Kaizen Health and Wellness
Spotlight Series
Guest Name: Dr. Christopher Dickinson
Guest Credentials: DO
Discussion Details: In this episode, Dr. Christopher Dickinson, an orthopedic surgeon, shares insights on joint replacement surgeries, recovery, and common misconceptions. Perfect for anyone considering or curious about orthopedic procedures and how to optimize outcomes.
Benefit of Watching
- When to consider joint replacement
- Recovery timelines and tips
- Differences between hip and knee replacements
- Impact of surgical approach on outcomes
- Common misconceptions about arthritis and surgery
Address of guest’s business:
6001 Westown Pkwy,
West Des Moines, IA 50266
Dr. Christopher Dickinson: Thanks for having me. Appreciate being here.
Dr. Bryan M. Ladd: So, yeah. Absolutely. Yeah, I’m really excited to have you on. You know, this is our first time talking in person, but I’ve heard a lot of great things from some patients, and so it’s great to have you here to talk to you.
Dr. Christopher Dickinson: Well, it’s good. I know I have some patients out there that [laughter] are saying some good things. So, uh,
Dr. Bryan M. Ladd: nothing but nothing but great things said for sure. So, what let’s jump into it here. you know, first off, what made you choose orthopedic surgery when you knew the training would consume the better part of a decade?
Dr. Christopher Dickinson: Yeah, I mean, it’s a good question. I I was always interested in kind of science and medicine and then as I kind of continued to go down that path, I was always somewhat of an athlete or tried to be at least. I swam in college and uh
Dr. Bryan M. Ladd: okay
Dr. Christopher Dickinson: it just a lot of there’s just seems like there’s a lot of overlap between like you know sports and orthopedics and as I kind of went further down the medicine science path I just gravitated towards ortho because to me orthopedics is something that we see a tangible difference very quickly with people that we work with you know you know more credit to like a lot of our internal medicine doctors that are out there trying to combat like chronic disease which is really hard Um, but like for example, when we have patients come in with knee pain or like a bad knee and you can do a joint replacement and, you know, couple months of a recovery and they’re back to doing everything they want to do. It’s it’s the tangible difference that makes a huge difference, I think. At least for me, just seeing my patients happy and back to doing the things they want to do. That’s kind of what brought me into it.
Dr. Bryan M. Ladd: Yeah, absolutely. That’s that’s similar to physical therapy, but I think for me, you know, you’re just able to you and we work with patients, you know, especially our post-ops for an extended period of time. And so, you get to see them, you know, from day one when they can barely move and see that progression over the couple months and and get them back. It’s it’s amazing. So,
Dr. Christopher Dickinson: yeah, it’s really fun to see. It’s just as they progress through the recovery and then ultimately get back to doing the things they love, but they weren’t really as doing as well as they wanted to before. you know, anything from I mean, I have patients, you know, biking 15, 20 miles at a time, you know, going on things like RAGBRAI, doing triathlons. Then I also have patients that just wanted to get back to playing with their grandkids just outside and being able to get down on the ground and, you know, do that type of thing.
Dr. Bryan M. Ladd: Yeah. Yeah. And and a lot of times they don’t think they’re going to get back to those things, too. And so, it’s really cool to see that.
Dr. Christopher Dickinson: Correct. I tell most people these days, you know, you you can get back to doing whatever you feel like you’re able to. I say maybe don’t go run marathons with with a joint replacement, but you certainly can do, you know, pretty much anything else. These implants are lasting a lot longer and they’re we just we see people that are doing a lot better with them now than we used to.
Dr. Bryan M. Ladd: Sure. Sure. Absolutely. I’m sure we’ll get a little bit more into that. One thing I wanted to talk about though, you know, as I read your intro, it said I said you’re board eligible and not board certified. So, take us through the board certification process. You know, how hard is that? And really why should patients care whether the surgeon is board certified or not?
Dr. Christopher Dickinson: Yeah, absolutely. So the the whole process really starts I mean it’s it’s two-phase. The whole process for board uh certification starts in your fourth or fifth year of residency. You kind of take like a multiple choice type test that basically covers all areas within orthopedics. So all the subsp specialty areas and then you’re basically pass fail and that’s kind of the easy part. Then uh you you know do a fellowship or whatever go out into practice and you start practice and then you have like you have five years to complete it from when you start but most people try and do it towards the earlier half of practice. So you have to collect a case log about 6 months worth of all your cases and then submit those and then those go up for review and then they select about 12 of your cases um to review and then you have to basically defend your decisions that you made, why you did or didn’t do something, you’re you know developing the diagnosis, what you did to plan for the surgery and all of that and then how you manage any complications that happen because inevitably you know in any type of surgery There’s always going to be some complications unfortunately and that’s kind of the stuff they want to make sure we’re able to manage on our own. So,
Dr. Bryan M. Ladd: Sure. Sure. Yeah. [clears throat]
Dr. Christopher Dickinson: You know, I think it it matters quite a bit being board certified. It’s just uh it it it just you basically gone through the entire process. There are a lot of hoops to jump through through this training. Um it’s kind of like the final hoop. And I think it just helps patients know that if they’re going to see somebody that’s board certified that they’ve kind of been through the rigors of everything and you know they’ve been been tested and they’ve had to defend all their decisions and so you know they’re probably making good decisions and helping patients get back to doing the things they want to do.
Dr. Bryan M. Ladd: Yeah. Now this is more for my own knowledge but do you have to renew that every couple years or you
Dr. Christopher Dickinson: you do Yeah. If I think it’s every 10 years it’s a little bit different. There are a couple different ways you can do it. It it’s certainly not renewing it is not as much as like getting it done the first time. It’s not like they go back and look at all your cases again or anything. It’s usually kind of like it’s more of like a kind of a you can think of as like CME or continuing medical education type stuff. I think you might have to take a test or review some stuff. I just I’ I’ve talked to some of my older partners who had to renew and they they had to go back and you know, for example, one of my partners who does hip and knee replacement, he had to answer questions about like hand surgery and it’s like I haven’t thought about this in 20 years. So So the process to renew isn’t isn’t so bad, but you you do have to renew it.
Dr. Bryan M. Ladd: Sure. Sure. Yeah. I was just curious, you know, when I I think for my board certification, the year before I took it, took the exam, they completely changed it. You know, it used to be for physical therapy, you’d get board certified, and you were just board certified, so you never had to renew. And uh then I you know I go to take it and they completely change it. It’s more in line with what you know yours is. It’s I think every three years we have to submit you know so many cases and CMEs. There’s so many different there’s different things you can submit every three years and then on that 10th year then you finally have to I think you you take an exam but I think it’s half of what the original one was and you submit everything and so yeah not quite there yet but yeah it’s it’s a process.
Dr. Christopher Dickinson: Yeah.
Dr. Bryan M. Ladd: Yeah. So looking back here, you know, what would you say is the hardest lesson residency or fellowship taught you that medical medical school never could?
Dr. Christopher Dickinson: I think it’s dealing with the patients with complications that’s the hardest part and that is something even as a resident, you know, fortunately they don’t happen that often in orthopedics, especially for, you know, something like I do, but but they certainly do. And it’s, you know, I saw my attendees in residency have to deal with that and talk to patients and, you know, there are variety of reasons why things happen. Some of it’s out of our control sometimes, some of it is wasn’t our control. But just walking through the patients and staying with them the entire way and getting them through those complications was something I watched them do, my attendants, and then I didn’t realize how difficult that was until I started practice.
Dr. Bryan M. Ladd: Sure.
Dr. Christopher Dickinson: Just being being accountable, being responsible. I mean, you have someone in front of you who’s going through a really tough time, and being able to help get them through that is extremely important, right? And that was part of the reason I wanted to do a fellowship in hip and knee replacement to learn how to do like complex hip and knee revision surgery, just because anything that ever happened to any of my patients that I did hip or knee replacement on, I wanted to be able to manage that. And then I also wanted to be able to manage, you know, anything that came in from around the state. Really?
Dr. Bryan M. Ladd: Yeah. Absolutely. I mean, you’re dealing with people’s lives, right? their their ability to function, you know, in society and that’s that’s a big deal.
Dr. Christopher Dickinson: Yeah. I mean, if someone loses their ability to function or function well, it’s it’s very difficult difficult time for them. And it’s, you know, difficult to get them back on their feet and doing the things that they’d like to be doing, just having a normal life, you know, just their activities of daily living. It’s amazing how, you know, sometimes that some things can go go so wrong, but, you know, we can usually get back people back to functioning decently after after problems do happen.
Dr. Bryan M. Ladd: Sure. Sure. Was there ever a surgery early in your career that humbled you?
Dr. Christopher Dickinson: There have probably been a couple maybe some of the bigger complex revision cases that I’ve done. You know, like I said, I I kind of see stuff from all over the state that get sent in or referred to us. You usually it’s people that have had a first time hip or knee replacement that something didn’t work out or something happened or they developed an infection. Those are pretty humbling cases, I think, because I I didn’t appreciate at first how much the followup would weigh on me and just like when you when you care so much and you see these people, you know, every couple weeks and like it’s just a slow process of them getting better, you’re like, I want them better faster, right? So, for like, you know, when you do a first- time hip or knee replacement, those people are doing great like pretty much right out the door. But when when we do these complex revision surgeries, I think it takes them a lot longer to get back to normal and it’s just a long process. So it’s humbling because it it it just basically takes time and you you feel like you should have done something differently maybe, but it’s not always the case. It just just takes time.
Dr. Bryan M. Ladd: Right. Now I know ortho trauma is kind of its own subsp specialty but is with your with your reconstruction background do you ever see any of those you know or you know ortho trauma takes care of them gets them stabilized gets them function in but then do you ever step in to kind of re revise a joint or
Dr. Christopher Dickinson: Yeah. Absolutely. So I work pretty closely with some of my trauma partners sometimes. You know, somebody will have a an accident and break their femur or their their pelvis or their acetabulum and they’ll come in with a bad injury and those guys will typically fix it and get them back to functioning. But often times, you know, they’ll develop what we call like post-traumatic osteoarthritis or, you know, post-traumatic arthritis. So, basically, because the the joint had a significant injury to it, they just develop arthritis a lot sooner and faster than they otherwise would have. And so, I work with the trauma guys. They’ll do all the plating and the screws and everything and then often take those out once everything’s healed up so we can re like basically replace their joint to give them a functioning joint without arthritis.
Dr. Bryan M. Ladd: Sure. So, Okay. Yeah.
Dr. Christopher Dickinson: And then often times too sometimes when people already have a joint replacement and then then they have an accident where they break the bone around it or something that requires a revision of the joint which I I do a fair amount of and I work with the my traumatologists as well help out with that.
Dr. Bryan M. Ladd: Yeah. Okay. Let’s shift here. Let’s talk about some misconception. So, what’s something almost every patient believes about arthritis that’s completely wrong?
Dr. Christopher Dickinson: I think in this day and age with everything out there, I think more there’s some thought that people think that if they develop a little arthritis, they might not never ever need anything like any treatment or that it’ll kind of just it’ll just stay.
Dr. Bryan M. Ladd: It’ll they’ll develop a little arthritis, but it won’t get worse. Yeah.
Dr. Christopher Dickinson: often times, you know, people come we’ll come in, we’ll give them like a cortisone injection, and I always have to tell people like, “This isn’t going to treat the arthritis. We’re just kind of almost delaying the inevitable.” You might not ever need a joint replacement, but the arthritis will certainly get worse over time. It’s just a matter of how bad it gets and if it gets bad enough to the point that it’s affecting your quality of life enough that our conservative treatments are not helping. And then we get to the point of discussing joint replacement. That’s kind of a a misconception sometimes that I think patients think we’re treating their arthritis with our conservative treatment. I think we’re just trying to manage it.
Dr. Bryan M. Ladd: Sure. And hope it doesn’t get to the point that you need need surgery, but if it does, we have good options, right? So, yeah. And I I try and tell people that too, you know, when they come in here and they’re like, can it be fixed? It’s like, well, I’m not going to fix, you know, once that arthritis is there, I can’t get rid of it, but through exercise, there’s things we can do.
Dr. Christopher Dickinson: Absolutely. And I think this is an important point that like the role you guys fill as a physical therapist. I get patients in all the time that are like, “Well, I have a bad knee. I have a lot of arthritis in my knee. I I shouldn’t do I shouldn’t go out, walk. I shouldn’t do things like I normally would cuz that’s going to make it worse.” Personally, I mean, yes, the joint is going to continue to wear out either way. But honestly, I always tell my patients, motion is lotion, and the more you’re able to maintain motion and strength, the less likely you’re going to need anything anytime soon, probably. I mean, I’ve seen some really bad knees before that like a lot of arthritis in them. They’re like almost bone on bone. You know, the cartilage is completely worn down, but they’re pretty active people. And I think they’re able to continue doing what they do because they stay active and they keep motion to the joints and they just don’t allow them to get stiff cuz I think once you get the the bad joints start to get stiff then people really start to have problems and more pain.
Dr. Bryan M. Ladd: Yep. Yep. What would you say causes people to wait too long before getting a joint replacement?
Dr. Christopher Dickinson: I think often times it’s just the hesitation that I think people know that as they’re as they’re developing more pain that what the answer is probably going to be when they come into clinic. Um and I think they’re a little hesitant to have any type of surgery which is understandable but you know you probably hear this all the time too where I like I see people after surgery and they’re like oh my gosh I feel so much better. I should have done that a long time ago.
Dr. Bryan M. Ladd: Yeah. So
Dr. Christopher Dickinson: and honestly people are scared to do it. It’s it’s a big surgery, but it it is it is and it’s becoming much more common place now. I mean, we just we’re doing so many more joint replacements than we used to that I think it’s become more mainstream essentially. And so people and almost everybody that comes in now has had a family member, a parent, you know, a friend that has had a hip or knee replacement and so they’ve seen a little bit of it.
Dr. Bryan M. Ladd: Sure. But
Dr. Christopher Dickinson: I still think people are a little nervous that, you know, we’re just going to jump right to say, “Oh, you need surgery.” Um, it’s not always the case. You know, we always try and manage things conservatively first, but you’re right. We we do see a lot of people that that finally come in, their joints been looks looks awful. It’s probably been awful for a while. They’ve just been struggling to deal with the pain and and we finally do replace their joint. Like, I waited too long.
Dr. Bryan M. Ladd: Yeah. Yeah.
Dr. Christopher Dickinson: Honestly though, those are some of the happier patients I’ve seen because I think they’ve been struggling with it for so long that they notice a difference much quicker.
Dr. Bryan M. Ladd: That’s true. So, I tell you I always tell them, you know, I waited or they tell me they waited too long. I said, you know, that might be the case, but you know, you’re you’re going to notice a difference much quicker. You’re going to be you’re going to appreciate this a little bit more, at least sooner. Sure. Yeah. Well, that was kind of my next question, too. You know, on the flip side of that, what causes people to have surgery too early?
Dr. Christopher Dickinson: Yeah. I think, you know, unfortunately, there are some people that will have you joints that are starting to wear out a little bit. They’ll come in and we’ll try pretty much all of our conservative treatment. You know, most of the time that’s going to give them some relief. You know, the injections, like I said, are they’re temporary. You know, ideally, they’ll they’ll give you some relief, but inevitably they’re not going to work forever. There are people I see every now and then that continue to have knee pain. You know, their arthritis isn’t that bad. They still have some joint space left in there, but everything else we’ve been trying just hasn’t worked or has stopped working essentially. And so I h I try and have a really frank discussion with these people that, you know, your joint isn’t doesn’t look that bad yet. I understand you’re having a lot of pain, but if we can try and put this off a little bit longer until, you know, your arthritis gets worse or you’re getting closer to being bone on bone, those the people that I think we pull the trigger too soon on just generally are not quite as happy. Um, I think it’s just setting expectations because, you know, I I always tell people like particularly for knee replacement. You know, this is not going to be your 18-year-old knee. I can’t guarantee you that it’s going to be painfree. It most of the time it is. Most of the time you’ll get back to doing all your normal activities, but like as we age, it’s not just the joint, but like your muscles and tendons, you get weaker, and that contributes to just painful joints. your your bone just isn’t as good. It’s just hard your flexibility isn’t as good. It’s just harder to do things like get down on the ground and get up from the ground and kneel down and do all those types of things that was way easier to do when you were younger. So, I I tell them it’s like I said, it’s not going to be your 18-year-old knee, but it’ll certainly be better than it what it was once it becomes very like very arthritic.
Dr. Bryan M. Ladd: Yeah, absolutely. And what’s you kind of touched on it, but what’s that exact moment when you know conservative treatment has run its course?
Dr. Christopher Dickinson: when somebody comes in and you can tell pretty quickly, especially if I’ve been seeing them a couple times and treating them for say a knee arthritis, get gone through some injections, they’ve tried some anti-inflammatories, they’ve done physical therapy, you can usually see that on their face, they just look tired, they’re worn out, they’re sick of dealing with it. And I always ask them like, “How much is it affecting your quality of life?” Cuz sometimes I’ll have patients that say, “Well, my my knee looks really bad. I should probably just get it done now.” on like, you know, we really don’t do this until you you’re having the pain with it. Like we’re we’re not we’re not just treating the joint. I mean, we’re treating your quality of life. And so if your quality of life’s diminished, and that’s something you can read on somebody’s face generally pretty easily after you got to know them a couple times, you know, it it makes itself pretty apparent. I can tell when some people walk in and they’re just they’re just done dealing with it. They know it’s done.
Dr. Bryan M. Ladd: Yeah. They have that Yeah. that beat down rundown kind of look on when it starts to affect [clears throat] their their sleep, you know. not just walking around or stairs or things like that, but they can’t sleep and it that affects everything.
Dr. Christopher Dickinson: Yep. Absolutely. I I have that question on my intake form when I have patients come in and how much is it affecting your sleep? How much is affecting your quality of life? Are you not doing your normal activities as much or at all as you as you would want to be. So, it’s it’s a quality of life thing, not so much. You know, I like I said, I’ve seen really bad knees before, but those people aren’t really having a lot of pain sometimes. So, I say you just continue to do what you do until you do have pain. and then then we can have the discussion.
Dr. Bryan M. Ladd: Perfect. Yeah. And this is this is a perfect segue as well. So, how much does an MRI or an X-ray influence your decision compared to what the patient is actually telling you?
Dr. Christopher Dickinson: Um, the act I put most of my decision-m and what the patient’s telling me. I think if sometimes I feel like we’ve as physicians we’ve gotten away from, you know, the subjective talking to the patient and just feeling out what their whole situation is cuz everyone’s in a little bit different situation, you know, and then we just look at the X-ray and show them the X-ray and, you know, like I said, somebody can have a really bad X-ray, but you know, they’re not having that much pain. I don’t think that person’s going to be doing great with a like a knee replacement right away. Now, eventually maybe, but you know, and when it comes to MRIs, I will occasionally order an MRI. I think there are some instances where the X-ray just it doesn’t look that bad, but what they’re telling what the patient’s telling me and the fact that none of our conservative treatment has helped a whole lot would indicate to me that it the joint might be worse than it looks on the X-ray. You know, sometimes people can have like labral tears around the hip, degenerative meniscal tears, you know, strains of the ligament, you know, focal like cartilage lesions in the knee that we don’t really see very well on X-ray. And so all that stuff shows up better on an MRI. So, in some instances, I will use that to help make the decision, but often times I don’t need an MRI to tell the patient that they’re going to they would or would not benefit from joint replacement.
Dr. Bryan M. Ladd: Sure. Sure. Yeah. You see that worn out joint and the the joint space is narrowed and
Dr. Christopher Dickinson: Yeah.
Dr. Bryan M. Ladd: and it’s matching up clinically then. Yeah. So, now hip versus knee replacement, which operation has changed the most over the last decade?
Dr. Christopher Dickinson: Well, I think both have changed significantly in the fact that we use a what we call polyethylene plastic. It’s so it’s like a little plastic piece on the knee that inserts in and that gives you a nice smooth surface and then it’s on the hip replacement side. There’s a cup that we put in with that polyethylene plastic. We found new ways to develop that, you know, in the last 15 20 years that it’s not wearing out like it used to. And so telling people now, you know, you if everything goes well, you can expect this to last 25 to 30 years. Honestly, it might be longer than that. So that’s one of the biggest changes that has come in certain in terms of the technology of joint replacement. One of the other things is, you know, I think as our field progresses, we’re doing more and more patient reported outcome research to see how patients are doing afterwards and how much it’s helped them. And I think that’s helped drive some new areas that we’re looking into in terms of like patient specific alignment with knee replacement. And this kind of starts to go into the whole robotic discussion potentially. I think at at this point robotic joint replacement, I think when compared to like a high volume hip and knee surgeon, there’s not any difference in the patient reported outcomes. At least there hasn’t been shown to be. So somebody that uses a robot versus somebody that’s doing a lot of these all the time, you know, those patients have very similar outcomes. There’s a whole discussion to have on robots, I think in the future that there’s certainly a role for it. I just don’t know that we know like that exact role yet because we just don’t know for example on the knee replacement side of things if as we look in more into individualized alignment you know we just don’t know what the basically the goalpost is like what we’re trying to get to what is that what is what alignment does that particular person need that’s going to give them the best result we can’t say yet I mean that’s something we’re looking at but and we’re we’re kind of starting to tailor things that way we just we just don’t know for sure and That’s where the robots will eventually come in and be helpful, I think, is when we do know that that that exact goalpost of what we’re trying to get, the robot can help us get there. But for the time being, I don’t think there’s any difference at this point.
Dr. Bryan M. Ladd: Interesting. Okay. Now, one thing I’m hearing more and more about, I’m guessing this is trademarked, but the Jiffy Knee.
Dr. Christopher Dickinson: Yep.
Dr. Bryan M. Ladd: And so, yeah. Can you kind of tell me like what’s, you know, your standard total knee replacement versus the Jiffy Knee? Like what’s the difference? What are the benefits, pros, cons, things like that?
Dr. Christopher Dickinson: Yeah, I did not train with anybody that did the Jiffy Knee. And you know, you hear all these things about minimally invasive and that that is what the Jiffy Knee is what we call basically a subvastus approach. So it it the incision into the joint capsule stays below the vastus muscle. So it does not cut into the quad tendon.
Dr. Bryan M. Ladd: Okay.
Dr. Christopher Dickinson: And so the what we found is that when you don’t cut into the quad tendon, there might be a little bit faster recovery in the front end of things than maybe the first couple weeks. And most of that comes with maybe pain a little bit, maybe function of the quadriceps, like if the quadriceps is just stronger and you’re not trying to repair that incision that we had to put into the quadriceps tendon. Certainly, I think there’s some good data to show, like I said, that it it might be beneficial in the first couple weeks, but what I do know is all the data in the long in long term shows that everything ends up being equal.
Dr. Bryan M. Ladd: Okay.
Dr. Christopher Dickinson: So, it it I do think there’s a little bit of marketing push behind the thing such thing as a Jiffy Knee. I I don’t do that subvastus approach yet. I’ve been considering attempting it and looking into it just cuz I am curious if it it will get my patients back to moving their knee faster, better without with less pain, but you know, I don’t I’m not convinced yet that I need to change my whole practice because I think my knee patients do pretty well as it is. But it’s something I it’s worth looking into.
Dr. Bryan M. Ladd: Well, along those similar lines, I guess, let’s talk about, you know, anterior versus posterior hip and, you know, what how you approach one versus the other and maybe what the recovery looks like as well.
Dr. Christopher Dickinson: Yep. So, I actually in residency I trained with some people that did an anterior hip approach and then in fellowship I actually trained with some people that mostly did posterior approach. I honestly think that and most of the data will probably show this too that again in the long run everything kind of ends up being equal between the two really what you should have done is what whoever whatever surgeon you’re going to see it feels most comfortable using and and sometimes that’s the posterior approach it’s probably getting phased out a little bit just because of how this big push to anterior but I I do think in the first couple weeks there’s probably a difference for some patients not everybody that the anterior approach you know get you up on your feet moving a little bit quicker. There’s probably not as much loss of strength and it’s just a little bit easier of a recovery as what I’ve seen in my own practice. But, you know, I think either approach is good. It’s just the anterior approach allows me to make a little bit smaller incision. I think there’s a slightly less risk of dislocation. Now, that being said, I think most people who use posterior approach have a also a very small dislocation uh risk or rate. So, that’s not that different. like they’re both less than 1% so extremely rare.
Dr. Bryan M. Ladd: Okay. Yeah.
Dr. Christopher Dickinson: But those are kind of the big things with between anterior and posterior approach. And so I do anterior approach for all my first time joint replacements and I use a bikini incision. I used to use the longitudinal incision. I just had a couple wound issues with that in the course of a couple weeks and I had trained with somebody that did the bikini incision and and the bikini incision is just this. It’s in line with your natural skin lines. So I found it just heals a little bit easier. I was not worrying nearly as much about the incisions and the wound healing issues as I as I was when I used the other incision. Neither one’s right or wrong. I just it’s just kind of practice dependent is my guess.
Dr. Bryan M. Ladd: Yeah. Okay. What are your thoughts on rehab after a total hip? Cuz we’ve seen it where, you know, we’ll get some patients right after a total hip. We’ll get some where physical therapy is not recommended or maybe we’ll see them like months down the line as well. So, I just want to get your thoughts on that.
Dr. Christopher Dickinson: When it comes to hip replacement, I truly think it’s probably dependent. I always tell people I never really send hips to physical therapy. Most of your therapy is going to be getting up and walking, but that’s not everybody. T if their joints really bad and they’re really stiff and like basically they’ve lost all cartilage and they’re like nearing fusion of their hip when I see them, they’re going to be something that’s probably benefit from physical therapy. Additionally, somebody that’s maybe a a little bit older, a little more a little bit weaker, they’ll probably benefit from from some therapy. And so I I rarely send somebody in the first couple weeks and then when I see them in clinic, I can kind of make a determination of, yeah, I think you might benefit from some some therapy. I think you’ll recover a little bit quicker if we get you moving and strengthening. Um, but you know, like I said, with the anterior approach and some of my younger patients really, I just tell them to get up and walk and they’re off with a walker in a couple days onto a cane off that pretty quick, too. And I don’t It is really amazing how, you know, people that can get up, you know, you you’d replace their entire hip joint like, but they can get right up right after surgery and and walk around. It’s it is amazing how quick people can recover from it.
Dr. Bryan M. Ladd: Yep. Absolutely. Um and like I said, it’s
Dr. Christopher Dickinson: I think it’s patient dependent too. It so the I always tell the people the best predictor of like your motion and strength after surgery and how you recover is going to be like the strength that you have going in. Um, and I know for some people with a bad joint, that’s hard because as as time goes on, the joint gets worse. They probably lose strength. They obviously lose mobility. And so the longer they’ve had that bad joint, the more likely they might need some therapy afterwards to kind of get things moving properly again, get the muscles functioning.
Dr. Bryan M. Ladd: Sure. One thing too and I’d be curious to get your thoughts on this uh and this is I guess more anecdotal from from what we’ve seen though we’ve been doing you know over the last year or two really we’ve done a lot of like balance and fall risk prevention and so it seems like we get people who have had a total hip but didn’t have rehab right afterwards who do fine for several years and then you get out you know you get out several years and now they’re having balance issues and that operated side is much weaker than the other side And so, um, that’s something I’ve kind of I’ve started asking people just cuz it seems like they don’t put two and two together cuz the surgery was so long ago. And it’s like, well, you had this major surgery, they cut through some muscles, you didn’t you didn’t rehab, you walked, which is fine. Maybe they’re working out in the gym, but now we’ve got all these balance issues and the hip is really weak. And so, I don’t know. I’d be curious to just see you see anything like that or what your thoughts are about it. I I feel like maybe it’s just a coincidence, too. But,
Dr. Christopher Dickinson: yeah, I feel like I have seen a little bit of that. And you know, that might be something that now that I think of it, there might be something to that where having a a posterior approach that does kind of cut into the the gluteus and yeah, you’re kind of messing around with the abductors a little bit more. I think I’ve seen some patients that have gotten, you know, five plus years out from that and they just have a little bit of weakness. No, I don’t think it’s weakness. It’s permanent necessarily, but
Dr. Bryan M. Ladd: Right.
Dr. Christopher Dickinson: Because in the anterior approach when we don’t really cut through any muscle, we just kind of go between them more or less.
Dr. Bryan M. Ladd: Yeah. Yeah.
Dr. Christopher Dickinson: So, I don’t know. I mean, I think that’s a good point. It’s it’s an interesting thought that it’s something to kind of pay attention to for me at least that seeing people ways out if they’re starting to have balance issues and their operative site is a little bit weaker. Could be that they you’re right, they just never rehabed properly.
Dr. Bryan M. Ladd: Right. Right. And some people too, I like kind of you said with with other things, it’s patient dependent. You know, some of those people just aren’t very active to begin with. And so, you know, maybe they’re they’re getting a total joint, but they’re sitting in a chair most of the day. So, that’s
Dr. Christopher Dickinson: Yeah, exactly. And I try and encourage all my patients to be active. I mean, I think like I like I was saying earlier about, you know, motion is lotion. Like, it’s still going to be that way when you have a joint replacement, too. Um, yeah, the arthritis isn’t going to come back, but you know, if you don’t use that joint, it’s just going to get weak and probably become painful and probably stiff. So, you got to use it.
Dr. Bryan M. Ladd: Yeah. Yeah. Let’s talk about total knees now, too. The recovery process for that. You know, that’s a little bit different from from what a hip looks like. And so, uh, I guess just kind of give us your philosophy on on rehab after a total knee.
Dr. Christopher Dickinson: Yeah, I feel like it’s ever changing a little bit. You know, when I was in residency, I think the push was start physical therapy as soon as possible and we got to get the motion back or else you’re going to lose it. And I think we were probably doing a little bit of a disservice to some people because we were starting to crank on their knees a little sooner than we probably should have. You know, sell a lot of my patients now. I start them with the CPM machine. I don’t know that there’s a lot of good data to support that, but I know patients like it. they just feel like it’s starting to move the joint. And I tell them that’s you can’t rely on that. You know, it’s nice to start moving the joint early, but I you really got to start firing those muscles when you’re ready. And the question is like when is somebody ready? I there’s the whole this whole quiet knee protocol that’s kind of come out recently and I don’t know that I’m following it to a tee, but I’m starting to kind of implement it a little bit in my practice. So, I tell a lot of my patients, you know, it’s extremely important the first week that you ice and elevate and you just take it easy. I want like less than 700 steps a day. You know, yeah, you can move it a little bit, but your bigger goal right now is to get the swelling to go down, the inflammation to kind of start to resolve a little bit. And then I think if you’re able to achieve that, then getting people into therapy, they just do better sooner. They’re not trying to push through pain necessarily.
Dr. Bryan M. Ladd: Yeah.
Dr. Christopher Dickinson: some of it, some of the therapy will be discomforting. But, you know, I think I’ve seen patients that have pushed it too hard with therapy a little bit early on and then have just been a little bit of a slow slower recovery. So, I think therapy is vital for knee replacements. Maybe some of my patients can do it on their own, not many. But I think that just maybe starting it a little bit later and getting them a little bit better spot in terms of the swelling and inflammation afterwards, it kind of helps set them up for success a little bit in terms of getting their motion back. I’ I’ve been pretty happy with, you know, a lot of my patients having near full range of motion about six weeks out.
Dr. Bryan M. Ladd: Yeah, I I think I’d agree with that, too. Because if you’re you know, if that joint’s swollen, it’s inflamed, we’ve got pain, and you’re just fighting against it, then you’re just you’re not really getting rid of that inflammation. It’s just staying there, and you’re it’s like this cyclical process where you’re, you know, you need to get your motion back, but it hurts and it’s swollen and now we’re cranking on it and it’s, you know, it’s it’s not helping any. So, yeah, I kind of like the idea of just letting it all calm down for for a little bit and then let’s get in there and let’s get some work done.
Dr. Christopher Dickinson: Yeah. I think like the quiet knee protocol, I think it’s really they don’t start therapy until like 2 weeks or something. You know, I want to move it in a little bit earlier than that, I think. But, you know, there’s some good data that shows, you know, people still get motion back if if they wait 3 4 weeks to start therapy.
Dr. Bryan M. Ladd: Sure. And so, I’m glad you mentioned the CPM. It’s something I always ask surgeons just because I’m curious. Everyone has a different take on it, but it seems like a lot of surgeons here still use them, and they all say the same thing that you say. It’s like, ah, there’s not a lot of data to support it, but people like it and they so let’s keep
Dr. Christopher Dickinson: Yeah. Like I’ve had a lot of patients come in and say, I I had so and so do my other knee replacement and they didn’t use a CPM, but I really like it. I’m like, and I I I give everybody the option to use it, but I also make sure I I specify that like this is not replace your therapy. This is just something to help with a little bit early on. So,
Dr. Bryan M. Ladd: Right. Right. Start getting some motion back in there.
Dr. Christopher Dickinson: Yep. Yep.
Dr. Bryan M. Ladd: What are your thoughts on prehab and getting people in, you know, strengthen it up, getting that range of motion as as good as we can before they go in for a total joint?
Dr. Christopher Dickinson: I I think, you know, I probably don’t send as many people to doing like prehab as I should. I I try to have the conversation with him about it most of the time because I do think that it makes a difference. Like the strength that you have going into surgery is just going to make the recovery that much easier. Um, you’re just going to have better muscle mass. It’s just your quad probably won’t shut down nearly as much. You know, if you have a weak quad going into knee replacement, it’s going to be a tough recovery to get that quad to wake up and then strong enough to support that knee and, you know, start getting full extension. So, I think there’s definitely a role for prehab. I always tell people the same thing. You know, if your strength strength and motion is here, like you’re going to you’re going to have you’re going to lose it after surgery regardless. So, if we can get it up here and it drops, well, we’re already above where you were before. It it does make a difference. Yeah. the surgery will certainly be a hit to it and so have you know if you’re able to increase it beforehand I think that’s helpful.
Dr. Bryan M. Ladd: Yeah absolutely. What would you say is something that patients obsess over during recovery that really doesn’t matter?
Dr. Christopher Dickinson: Swelling probably. You know I think there’s a a level of swelling that to be concerned about sometimes.
Dr. Bryan M. Ladd: Sure. Yeah.
Dr. Christopher Dickinson: And everyone’s different. Everyone’s tissues going to react differently. Some people are just more prone to swelling and particularly with knees. But, you know, I still have patients coming in at 3 months out. They’re like, “Yeah, it’s great. I’m up and doing everything I want to do, feeling good, but I still get swelling in my knee.” Like, that’s something that’s probably going to be there maybe a little bit forever because you did have surgery on that leg, but you know, it can persist for up to a year afterwards certainly. Um, now I think it’ll certainly get better in the coming months here, but and so it’s just kind of interesting that people are doing so well and they’re like, “But I still have all this swelling.” I’m like, “It’s not that bad. It’s certainly there. Yes, that knee is still a little bit bigger than the other one.
Dr. Bryan M. Ladd: Yeah. But that that’s probably the the one main thing like that aesthetic piece that you talked about earlier.
Dr. Christopher Dickinson: Yeah. And like
Dr. Bryan M. Ladd: Well, I understand you’re having a little swelling, but you’re having pain or like
Dr. Christopher Dickinson: Right. or you know people sometimes complain about like swelling or often like with knee replacement like a little bit of clicking like the feel like the it’ll pop or click a little bit. I always tell them it’s like it is metal and plastic in there. It’s pretty normal. Typically, as you develop more scar tissue in there, that’ll happen less or it’ll be less noticeable. But I I always say if you’re not having pain, it’s a it’s a good sign.
Dr. Bryan M. Ladd: So, and on the flip side of that, then what’s something that patients ignore that absolutely determines their outcome?
Dr. Christopher Dickinson: I think when it comes to knee replacement, probably working on the strength in the quad, getting that built back up strong. Yeah. you know, we we care about motion a lot because we need you to get to a functional range of motion, but I feel like sometimes people get the motion back. They’re like, “All right, I’m good. I’m done with PT.” I’m like, “I would still like you to do the exercises at home at least and keep working on strengthening that leg.” So, I often do not resurface the patella or the kneecap unless it’s truly a lot of like a lot of arthritis under it. I just think it’s hard to reproduce the exact thickness and the the mechanics of the tracking of the kneecap if you resurface it every time. And so I and for that to be for people to do well with that, I feel like they they need to build up particularly the vastus medialis of the quad to really help with that patella tracking because I have had some people that that have come back and said, “Well, my my kneecap hurts.” You know, you you didn’t resurface it. like you know we talked about maybe you would maybe you wouldn’t I kind of make the call at the time of surgery and often times I’m about 80% not resurfacing and I found that after I had a discussion with these people we get back into some therapy or they they work on building that vastus medialis muscle up and um you know they they’re able to do things like stairs get easier they’re able to get up from a seated position without having to use their arms and so I think you know there’s they’re always like well do I need to go back and have it resurface I’m like no let’s work on some strengthening I think you’re just a little weak still. And you know, a large majority of the time those people will come back and say, “Yeah, everything’s better.”
Dr. Bryan M. Ladd: Yeah. If someone wants the fastest recovery possible, what are the biggest predictors?
Dr. Christopher Dickinson: Strength going into it. The first couple weeks, like I said, taking it easy, not pushing things too hard. You know, I think like the first really the first three days are vital in terms of, you know, icing, elevating as much as you can. And that and when I say elevating, I’m like hip or knee. try to get above above the heart level. It’s harder with your hip obviously, but your knee, you know, you can lay down on the couch and prop that thing up and help with the the swelling, the inflammation. I think those are vitally important. I think it kind of sets the stage for the whole recovery. And then just protecting the incision. I use two different kind of dressings over it that are kind of both adhesive and you can sh you can shower both of them. But I think just protecting that, making sure it stays clean and dry and is that bandages are peeling off cuz the last thing you’d want is like a wound complication. That’s always like our biggest fear. Um cuz then you get into the realm of, you know, am I worried about infection or is the wound breaking down? You know, that’s all concerning stuff.
Dr. Bryan M. Ladd: Yeah. So, how much of recovery is actually surgery versus the patients putting in work afterwards?
Dr. Christopher Dickinson: I always tell people it’s a two-way street. You know, I do my job on the day of surgery, but you have to do your job in the recovery process. And unfortunately, your job is going to last longer than mine. I tell people for both hip and knee, it’s going to be a 3-month recovery. Now, you know, the first 6 weeks are going to be harder. That back half 6 weeks, things get easier. You get back to doing more your normal things. But certainly, I I try and set the stage for them that, you know, they need to be putting some effort in. Um because they’re if they don’t, you know, say their knee gets stiff or they don’t get all their strength back, I mean, like, you’re not going to like it. It it’s not going to function the way you want it to. It’ll still be sore and painful potentially. It’ll be stiff and that’s just it’s not going to work out well.
Dr. Bryan M. Ladd: Sure. Yeah. Is there anything that we haven’t talked about that you want people to know?
Dr. Christopher Dickinson: I don’t know. I feel like we we certainly covered quite a bit. Um, you know, I think the big thing is is, you know, try and exhaust all conservative treatment options when you start to develop painful joints. You know, I think cuz what we do have that it works pretty well. you know, physical therapy, bracing, anti-inflammatories, injections, those are all pretty tried and true. And then, you know, once it gets to the point where it’s none of that’s working anymore, it might be a time to have a discussion about surgery.
Dr. Bryan M. Ladd: Awesome. If people want to learn more about you, if they want to find you, how can they do so?
Dr. Christopher Dickinson: On the Des Moines Orthopaedic Surgeons website, my bio on there, um, which I think you read from a little bit earlier, a little bit about me.
Dr. Bryan M. Ladd: I did. Yep.
Dr. Christopher Dickinson: And then, yeah, that’s probably the best place to find me.
Dr. Bryan M. Ladd: Perfect. Awesome. Well, Dr. Dickinson, thank you so much for taking time out of your busy schedule. I really appreciate it.
Dr. Christopher Dickinson: Yeah, absolutely. I appreciate you having me on. It was great talking to you. Thank you.