feels like their natural joint.

 

Alan 

I've seen these YouTube videos and maybe places where they take the hammer and start... you don't do you?

 

Dr. Sah 

Well, don't get me wrong, orthopedics really is carpentry of the bone, if you will. So certainly we like our tools as orthopedic surgeons, we have the saws, hammers and drills as well. So that does go on with these joint replacements, but as you experienced, people can get up and start recovering right away.

 

Alan 

You're doing eight surgeries in a day. You got a team, they get everything ready. How long does it take you to do your piece?

 

Dr. Sah 

So fortunately to have a great team, to have the patient prepared to turn over the room to get the next patient in line, right? It takes a lot of preparation and teamwork. The actual surgery itself, the total knee can be done in under an hour. So perhaps 15 minutes a total hip, probably the same 50 to 60 minutes. So in a very short period of time these patients have their joints replaced. They're in the recovery room for a couple hours, and they're up walking on it within an hour after that.

 

Alan 

That is absolutely amazing. So, when we look at the Washington Healthcare System, right now you have an option to go to an outpatient, or the full gamut of the hospital which has a specialized wing over there. How do you decide who gets what?

 

Dr. Sah 

So, at the main hospital, we have a three floor building for our Center for joint replacement. It has 30 private rooms, and that's really designed for in patients so for people are going to spend the night they can stay there, the only people in that building our elective joint replacement patients, which means the only nurses and therapists in that building are taking care of joint replacement patients. So only healthy people are there, which obviously has a great impact on infection risk and other things. But for people who do not need to stay in the hospital overnight, I'm director of the outpatient joint replacement program. So, I began that in 2014 at the outpatient surgery center across the street, where again, people can have them replaced and go home in just a few hours. And so the benefit of that is they're not in a hospital at all. And they're going to be sleeping in their own bed, the night of surgery.

 

Alan 

What percentage of people go through the outpatient with you?

 

Dr. Sah 

About 10 to 15% of my patients are doing outpatient surgery at the surgery center. But about 60 to 70% of patients are going home the next day or the same day from even the inpatient side.

 

Alan 

When you look at the future, I guess we got an aging population here of baby boomers, you see things getting a lot busier for you?

 

Dr. Sah 

We believe so, with people aging, with people wanting to be more active and wanting to be more active longer, we expect to see a exponential increase. So total knees in the United States, there are about 700,000 done per year. It's expected to top 1 million in the upcoming years. So this is going to continue to increase as our patients age.

 

Alan 

So Dr. Sah, for the listeners, how do they reach out to you for inquiring about their knee surgery?

 

Dr. Sah 

They can call the office, the office phone number is 510-818-7200. My website has a lot of this information as well as contact information and that website is www.SahOrtho.com. Either of those avenues will help give them more information.

 

Edited for Concision and Clarity

 

 

 

 

 

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