Hip and Knee Replacement Specialist – Dr. Boghosian
Toree McGee: Hi there, I’m Toree McGee, and this is The Rapid Recovery Report, sponsored by ROMTech, the modern technology of rehabilitation. So, we’ll be doing a weekly series, this, every Thursday at 4:00pm Pacific, 7:00pm Eastern, and we’ll talk to different guests, be it surgeons or our own personal ROM star employees, as we like to call them, folks in the medical field, patients. And we’ll talk to you, and show you a little bit about our product, the PortableConnect, which is pretty darn cool, and we’ll talk about it a little bit more. It’s a high-tech recovery device that’s geared to get patients moving and recovering faster from injuries and surgeries. So, if you wanted to learn a little bit more about that, you can check us out at the social handles listed in the description below.
But today, we have a really awesome guest. I’m going to bring him on, and start the introductions here. This is Dr. Boghosian. He is an orthopedic surgeon, and specializes in adult primary and revision joint replacement on the hip and the knee. I’m going to run through your credentials here, Dr. B, so just hang tight.
He completed his fellowship training at the world renown Cleveland Clinic, where he gained extensive experience in minimally invasive techniques to treat osteoarthritis of the hip and knee. He completed his residency at South Pointe Hospital, where he served as chief resident, and after obtaining his medical degree from Lake Erie College of Osteopathic Medicine and his bachelors from San Diego State University. He’s a California guy, at heart, I think.
So, while at the Cleveland Clinic Foundation, he trained in utilizing minimally invasive techniques in hip and knee replacements, such as direct interior hip and some fastest approach to the knee. And he became proficient at computer navigation to reconstruct joints.
So, that’s the kind of exciting thing that we’re going to be talking about today. Gaining valuable knowledge and experience in managing revision cases for patients who have complicated and failed knee and hip replacements, and using that knowledge, Dr. Boghosian has kind of used his surgical skills in the arena of robotic technology, and teaches the application to fellow colleagues as well.
So, we’re really excited to be talking to you today, Dr. Boghosian.
Dr. Boghosian: Well, Toree, thank you for that. That’s a great deep introduction. I certainly appreciate that. Appreciate the invite to be on your show today. I’ve very excited about it. Thank you.
Toree McGee: Yeah, we’re looking forward to talking some high-tech stuff.
Dr. Boghosian: I’m equally excited about it. It’s been a long time [inaudible 0:03:09] chatted about this a little bit, and ROMTech is no exception to the rule, so I’m excited to have that as a part of my armory in [inaudible 00:03:16], and taking caring of our patients.
Toree McGee: Yeah, absolutely. So, just for the folks watching at home, if you guys have any questions that you would like for Dr. Boghosian to answer, go ahead and pop them in the comment section. And time-willing, we’ll get to them here when we’re done with our series of regular questions. All right, well, let’s just get started.
So, you seem to believe in a pretty high standard of technology in your practice, I mean whether that’s prescribing the PortableConnect, or using technology to execute your knee and hip surgeries. So, what drove you to learn and practice robotics in your work?
Dr. Boghosian: It’s a great question. I think it’s all about being a better version of yourself, and we kind of grow up thinking that we’re going to do something in life. And you get to that stage in life, and become a doctor, and then all of a sudden, you become a surgeon, and then you become an orthopedic surgeon, and you specialize in hip and knee replacements. It’s like one step after another. And once you’ve been doing hip and knee replacements for some years, you start to think, well, has this change much in the last 40 years? Are they doing things any different?
And fortunately, the industry has really evolved and changed the last 5 to 10 years. Robotics has really changed the nature of orthopedic surgery and how we do hip and knee replacements, which really lends for the longevity and the accuracy and the minimally invasiveness of the operation. So, for me, it’s adopting technology to help me become better than I was yesterday.
Toree McGee: I love that. I love that. I feel like that’s something that can be applied in any aspect of life, but especially in the medical capacity, for sure. So, tell me, what exactly is entailed in the use of robot-assisted surgery technologies? Can you describe the process for us?
Dr. Boghosian: Yeah, absolutely. I mean, [inaudible 00:05:02] have done surgeries, because you have to have the baseline as to what’s changed, what’s different. And say a knee replacement, because I think it’s easier to describe. If someone has a knee osteo arthritis and they have a disease in their knee that’s causing them to have bone-on-bone disease and inflammation and pain and swelling and fluid, the joint [inaudible 00:05:24].
Toree McGee: Dr. Boghosian, I think you cut off there after talking about fluid in the knee. So, we’ll wait a second to see if maybe your Internet catches back up with us.
Dr. Boghosian: How are we doing?
Toree McGee: Oh, I hear you. I hear you and I see you.
Dr. Boghosian: How about now?
Toree McGee: You’re freezing up a little bit, but I think I can hear you pretty clear.
Dr. Boghosian: Speaking of technology.
Toree McGee: I know, right? Gosh, that’s what happens when we do these.
Dr. Boghosian: Why can’t I get a good Wi-Fi signal around here? What’s going on? Well, how are we doing now? Can you hear me okay?
Toree McGee: Yeah, I hear you okay now.
Dr. Boghosian: All right. Well, I’m back on Verizon. I just got off of Wi-Fi, so thank you for that, Verizon.
Toree McGee: Okay.
Dr. Boghosian: LTE. So, in order to better understand robotic surgery, I think it’s important to understand nonrobotic surgery and the traditional way of doing surgery. So, when we think of someone who has arthritis of the knee, they effectively have a loss of cartilage on the ends of their thigh bone and the top of their shin bone, and therefore, they have bone-on-bone disease. So, really, the objective of the orthopedic surgeon is to remove that arthritis by shaving away or cutting away the ends of the thigh bone and the top of the shin bone that make up the knee. And of course, you need to replace that with something, so traditionally, what we do is we replace that with metal and plastic, and therefore, it’s a knee replacement.
Toree McGee: Sure.
Dr. Boghosian: Happen to have a little model to show you.
Toree McGee: He brought props.
Dr. Boghosian: I brought a prop, how do you like that?
Toree McGee: I love it.
Dr. Boghosian: So, this is a knee replacement. And this is, as you could see here, a femur up top, a tibia below, and then a piece of plastic in the middle. And what the objective of the orthopedic surgeon is to cut away the ends of the thigh bone and the top of the shin bone, so that we have these perfect cuts on the end of the bone, and we do that with a saw. And traditionally, what we’ve done is we make all of our measurements, and we pin guides onto the bone with pins and slotted guides through which [inaudible 00:07:32].
Toree McGee: Oh, I lost your audio.
Dr. Boghosian: Yeah, I had an incoming call. I missed a client. Okay, good. So, really, what we want to do is we want to make these cuts, and we want to make these cuts as perfectly as possible. And in the past, what we’ve done is we pin guides, and we made those cut through the guides. And frankly, the placement of those guides can provide one source of error, and of course the manual use of handheld saw can be the other source of error. And any imperfections in the process can lead to a short-term knee replacement that may fail in three, five, six years, or even sooner. And our objective is to perform the operation so perfectly with such accuracy that the knee replacement lasts 25, 30, 35 years.
So, enter robotics. And what we do in robotic surgery is we obtain a CAT scan of the patient’s knee prior to surgery. We obtain the overall alignment of the leg, because we can change and fix the alignments. Some people are bow-legged and some people are not, we can fix that. And so, once we have the overall alignment, we have a CAT scan of the patient’s knee, and we can build a three-dimensional model of that patient’s knee. Once we have a 3D model, now you put it in the computer, and you could remove the arthritis, and make all your cuts on the computer. It’s almost like CAD software or architectural drafting software, right?
Toree McGee: Yeah.
Dr. Boghosian: And you can left click, and you can rotate the femur, and rotate the tibia, and you can flip it upside down, and you could see if there’s any metal overhanging the back of the tibia. You could see exactly if your components are fitting perfectly to contour the patient’s anatomy. You could change the position, the angle of the patient’s knee. Remember, we’re not even in the operating room yet. This is computer-work still.
So, once we have all that information, and have come to the conclusion that, okay, I put this patient’s knee replacement in perfectly, I’ve done it with the robot, with 3D software, now I can enter the operating room, I expose the knee. And now, I bring in the saw and the robot, and I registered the patient’s knee to the robot. There’s a series of registration and verification, which takes about 10 to 15 minutes. Once I do that, the robot knows exactly where this patient’s anatomy is at all times during the operation. There’s a saw attached to the robotic arm of the robot. And once I click the trigger on that saw, the saw comes in, and angles itself to the perfect angle, pitch, and direction to which I want that cut made, based on the plan that I dedicated previously.
So, all I do, as a surgeon, is I do the surgical exposure. I open up the knee, so that the robot can get in. And then I click the trigger, and once I’m holding the trigger, the robot sets the direction, the angle, the depth of cut, and the pitch of the blade.
Toree McGee: Holy cow, that’s incredible.
Dr. Boghosian: There’s some videos on the website, on my website that show exactly how these things work. And it’s pretty amazing, and people come in the operating room to learn the stuff all the time, and when they see this kind of happen, it’s always an eye-opening experience, because it’s pretty cool to see the robot just put that saw on the exact spot.
Toree McGee: Yeah, it’s like autopilot.
Dr. Boghosian: It becomes autopilot. It really does. And it highlights the accuracy of the robot when you take the patient’s leg, and you move the patient’s leg a half a centimeter, and you see the robotic arm and the robotic saw move literally simultaneously as the robot adjust the position of the leg. There’s no delay. There’s no lag time. It’s happening instantaneously.
So, what that allows us to do is that allows us to make these cuts absolutely perfectly. And by doing that, you improve the longevity of the implant, you improve the accuracy of the placement of the implants, so there’s no overhang, there’s no metal touching skin, I mean tendons and so on. And then, you also improve the ability to do the operation in a less invasive way.
Toree McGee: That’s amazing thing.
Dr. Boghosian: And we’ll probably going to talk about minimally invasiveness with how it relates to robots here in a second, so I’ll leave that for later.
Toree McGee: It’s like you know what I’m going to ask. So, we’ll come into that then in a little bit. I mean, you kind of already answered this, but I mean, is robotic surgery better than traditional surgery, in your opinion, for knees and then for other, I guess, surgeries as well?
Dr. Boghosian: Yeah. I mean, I actually think it is. If I was having a knee replacement or a hip replacement today, yeah, I would want it done robotic, because it improves the accuracy, minimally invasiveness, the recovery process, and the longevity of the implant. So, we’ve come a long way, if you think about the last 40 years or 50 years hip replacements and knee replacements have been performed. And I think that the incremental changes that had happen decade-over-decade had been rather minimal, some nice improvements, particularly to the implants themselves, but never before have we seen such an acceleration in the technology of how to place these components, which is where robotics came in.
Toree McGee: That’s amazing. I mean, I’m in your boat. Now, you sold me on robotics completely, sold, done, if I ever I need a surgery.
Dr. Boghosian: I hope you won’t need a knee replacement or hip replacement any time soon though. You look too young for that.
Toree McGee: If ever I need a surgery, I’m always going to ask, is there a robotic option, because that’s what I want. So, how long were you in practice before utilizing robotics?
Dr. Boghosian: So, I started my practice in 2010, and right out of the gate in 2010, robotic knee replacement surgery was available for the purpose of doing partial knee replacements only.
Toree McGee: Interesting.
Dr. Boghosian: Yeah, it wasn’t until later that Stryker bought the company, the company being called Mako. Stryker bought Mako sometime later, and then they developed the total knee and total hip platform. So, that’s been around for probably 4 to 5 years, and significantly adopted with regards to its use in the last 2 to 3 years. And I’ve been using it now for about three year.
Toree McGee: And I’m sure there’s just, I mean, a night-and-day difference in traditional versus robotic surgery.
Dr. Boghosian: There is.
Toree McGee: Does it make it a faster process? Are patients on the operating table less time?
Dr. Boghosian: No.
Toree McGee: Okay.
Dr. Boghosian: No, it’s actually a little bit longer, because there’s a registration process where you have to tell the robot where the patient’s anatomy is, and frankly, that takes a few extra minutes, but we’re talking single-digit minutes to 10 to 12 minutes. We’re not talking an extra hour.
Toree McGee: Got it. Okay.
Dr. Boghosian: And you bring up a good point, because most patients think that a knee replacement takes 3, 4 hours. Well, it doesn’t. A standard knee placement without robotics could take me about 35, 45 minutes. And then a robotic knee placement maybe takes 45 minutes to an hour. But keep in mind that, I’m not trying to brag, but that’s all I do, right? So, I’m a two-trick pony. All I do is knee replacements and hip replacements. So, we at Eisenhower have fine-tuned the system, so that we have the same surgical techs, we have the same anesthesiology team, we have the same, in my case, physician assistants. We have the same processes being repeated over and over and over and over and over again.
So, if you think about the model of efficiency, and you take for example Tesla, and they’re building cars left and right. They’re not reinventing the wheel every time, right? New patient comes in, you do it the same way you always do it. My surgical tech team knows exactly what instrument I need next, and they put it in my hand. I’m not looking back, asking, no, no, I want that one on the back table. So, the process is extremely efficient.
Now, there are places where it might take them two hours or three hours to do a knee replacement. That’s not necessarily a bad thing, but we’ve finetuned that process so much that it’s about an hour or under an hour per operation.
Toree McGee: Wow, that’s amazing. I mean, you can just assembly-line them, put them up, and knock them down.
Dr. Boghosian: Yeah, it’s bad to think about it that way, because you don’t want to think of your patients as Tesla cars, that’s not our goal, but—
Toree McGee: But at the same time, being able to help as many people as quickly as possible, because if you need a knee replacement, you don’t want to be putting it off, and living with issues and pain.
Dr. Boghosian: That’s the key. The key is trying to help as many people as you can.
Toree McGee: Yeah, absolutely.
Dr. Boghosian: And doing it well, so that these implants last a long time, and they’re not coming back two, three years later with a knee that doesn’t work anymore.
Toree McGee: Right, absolutely. What a difference, I’m sure. So, as a surgeon who’s fully embraced technology, in your opinion, has prescribing the PortableConnect complemented your use of robot-assisted surgeries, and how if so?
Dr. Boghosian: Yes. So, I adopted PortableConnect fairly soon after robotic surgery became a standard of my practice, so the two kind of go hand-in-hand, right? And I’ll tell you, before robotics and before PortableConnect, patients were coming to the office, and they say, “Oh, Dr. Boghosian, you’re a miracle worker, my knee replacement is working beautifully, the recovery was great,” yada, yada, yada. And now, I don’t hear that very often. Here’s what I hear, I couldn’t have done it without the bike.
Toree McGee: Well, I’m sorry to steal your thunder there.
Dr. Boghosian: It’s okay. You know what, it’s okay. If the patients are coming in, and they’re doing great, that’s all I care about, right?
Toree McGee: Right.
Dr. Boghosian: But literally, they come in, and the two comments I hear are either about how great robotic surgery was, and led to their rapid recovery, which I’m sure it did, or how great the PortableConnect was, and how quickly it led to their rapid recovery. Frankly, I don’t care, right? As long as the patients are doing well, that’s all that matters.
Toree McGee: Oh, my goodness. Well, just know that you are well loved, and it’s not just because of the PortableConnect, I’m sure.
Dr. Boghosian: That’s right. They really do. They tell me that all the time. It was just yesterday, I had a patient and his wife. I did a hip placement on him about a month ago, and I did a hip replacement on his wife, and I think it was August. And they might actually be watching this, because I told them about this webinar yesterday. As they were walking out of my office, the wife stopped, and she said, “You need to don’t understand that you’ve completely changed our lives.” And I said, “Well, that’s great, I appreciate that, how do you mean?” And she said, “We are very active people, and for about two, three years, prior to my hip replacement and his hip replacement, we haven’t walked, we haven’t hiked, we haven’t played tennis, we haven’t played pickleball, we haven’t done much. Our grandkids haven’t seen us, because when we do go to see them, it hurts so bad to physically play with them that we tend to not go as often.”
And I could see her getting emotional, but she didn’t quite cry, but I could see like glassy eyes that I really have an effect on these people’s lives. And there’s no reward in the world that can amount to that. It’s pretty amazing.
Toree McGee: Oh, that makes my heart so happy to hear.
Dr. Boghosian: Makes us happy to hear all the time, yeah.
Toree McGee: Yeah, I love it. Let’s stop Talking about it, because otherwise, I’m going to go. All right, so in your opinion, what role do you feel that robotic surgeries will play in the future?
Dr. Boghosian: I think we’re in the infancy of robotic surgery. I mean, if you think about where we’ve come in the last 10 years, it was partial knee replacements only, and then total knee, total hip. Right now, we do very little revision work with robot, but I think in the future to come, I have a young boy who’s five years old, I’ll tell you, I don’t think conventional surgery is going to even be an option when he’s my age or practicing if he chooses to go on orthopedic surgery. The technology is advancing pretty rapidly, and I think we’re going to get to the point where not only does it improve accuracy, but it significantly improves recovery and minimally invasiveness.
Toree McGee: Is there a surgery, I guess in your opinion now, that would benefit from robotics that the technology is not quite there yet?
Dr. Boghosian: Yeah, revision surgery. In my field, it’s revision surgery, yeah, absolutely. I mean, revision surgery, and by that, I mean for your viewers, is it’s when you’re taking out a knee replacement that was put in 10, 15, 20 years ago, or hip replacement that was put in 20 years ago, and has failed for whatever reason or not. And to be able to do it robotically, and that’s where I think you have the best opportunity to improve accuracy and placement, because revision surgery, it’s one of those situations where accuracy is the most important thing, because you could do a revision operation, say hip revision for someone, and although you intend for it to last another 20, 30 years, they never do. A revision operation for a hip is going to last half for a third as long as the original operation. So, if you can improve the accuracy and the placement of those components, you can potentially improve the longevity, and making it hopefully the last revision for that patient, not the first of three or the first of four.
Toree McGee: Yeah, for sure. So, talking then about recovery and I guess longevity of knees after a revision or a replacement, how has the PortableConnect shaped patient recovery? And what did recovery look like before?
Dr. Boghosian: One of the most challenges things for patients to obtain in the early postoperative period, say particularly around the knee placement, is the concept of co-contraction, right? So, in co-contraction, you have your quads and your hamstrings. And when you’re fresh out of surgery, everything wants to tighten up. They want to contract at the same time. And when they do, they’re opposing each other and they’re fighting each other. So, the knee tightens up, the joint tightens up, the pain increases, the swelling increases, the inflammation increases. And what would you or I do if we’re laypeople, and both sides of our joints were tightening up, and both sides of the muscles are tightening up? We’d freeze.
Toree McGee: Right.
Dr. Boghosian: Right. You’d freeze. You’d sit down. You’re like, oh my God, I’m not going to move it, because it hurts to move. And when I move it, my quads fire and my hamstrings fire, and it hurts. So, that’s the early phase of recovery, and patients really struggle with that. Traditionally, the first two weeks of a knee replacement are the most miserable. I tell my patients, it’s not a cakewalk, be prepared, it’s going to hurt like hell for two weeks. And after two weeks, it gets a lot better. And I found that patients who have the PortableConnect, because it allows them that passive range of motion, they basically get on the bike, and the bike is doing all the work for them, the muscles are relaxed. And so, they’re moving, and as they’re moving their knee and they’re moving their joints, and they’re circulating the blood in their vessels and so on, they start to realize, okay, I don’t need to be so tight, I don’t need to stiffen up. Let the machine do the work for me.
And I’m talking six hours after they get home from an operation. I’m not talking about four days later. Four days later, they’re doing passive assisted. So, it’s passive, passive assisted, and then active. Those are the three ranges of motion that ROMTech provides them.
So, in that early phase, you just put your feet on the pedal, and the pedal is doing all the work for you. And when it’s doing the work for you, you’re moving that joint. And by moving that joint, you’re stretching and relaxing those muscles, and you’re allowing them to return back to their normal state.
Toree McGee: Yeah, things that I wish my Peloton would do, and keep me in shape.
Dr. Boghosian: Yes, right, I do it for you.
Toree McGee: If only. Maybe one day we’ll get robotics for me to be in really good shape, but as for now—
Dr. Boghosian: Maybe ROMTech should buy Peloton, and see if they can come up with something.
Toree McGee: I wish. That’d be great.
Dr. Boghosian: Yeah.
Toree McGee: Well, it’s funny in the comment section, we’ve got absolute game changer. And it’s true. I mean, robotics and the PortableConnect, especially in tandem, are game changers in the realm of lower extremities, and especially in knees. So, I have one last thing here. I know we heard that there were some big news coming out of Eisenhower this June, so can you expand on that a little bit, so our audience knows what’s up?
Dr. Boghosian: It’s been a long time in the making, oh my God. So, Eisenhower Medical Center in Rancho Mirage is a wonderful hospital, top-notch, one of California’s best hospitals, and they are and have been for the last 2 1/2 years or so are building a huge expansion on the orthopedic program. So, we took our little Desert orthopedic center office, and we’ve expanded it both in the north and south directions, and built this, I think it was like $70 million or $80 million expansion.
Thanks to our donors, by the way. We have many donors that help to make it a reality. And talk about state-of-the-art, talk about technology, I mean this is just incredible. The amount of technology in those operating rooms just supersedes anything. And I’ve traveled Cleveland Clinic, Mayo Clinic, Hospital for Special Surgery. I’ve seen in one fashion or another some of these huge institutions that have all the money at their fingertips, and all the technology at the fingertips. And Eisenhower’s purpose when developing this, they wanted to future-proof this or future-proof it as long as they can, and they did exactly that. I mean, the amount of technology in those operating rooms are just mindboggling.
And I’m so excited. Come June, it opens up, and we can start operating there. It’s a very exciting time.
Toree McGee: Well, that’s fabulous. Maybe one day, we’ll be able to do an on-location one of these, and you can give us a tour. It’d be so much fun.
Dr. Boghosian: That’ll be great.
Toree McGee: I’d love to take a trip down to Southern California, and see you.
Dr. Boghosian: Would love to have you, any time. Actually, don’t have any time. Don’t come in August.
Toree McGee: No, okay, that’s fine.
Dr. Boghosian: No, don’t come in August. Chances are, I may not be here much.
Toree McGee: Fair enough. That’s fair enough. Well, thank you so much, Dr. Boghosian, for taking your time and chatting with us. Thanks for bringing props, that actually really helped somebody who’s never been in the operating room myself, to kind of see what it is that you do, so we appreciate it.
Dr. Boghosian: Absolutely. Toree, thank you for the invitation. I appreciate it. It’s been a wonderful experience.
Toree McGee: Of course. And thank you to everybody who’s watching, commenting. Feel free to share it with your folks, and reach out to Dr. Boghosian if you’re looking for a knee or hip replacement in the California area. He’s your guy. Feel free to check us out at www.romtech.com. Follow and subscribe to our socials, so that you can be up to date on all of the exciting things that we’ve got going on. Remember, we do one of these every week. Thanks so much you guys for hanging out with us, and we’ll see you next time. Bye-bye.
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