Artificial Knee Replacement - James T. Mazzara, MD
Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.
Dr. Mazzara: Good morning.
Dr. Sechrest: Dr. Mazzara, what I would like to discuss next is artificial replacement of the knee. Now, this has been around for years and years and years in this country and even longer in Europe, and I think people got pretty used to the notion that when the knee wears out we replace it. There has been a lot of change over the last few years in terms of knee replacement, so what I want you to do is bring us up to speed in terms of where we are with total knee replacements, how you use that in your practice, and a little bit about how it's done. So bring us up to speed about artificial knee replacements.
Dr. Mazzara: Well, total knee replacements are actually very effective reliable treatments for end-stage knee osteoarthritis in patients who have tried and not responded to other, less invasive, treatments. So, if somebody comes into the office with knee pain, if they have had conservative treatment with medication or activity modification or injections or sometimes therapy, they can become a candidate for a total knee replacement if all other options have been exhausted. It's something that we used to restrict to older patients, and the earlier philosophy was that you used to have to wait you're 65 to have your knee replaced, but with new technology today we're actually finding that it's a very effective reliable way to treat even younger patients. I have patients in their 30s and 40s who've had to have their knee replaced for one reason or another, after having exhausted all other non-operative, and even some surgical, treatments that don't require replacement of the joint. In the patient who comes in who needs a knee replacement, they are counseled and we discuss the options, including living with the pain and discomfort. If they can live with it, that's not entirely a bad thing. Generally patients are at a point where they have exhausted their options, they've decided they can't live with it, they have pain every day, and their quality of life is so adversely affected by their knee pain, that their only realistic choice is to have their joint replaced. So, after a thorough discussion of the risks and benefits of surgery, they might be scheduled for a replacement. Technically, what we're really doing is resurfacing the knee. While some patients may ask, "Well, are you removing the entire part of the joint?", really what we're doing is removing the end of the bone, resurfacing by cutting the arthritis off the end of the bone and replacing that with a metal prosthesis in-between which is a surface of polyethylene or plastic giving us new smooth surfaces to work with.
Dr. Sechrest: Now, a couple of questions, and I think in terms of us, as surgeons, knowing what we know about the artificial knee replacement, how long we can expect it to last, how well a job it does, or how good a job it does in terms of pain relief and that sort of stuff. Sometimes, I think patients have this notion that, "Well, if I'm having knee pain, I'm a candidate for an artificial knee replacement and it must be better." So I want to have a little bit more broader discussion about when should a patient really say, "A knee replacement is a very good solution for me and continuing to live with this is not", because I know a lot of patients tend to think the solution is that we're just withholding that solution of artificial knee replacement, when we're really trying to give them guidance to say, "Wait, wait, wait" and they're saying, "No, no, no, no". How do you deal with that situation?
Dr. Mazzara: Well, those are patients who have probably not been the full range of conservative options, and so it's really a matter of education, and education is available either through your physician, through our office â€“ we give you reading material and refer people to our website where they get a lot of information about the less-invasive options available for knee osteoarthritis. Eventually, when you get to that point where you're able to look back and say, "We've tried this less risky treatment" then we can go ahead and discuss the knee replacement, because that's really a point of no return. You can't decide that you want your old knee back if you're not completely satisfied with your total knee replacement. Now the success rate of total knees is actually very high. The survivorship and reliability of knee replacements that we did many years ago would suggest that a well done total knee replacement can last patients 15-18+ years and there are a lot of old knee replacements that are still intact and functional after many years. Some of the limits that we faced previously with our older knee replacements was that some of the plastic would wear out. Well, newer designs in plastic and polyethylene in the knee allow us to predict that the longevity of that knee replacement may be that much longer. So there are actually instances where, if people come in and have not had all of their conservative treatment or less invasive treatment, sometimes including therapy and knee arthroscopy, we may discuss that with them first, and that may be a little bit more important in some younger patients and in patients who have milder or moderate degrees of arthritis, we might make some other recommendations in terms of less invasive treatment than knee replacement.
Dr. Sechrest: Now, in the old days, I can remember when I was going to medical school and going through my orthopaedic rotation as a medical student, and spent time on the orthopaedic service, I can distinctly remember having patient after patient come in, who was under the age of 65, and having that surgeon say, "Come back when you can't sleep" or "Come back when you're 65. Come back when you can't walk." Today that's not the case. We don't wait to that period of time or to those situations to recommend a total knee replacement. When do you think that reasonably patients should consider this is an option for me?
Dr. Mazzara: I think waiting to you can't walk is a little extreme so we don't generally recommend that at this point. But I do recommend that patients wait until their quality of life is affected to the point where they're not happy with how the knee feels throughout the day, throughout their normal work activity, leisure activity, when they can't do things without having their knee pain interfere with that task and their quality of life is adversely affected where the only choice they have is to go ahead and have the knee replaced.
Dr. Sechrest: Now another thing that I've commonly talked with patients about and that's the very active patient, and that's the patient who perhaps is a competitive tennis player, patient who is a runner, and what they want to know is, "Am I better off putting up with what I'm putting up with in terms of knee pain, or should I consider a knee replacement." What's your advice to that patient?
Dr. Mazzara: Why, I would tell you that somebody's who is an avid runner, or competitive tennis player, really wouldn't do well long-term with a total knee replacement. They'll do well with short-term, but long-term, what will happen is the increased stress and strain on the ligaments and on the prosthesis will cause it to prematurely wear and sometimes patients will develop laxity, and stress and strain on the ligaments can have a negative effect on the interface between the bone and the prosthesis and can also cause the polyethylene or the plastic to wear at an accelerated rate so I tell patients that if you're running, I wouldn't replace your knee. If you're playing singles tennis, you can play doubles tennis; and I think any activities in sports that require running, twisting, pivoting, anything that's going the require the knee to slip and slide back and forth is potentially bad for total knee replacements, so I generally recommend those patients wait and probably consider an alternative, or living with their symptoms, or very possibly, changing that part of their life so they can make sure that the knee replacement that we put in there will last them a good long time.
Dr. Sechrest: In your experience, what sort of conditions lead most commonly to requiring an artificial knee replacement?
Dr. Mazzara: Much of the arthritic change that we see is just normal wear and tear. We also see that patients who've had previous trauma, previous injuries, ligamentous instability from old anterior cruciate ligament tears, and patients who are substantially overweight put a lot of stress and strain on their joints and cause them to wear out prematurely. Some people will also have a genetic predisposition and, in fact, that probably is the biggest contributing factor is your genes. It's the anatomy of your knee, the anatomy of how you make the cartilage, and how durable that cartilage is; and so you'll see patients who are very active who may have ligament tears, and ligament injuries for many years and come in and really don't have a lot of arthritis. On the other hand, other patients with the same type of injury may have very advanced arthritis over the same time frame. So a lot of it is genetics and your activity, and what you do at work and at home.
Dr. Sechrest: So when you're discussing the possibility of a total knee replacement, and you and the patient have made the decision that they may be appropriate for a total knee replacement. What should that patient expect in terms of preparation?
Dr. Mazzara: Well, they have to be cleared medically before surgery. They have to see their primary care physician, and have a full medical evaluation, because the stress of surgery certainly has an effect on other body systems. Prior to surgery, they would also be asked to give us a list of their medications and then they're scheduled for surgery and the patient is admitted the day of surgery, generally stays about 3 days, following which they will either go home or, in the majority or circumstances, go to a rehabilitation facility where they do physical therapy for that week or so postoperatively. Then they're required to do outpatient physical therapy after they have discharged from the rehabilitation facility.
Dr. Sechrest: Now we've gone through several different preoperative issues with total knee replacements. In the old days, we used to know that patients were going to require a blood transfusion, and then we went through this phase where patients donated their own blood in preparation for surgery thinking that if they needed blood replacement that they would get their own blood back, of course, if they didn't need the blood replacement it would go into the blood bank so it wasn't wasted. What's the current thinking? Do you find that patients require blood transfusions after surgery? Do you ask those patients to bank their own blood?
Dr. Mazzara: I've actually found that the majority of patients do not require transfusion after a knee replacement. The procedure itself takes about an hour to do. There is not a great deal of blood loss during the surgery? After the surgery, certainly there is some blood loss, but what we're able to do is actually collect that blood postoperatively and re-transfuse that blood that's collected through the postoperative knee drains; give that blood back to the patient. So, with this new technology, what we're able to do is give back the patient the blood they actually lose following surgery, and that eliminates the need for having that patient donate blood preoperatively. What we've found is that those patients would come to surgery anemic, because they donated their own blood we find that's not necessary, and I don't ask patients to donate their own blood before surgery. Most of those people don't need a transfusion from another donor after surgery either. They get back their own blood. They may have a little anemia after surgery. If they do, those patients are generally asymptomatic from that little anemia, and that then resolves over time with iron supplements.
Dr. Sechrest: Can you show us a little bit about how a knee replacement is done and what an actual artificial knee looks like?
Dr. Mazzara: Sure. This actually a model of a femur and a tibia into which a total knee prosthesis has been implanted. Essentially what we do surgically is we make an incision over the front of the knee and we try to keep the incision and the tendon exposure small enough so that we minimize the soft tissue trauma, but we need sufficient exposure to get the inside of the knee. Then during the procedure what we're actually able to do, is we're actually able to use very specific guides and we cut the surface off the end of the bone of the femur down here, of the tibia up here, and we cut the arthritic surface off the kneecap or the patella. Once we have done that and we have adequate balance, we need very nice position of our prosthesis. We need the ligaments on either side to be properly balanced. Then what we'll do is we'll take this Hi-flex knee replacement, put some cement on the back or some methylmethacrolate and cement that onto the end of the bone. So we put the cement here and here on the tibial surface. In this area we see a plastic, or a polyethylene, insert. This polyethylene insert is the new joint surface on which the femur rubs as you stand and walk. As you see on the resurfaced patella, that will allow us to have a new fresh surface so as you bend your knee, if you have arthritis in the back of the knee surface, it's now plastic against metal. So what we're really able to do is resurface the joint and then we close everything up. We suture the tendon. On the side, we close the skin. We put a couple of plastic drains that come out of the knee. We put a big padded dressing on the patient, then they go to recovery. The next day they start some physical therapy. They're up and out of bed, and walking right away.
Dr. Sechrest: A couple of questions: In the past, I think there has been some recommendations that maybe some patients don't need their kneecap replaced and some surgeons for a while were not replacing the kneecap if the cartilage looked like it was stable and it didn't need to be replaced. What's your take on that?
Dr. Mazzara: I tend to replace all of the patellar cartilage. I think people do better in terms of reliable outcome in terms of pain relief and function. The potential disadvantage of leaving the cartilage is that people have continued pain after that, and I don't think the data would support leaving that or not resurfacing that; so my preference is to resurface the patella as well.
Dr. Sechrest: And the downside is that if they still have pain you have to go back and do a second operation to go ahead and replace the patella.
Dr. Mazzara: That's exactly right.
Dr. Sechrest: The other thing I would like to have your opinion on is it's also been somewhat probably surgeon's choice about whether to use cement in all of the components or whether some of those components do just as well with the new bony in-growth type of implant where, instead of putting cement there, you allow the bone to grow into a porous coating. What's your opinion on that and what's your standard total knee?
Dr. Mazzara: My own approach is really based on my experience and training which is based on a lot of long-term data which suggests that a cemented total knee probably gives you the best fixation, and if properly done, gives you the longest durable result in terms of pain relief and connection to the bone. So, my own feeling is that and my own practice involves cementing all the total knee replacements.
Dr. Sechrest: Now let's move on to after surgery. What should a patient expect after surgery because obviously this is a procedure that we're still doing as inpatient procedure mostly. So, this patient is going to be in the hospital â€“ how long and what's the recovery like?
Dr. Mazzara: After surgery, there's a bit of pain certainly for the first 2 or 3 days. There's need for injectable medication. In many cases we'll give patients nerve blocks that get them through the surgery and the next day or two, actually fairly comfortable for patients if they have a good nerve block. There is injectable medication for the first few days, and then we get them out of bed and make a transition from injectable medication to oral medication. It's generally about the 3 day mark where patients are able to get up and go to the rehabilitation facility where it's just an extension of their care. They're not being discharged to home, they're going to a rehabilitation facility where there are still nurses and therapists around them, and still individuals able to give them pain medication and help them get out of bed and do some of their daily activities. After about a week or so in the rehabilitation facility, they can generally get up and go home if they're somewhat independent, and then they do outpatient therapy. Most of those patients are encouraged to do outpatient therapy at a rehabilitation facility. Where they get in the care and they go there, and they get back home, as opposed to having somebody come in the house, which is another option, but sometimes patients who do home physical therapy don't have the benefit of all the equipment that you have at a facility, it's sometimes a little better to do it at a rehabilitation center.
Dr. Sechrest: When do you like to actually get patients walking? I know a lot of people have pushed the envelope to trying to get people up even the same day of surgery. What's your opinion on that?
Dr. Mazzara: Well, we give them a break the same day of surgery. We get them out of bed the next day, and we very often put them in a what's called a CPM machine which is a machine that helps move knee back and forth. It's a mechanical device and it's like a footrest that elevates the leg and it bends the knee back and forth and that can be very helpful; not so much long-term in terms of range-of-motion, but short-term in terms of range-of-motion. Actually patients like it, it seems to help with their pain as well.
Dr. Sechrest: So, they're home. How long do you find that it takes them to get back to walking without any assists such as a walker or cane. Do you let people bear weight on their knee immediately?
Dr. Mazzara: Absolutely. They get up and they can walk and they can bend their knee as far as they can tolerate the day after surgery. There's no need to restrict weight bearing at all after a total knee replacement, and in terms of how quickly they get back to independent walking and ambulation, that is very strongly dependent on how functional and how strong they are prior to surgery. What I find is that younger, fitter patients tend to do better faster than patients who are a little bit older, who are weaker, who are more deconditioned. It takes longer for the senior patients who are more deconditioned to get back up and walking again. So, it can be a matter of a week or two before somebody can walk with minimal to no assistance, maybe with a cane at a couple of weeks; while other patients, even at 3 and 4 weeks, because they've had such a long period of time of arthritis and deconditioning, they can still need some assistance at sometimes 3 and 4 weeks. Again, it has a lot to do with how long have those individuals had arthritis, how old are they, and how fit, flexible, and strong are they before surgery, that's what's going to influence a postoperative recovery. Resurfacing the joint may relieve the pain, but it doesn't necessarily mean that immediately after surgery, all those muscles and tendons around the knee are at peak performance. The worse they are before, the longer it takes those muscles and tendons to recover after. That's one of those extra discussions we have with patients who I think may take a little bit longer to get better.
Dr. Sechrest: So, any recommendations you would have for patients that we haven't covered in terms of what their expectations should be after surgery? I mean, where does the knee go at this point?
Dr. Mazzara: Well, I would tell you that postoperatively the results that we see are as varied as the patient population that we see and, having patients come back after surgery, I know they sometimes expect to have no pain because they've had the knee replaced; and in fact they may not have any pain from the arthritis but what we try to help them understand is that the muscles and tendons still need to be rehabilitated, reconditioned, and it can take quite a while for some of that soft tissue pain to get better and to go away. The more demanding they are on the knee, to a certain extent that's good, because it helps to rehabilitate the knee, but they might also notice that it hurts a little bit more when they stress and strain the knee, and it's up to them to discuss with me what kind of activities are okay and how hard can they push the knee after surgery. In many of those instances it's probably just a temporary inflammatory phase of the healing process which, over time, will get better and go away.
Dr. Sechrest: Now, if it doesn't go away â€“ we've all had the experience, I think, of having that patient who's had a knee replacement and continues to have a little discomfort in the knee. What are you worried about as an orthopaedic surgeon when you see that pain continue over that 12 month period? Is that always a reason for concern or do you have some knees that just don't get completely pain relief?
Dr. Mazzara: There are always going to be a certain number of total knees that we do that look beautiful on an x-ray, there may be no sign of any problem, no sign of any infection, no sign of any tendon problems, but still hurt for reasons that we don't fully understand, and I don't think we have a good answer as to why some of those knees hurt. We do see them in practice. They are few and far between, but they do occur. Sometimes patients will have a good looking knee clinically, but end up having a very subtle infection in the knee. Those are things that need to be evaluated and treated through blood testing and other means and other patients will just have a simple bursitis and tendinitis of the knee. So, not every painful total knee means that it's infected or that it's a mystery. Some of these painful total knees after surgery, if properly evaluated and treated, can be made to function and stop hurting because some of those people come back and have an isolated bursitis or tendinitis.
Dr. Sechrest: Now, that leads us to another discussion, and that is the discussion about complications of artificial knee replacement. What do you as an orthopaedic surgeon worry about after the surgery or even during the surgery? What complications can occur during the surgery? Immediately after the surgery? And then, over the long haul?
Dr. Mazzara: Well, during surgery, you always worry about things like nerve damage, bleeding, or arterial injuries, fractures of the bone, rupture of a ligament that you otherwise need to be intact during or after the surgery for appropriate stability, and then, anesthetic related complications. Those are probably the biggest, most significant ones. Postoperatively, we again obsess about infection and blood clots, and stiffness. We like to get a certain degree of balance and flexibility in the knee. Patients invariably, because of pain and discomfort, will get stiff after surgery. A lot of people make lots of scar tissue. Those people who make scar tissue tend to become stiff and sometimes have pain from that postoperative stiffness. Long-term, however, we worry about a loosening of the prosthesis from other reasons just like wear and tear of any device, any artificial implant over a period of many years you'll get loosening between the cement and the bone interface. With older forms of the polyethylene we'll see rates of wear and tear of that plastic at that point, which can then cause loosening of the prosthesis; and secondary infection. If you have an infection elsewhere in the body, that can certainly seed and send little satellite bacteria off to the artificial joint replacement which can cause a secondary infection.
Dr. Sechrest: Now what are your recommendations? I know there's been some controversy over the years about whether patients, who have implants, and especially total joints, whether it's a knee, a shoulder, a hip, or whatever, that they're at higher risk if they have procedures such as, for example, a colonoscopy or even dental work; anything that may seed the blood with bacteria. Are you recommending that those patients take antibiotics before that procedure is done?
Dr. Mazzara: Yes, I do. Any kind of dental procedure, any kind of GI (gastrointestinal) procedure, any kind of urologic procedure, any kind of systemic infection, I generally recommend that those patients take an antibiotic prophylactically before the procedure, and treat any kind of other infection fairly aggressively, especially if they have the total joint replacement anywhere in the body. So somebody who may cut a finger or have an ingrown toenail that gets infected in the place of a total knee or total shoulder replacement should treat that infection aggressively because the potential is those bacteria get into the system and seed the prosthesis causing infection and causing the prosthesis to become loose and need to be revised.
Dr. Sechrest: One other thing that people are always asking and that is airports. I think that everyone with an implant is worried whether or not they'll be able to get through the screening at the airports. How do you advise patients and do you do anything special for those patients?
Dr. Mazzara: Those patients generally get a little card that says they have a total joint replacement. I sign it and I specify where it is and those patients are generally pulled aside. They're wanded or inspected by the TSA inspectors. They always get through. Nobody's ever had a real significant problem with that.
Dr. Sechrest: I think we've seen the case of total knee replacements getting better and better and better over the last 30 years to the point of where it's an incredibly effective operation for relief of knee pain that's coming from any sort of wear and tear phenomenon. I just want to put you on the spot and ask you. Where are we going next? What do you see the future of total knee replacements being and what do you see in terms of new procedures or new technologies that may change the way we do these today.
Dr. Mazzara: Well, I think what we've seen very recently has been a modification of the kind of knee replacement that we use at this point. The prosthesis that I use has been modified to where it is a gender-specific knee replacement. It's been changed in certain ways to accommodate the variations in female anatomy in terms of the position of the patella and how it moves back and forth in the knee and the size of the prosthesis. Prior to that it was modified to allow more flexion of the knee, and very recently there have been improvements in the polyethylene that we implant in the knee so that we have a much durable plastic insert in the knee. Over a period of time what we're seeing is that there are new prostheses on the market which are actually rotating platform total knee replacements which are, at least by design, supposed for a more natural feel to the knee and we're also getting to the point where we're considering actually; partial knee replacements have been done for quite some time, but we're able to localize these knee replacements in individuals who may have patellofemoral arthritis; there are partial knee replacements that isolate the replacement to the patellofemoral portion of the joint. So aside from those modifications addressing the location of the arthritis, I think the improvements have really been to the prosthesis, how it's designed, and how the components have been manufactured.
Dr. Sechrest: And you think this is going to continue into the future. Do you think there are still some benefits to be had by improving the designs?
Dr. Mazzara: I think there are. This is a prosthesis that has evolved over a period of years. The prosthesis that I implanted 16 and 20 years ago when I was in training is not the exactly the same prosthesis as I would implant at this point. It's a process of continuing improvement and modification. We always look back at how did we do this before, how can we do it better, and I think when we examine the prosthesis and what we do very critically, we can always make improvements.
Dr. Sechrest: It's interesting, and I'd like to pick your brain about this, but I always have a habit of asking patients whether or not they can tell they have and artificial knee in the knee joint, and a lot of patients wonder whether this will ever feel like their knee so that they don't know they have a knee replacement. What's been your experience when you talk with patients?
Dr. Mazzara: I think patients will generally say it feels almost normal. It doesn't actually feel like a normal knee, but it's far better than it was before. You do have some patients who come back and they say, "Well, it doesn't feel like it's any different than a normal knee", but I think the majority of patients will say, "I know it's a little bit different and it may feel a little different in one way or another, but it's far better than it was prior to the surgery".
Dr. Sechrest: Yes, I know one other thing that people sometimes will come in and they're more curious about it, it's not causing pain, but sometimes that kneecap has a little bit of a click.
Dr. Mazzara: Yep.
Dr. Sechrest: When it hits the metal and you can hear it. You can hear it when they walk, and you generally just have reassure them that it's a normal sort of thing. It's not bothering them, but they're concerned. You know, if your car makes a funny noise, you're going to get it checked out.
Dr. Mazzara: Well, when you have a normal joint, there will generally be a little bit of play, a little bit of mobility between the joint surfaces. The difference is that, in your normal joint, it's soft cartilage. When you have a total joint, it's metal against plastic, and you want to get, you strive for, good ligament balance in a total knee replacement. So generally, you're going to get a little bit of click or play in there, but that's very natural and very normal. It's not a concern, and it's one of those things that really needs to be expected. As I said, you don't feel it in the normal knee because the surfaces are very different and it's cartilage against cartilage, and, in the metal and plastic knee, you notice it a little bit more because the surfaces are much harder.
Dr. Sechrest: Are you seeing with your total knee replacements now that people will regain their full flexion? In the old days, we always felt like that if you could bend your knee beyond 90 degrees that was a successful knee replacement. Now, I think, people are striving to get that 120 degrees, and even further, back into that normal range. What's been your experience? Are we seeing improvements in flexion?
Dr. Mazzara: Well, we are, and part of that is design of the prosthesis. The prosthesis is designed to permit 155 degrees of flexion and full extension. What we see, however, is that patients who come back will have varying degrees of flexion, generally not 155 degrees, often somewhat less. But those patients are, very frequently, individuals who make a lot of scar tissue, so if somebody gets 120 degrees of flexion when that prosthesis allows for 155 degrees, I still think that's a good result if they don't have any pain. Much of that over a longer period of time gets better. We strive for people to come back at 6 weeks and have a lot of flexion. We like them to have 90 degrees of flexion as soon as possible. We like them to have 120 degrees certainly within a month or so, but there are lot of patients who don't, and if you watch those people over a period of time as they get to 9 and 12 months, they'll get a lot more motion back. So the eventual range-of-motion that a patient gets, to some extent, depends on how much they start with and, to another extent, depends on how much scar tissue they make; and patients will tolerate different degrees of discomfort during therapy. Some patients can push themselves quite well and other patients don't deal with it. We have to manage them with medications and sometimes a different form of therapy. Sometimes we recommend some aquatic therapy for individuals.
Dr. Sechrest: Now as you follow these patients over the long-term, what's your routine? When do you like to see patients back and what are you looking for as you're seeing those patients back over the years?
Dr. Mazzara: Well, we like to see everybody back about a year after surgery, and then the year after that, and then after that point we'd like to see them every couple of years. What we're really looking for are problems with the connection between the bone and the cement and the prosthesis needs to be in good position. We're monitoring for any kind of problems that they may be having. Patients who have any issues after surgery can always come back, even if it's a problem that's not there at a year, the door is open and they should come back and see me.
Dr. Sechrest: Well, thanks. It's been a wonderful discussion. I think it's useful information for people who are faced with the decision about whether or not to have an artificial knee or not. Any other last closing comments that you would like patients to know who are faced with this decision?
Dr. Mazzara: Well, I think a total knee replacement is an excellent option for the right patient under the right circumstances, and it's really up to the patient to decide that they're willing to take that step and they're willing to work hard, and it's our job as orthopaedic surgeons to do our best for our patients and get them the best outcomes.
Dr. Sechrest: Well, thanks a lot. Thanks for coming by and discussing this important topic.
Dr. Mazzara: Thank you.
Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.