Worries about AI; a treatable heart condition; fixing injured joints: Upstate Medical University's HealthLink on Air for Sunday, Jan. 24, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a bioethicist discusses the use of artificial intelligence.

Serife Tekin, PhD: ... Ethicists and scientists have to talk to each other and move hand in hand to foresee unintended consequences and unintended effects and harms of these technologies. ...

Host Amber Smith: A cardiologist explains diagnosis and treatment of cardiac amyloidosis.

Cynthia Taub, MD: ... We need to diagnose them and hopefully treat them early before they go down to end-stage heart failure realm. ...

Host Amber Smith: And an orthopedic surgeon tells about joint replacements that are necessary after traumatic injury.

Zachary Telgheder, MD: ... If you think of the hip as a ball-and-socket joint, it's relatively common, especially in patients over the age of 50, to break right below where the ball is. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn about cardiac amyloidosis. Then we'll hear about joint replacements after injury. But first, we'll explore some of the ethical concerns with artificial intelligence.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Computers and machines these days perform more and more cognitive functions that we associate with human minds. This rapidly advancing technology is known as artificial intelligence, or AI.

For help understanding the ethical concerns tied up with AI, I'm talking with Dr. Serife Tekin. She's an assistant professor of bioethics and humanities at Upstate.

Welcome to "HealthLink on Air," Dr. Tekin

Serife Tekin, PhD: Thank you, Amber, for having me.

Host Amber Smith: Whether it's used in medicine or in other fields, AI depends on massive quantities of data and software with complex programming and mathematical algorithms.

Do these or should these algorithms follow the "do no harm" oath that physicians take when they enter the profession?

Serife Tekin, PhD: That's a great question, Amber. In so far as the "do no harm" oath or the primary ethical principle that guides medical practices, it's hard to say whether AI does follow because there's no centralized system that is behind AI. So when we talk about learning things like "do no harm" principle, we assume that there's an agent, there's a human person, there's some rational being that is contemplating what they're about to do and assessing its consequences and then deciding accordingly.

While AI tools provide us with a lot of tools to kind of analyze data, maybe calculate potential consequences or outcomes of that data, it is not centralized in a way that will make a cost-benefit analysis to anticipate and prevent that. And that's what we have in human intelligence, and I guess, contemporary research and artificial intelligence is trying to make AI make these self-governing decisions, but we are not quite there yet.

Host Amber Smith: That's a good point I mean, there's a multitude of people that are embarking into AI or already using it in some ways, but no centralized authority telling them the rules of the game, really.

Serife Tekin, PhD: Absolutely. Absolutely.

Host Amber Smith: Well, let's talk about some examples of how AI might be able to improve care for patients.

Serife Tekin, PhD: This is great. Let's start with the positives. So, contemporary health care is very complicated to navigate, especially in the context of United States, right?

So take an ordinary patient, and they want to see a dentist. So they need to find a dentist that might take their insurance that might be able to address their particular problem. So if you just need cleaning, that's a different story. But if you need a more complex procedure, you need to make sure that the dentist will be able to provide you with the services that you need.

So I think there's a great kind of use here for an artificial intelligent technology that might match patients' needs with available providers, according to their particular insurance. And help us kind of come up with a dentist, who's available, who's receiving patients; that will give us what we need. So I think that might be a good use. And I know that there are some technologies that do that in the context of mental health that matches the patient with a provider who might meet their needs. So I think these kinds of, I call it, like, the facilitator roles, are good places for artificial intelligence technology.

Host Amber Smith: So that could replace the dozens of phone calls a person would previously have to make, calling each dentist they could find in the Yellow Pages and just seeing if they take their insurance and if they can help them. And that would be a huge time saver, it sounds like.

Serife Tekin, PhD: Exactly, exactly. I'm a fan of using technology in this way.

Host Amber Smith: Are there ways that you've looked at that would be helpful to medical providers?

Serife Tekin, PhD: Yes, and I think we can first generally talk about AI's ability to help patients track their experiences, their symptoms, whether it's psychological or even physical. So something like maybe diabetes might require the patient really overseeing their blood sugar levels and how the insulin works and so on and so forth.

And I think, insofar as medicine is increasingly trying to be patient centered, that kind of data becomes extremely important for the clinicians, for the providers, just to see what the patient has been up to in the months that they haven't seen them. And as you know, we have a very big scarcity issue in medicine in that we simply do not have enough providers that could meet the needs of patients.

So if we can, again, use artificial intelligence technologies to track patient behavior or patient experience in the kind of off-clinic time, that might help assist in the clinical context in a way that I call "triangulation" -- so the AI, the patient and the provider, they can come up with a diagnosis of patient's progress and then make decisions as to what else they can do in the next stages of treatment.

So I think it can be helpful for clinicians, through that.

Host Amber Smith: So it wouldn't replace the doctor, but it would augment or help them. It'd be a tool for the doctor to kind of keep track of patients.

Serife Tekin, PhD: Precisely, especially at this stage of AI's applications in medicine, where unknowns and uncertainties are definitely a lot higher, a lot more, than the knowns.

Currently, I think it's an ethical obligation also to use AI as a supplement to the provider instead of a replacement.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking to Dr. Serife Tekin. She's an assistant professor of bioethics and humanities at Upstate, and we're talking about artificial intelligence, or AI.

So let's look at some of the ethical worries. Will AI be reliable?

Serife Tekin, PhD: Question of reliability is very important, and we can think about reliability of science in two senses. One is our reliability of our treatment methods over a large population, right? A lot of advances in medicine happened not because they successfully treated one patient, but the results were replicable over a group of patients.

And then we decided to, say, use vaccines or use medications that can be available to a large number of people, large group of people. It's up in air currently whether AI has that kind of reliability, simply because medical applications have not been replicated to help us draw a generalization as to whether they can help with a large group of patients, right?

And that brings a lot of ethical questions. If the medical applications of artificial intelligence have not proved their scientific reliability, is it then ethical to start using them to treat patients simply because we don't have enough research?

That brings me to the other important ethical layer. We talk in medicine of unintended consequences or unprecedented risks. So in certain medical conditions that do not have solutions, it might make sense for the clinician to turn to AI and try an experimental method of intervention.

And we do that in cancer treatment a lot. We have a lot of experimental interventions that we don't know the consequence yet, but the patient is in really late stage, things don't look good for them, so we give it a try and use this experimental method. In that sense, risks are not that high because the patient is already in a vulnerable situation.

But with AI, there are lots of treatments that have not proven their effectiveness, yet they're being pitched as the next breakthrough intervention. And I worry that if these kinds of treatments are replaced by other existing and maybe more effective treatments, we might be doing more harm for the patient than good.

So, I think, in this sense, ethicists and scientists have to talk to each other and move hand in hand to foresee unintended consequences and unintended effects and harms of these technologies.

Host Amber Smith: Who would be accountable when AI gets it wrong?

Serife Tekin, PhD: Currently, no one. In fact, there are some in my area of research, in mental health ethics. I have been looking at certain apps that provide, in quotation marks, "psychotherapy" to patients where there's no agent. Again, it's just a complex algorithm, an AI, that's driving that kind of app. And some of these apps have made recommendations to patients that actually are extremely dangerous and harmful, and there was no one to look up to.

And especially when we think of teenagers, for instance, using these kinds of apps, where there's no adult involved, there's no mental health provider involved, when things go wrong, usually the company, that's often a private company, profit-making company, who's developing these apps, they pull their product out of the market, but the harm is already done. And it's unclear how patients or people who are negatively affected by this could pursue action against those, especially when your health is declining. Any kind of compensation or lawsuit that you'll get, I mean, that's not going to bring you any concrete health-related results.

So, that's a huge question.

Host Amber Smith: Well, I think in theory, AI is meant to get better over time. It teaches itself, or it learns more as the more it goes. But do you have any concerns about it picking up, I don't know, our bad habits, learning to discriminate or developing inherent biases?

Serife Tekin, PhD: AI is not a miracle, right? So it's looking at the way humans think, the way humans produce knowledge, the existing knowledge that we produce, right? So it's all about our practices. That's the raw data for AI. So whatever failures that we might have as humans will also get translated into AI.

I always give my students examples of, like, hiring practices, right? AI learns to make a decision to hire the next CEO of the company based on existing CV's (résumés) by looking at past hiring practices that we have used. So let's say some random factors like people with glasses (laughs) have been, over time, chosen as the CEOs. This is not necessarily a thing that we would put in the qualifications of the CEO that we are looking at, but AI is intelligent in kind of crunching data that might pick out that information and might choose our next CEO based on whether or not they have glasses, and that would be not credible.

So in that sense, I think AI is not going to change our bad habits or correct them. In fact, it might perpetuate some of those bad habits because it feeds back into the system at the end. So we have to be careful about that.

Host Amber Smith: Can we teach AI to distinguish the bad information from the good-quality information?

Serife Tekin, PhD: I want to believe that, except that we do not as humans have an agreement on what good information and bad information is. And this is why I think there's no running away from AI, and we should embrace it, but we really need to work together with computer scientists, humanities scholars, ethicists, hand in hand, because a lot of engineers who are behind designing these apps are not necessarily informed about how we think about distinguishing good science, good scientific research or good information from bad information. Maybe social scientists or humanities scholars might be more trained about that. So I think if we engage in a conversation and collaboration between different stakeholders, different kinds of experts, as we are engaging in AI research, we might be able to control some of the potential harms that this technology might generate.

Host Amber Smith: It seems like a really scary time, like the machines are about to take over the world. Do you see it that way?

Serife Tekin, PhD: I'm not as pessimistic. In the history of science and technology and medicine, actually, you see these kind of inflection points, where there's like this big invention or big thing, and everybody gets so enthusiastic about it. We stop talking about anything else. And then that enthusiasm fades as people are disappointed a little bit, right?

So I think right now, when we are in that like boom, explosion, period, and a lot of people are paying attention to it and engaging with it, and it does look like they might take our jobs et cetera, et cetera.

But I think it will stabilize, and we will maybe learn to understand that there are different contexts in which AI can help us and maybe replace some of our jobs. But it will require a high level of human engagement and human component. So I'm not, I guess, as worried yet.

Host Amber Smith: Just because we can train machines to think like humans, does that necessarily mean that we should, and what do we need to think about before we do?

Serife Tekin, PhD: I think it's really important to rethink what it means to be a human. So, yes, we are mostly reasonable, responsive, rational beings, and calculation, language, thinking are our important capacities, and that's what we seem to be trying to make AI like, right? Like us, intelligent like us. But on the other hand, we're intrinsically embodied and social beings, right? We have physical bodies, flesh.

We do not have, like, automatic car parts, right? We live in communities, we touch each other, we talk to each other, we engage with each other, and I think a lot of our intelligence emerges from this very embodied and social nature of human beings, which is unclear whether that could be replicated in the context of AI. They are not flesh, like us.

Host Amber Smith: Well, very interesting. I appreciate you making time for this interview, Dr. Tekin.

Serife Tekin, PhD: Thank you so much for having me.

Host Amber Smith: My guest has been Dr. Serife Tekin. She's an assistant professor of bioethics and humanities at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

The challenges of diagnosing cardiac amyloidosis -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Today I'll be talking about a cardiac condition that can lead to heart failure, but could be treatable if diagnosed early with cardiologist, Cynthia Taub. Dr. Taub is professor and chair of medicine at Upstate, and her specialty is echocardiography and cardiac imaging with a special interest in cardiac amyloidosis.

Welcome to "HealthLink on Air," Dr. Taub.

Cynthia Taub, MD: Thank you, Amber. I'm delighted to join you today, and I'm excited to talk about cardiac amyloidosis.

Host Amber Smith: Well, let's start with a description of what cardiac amyloidosis is.

Cynthia Taub, MD: Well, first off, let's talk about amyloidosis. It is a systemic disease affecting many organs in the body, such as the heart, kidney, lungs, joints, and the brain. Talking a little bit about the history, I found this really fascinating: Dr. Rudolph Virchow, in 1854 -- so that's about 170 years ago -- introduced a term, amyloid, to describe a peculiar staining on brain tissue. He believed that what he saw must be starch. As it turned out it was not starch. It was misfolded protein.

So what does it mean, by misfolded protein? Think about a Swiss army knife. When it is nicely folded, it's harmless. However, when it is misfolded, some sharp edges are sticking out. When depositing in tissues in the body, misfolded Swiss army knife becomes toxic and damaging to the entire system.

So I just first talk about the amyloid, per se, but let's focus on cardiac amyloidosis.

Host Amber Smith: Well, let me ask you: You use the term "misfolded." What causes the proteins to be misfolded?

Cynthia Taub, MD: There are many reasons. It depends on the reasons for amyloidosis. That goes back to describing different forms of amyloidosis.

One is a misfolded protein, transthyretin amyloidosis. People call it ATTR amyloidosis. And the protein is made from liver. And the connection between these protein units can become unstable. Therefore they can be misfolded. And another form is from plasma cell, which makes immunoglobulin light chain amyloid. We call it AL amyloidosis. And that immunoglobulin can clump together, leading to the misfolding.

So these are the two bigger picture of precursor proteins, but among the transthyretin protein misfolding, there are two other reasons, to answer your question. One is because of aging. When we age, these protein can become more prone to misfolding. Another is hereditary, familial TTR of protein misfolding. We can talk a little more on that later.

Host Amber Smith: So this is an inheritable disease, or does it ever just develop on its own without a past history in the family?

Cynthia Taub, MD: Oh, there are wild types, meaning without family history. As you age, you might develop misfolding of the protein. But, a number of mutations can be transmitted through family tree and causing these hereditary misfolding of the protein. And so far more than 140 genetic mutations have been identified that may contribute to the misfolding of the protein. In the genetic mutations, I think it's important to mention thatone of the mutations -- V 122 I, you don't have to know exactly what it means -- but there is a substitution of valine by isoleucine. These forms of mutation were found in 4% of African-American population in the U.S. So we need to identify these mutations and make early diagnosis of vulnerable population that may develop cardiac amyloidosis.

Host Amber Smith: How common is cardiac amyloidosis compared with other heart diseases?

Cynthia Taub, MD: Yeah, that is an intriguing question. Twenty years ago I became aware of cardiac amyloidosis, and it was called a "zebra" -- it was considered very uncommon. And now when you look around, they're "horses" -- if you see them. You have to be aware that they exist.

So, let me give you some numbers. So the ATTR cardiac amyloidosis was found in up to 16% of patients who need aortic valve surgery for aortic stenosis. And these patients are from 80 to 84 years of age. So as you age, as you survive to your golden age, there are a lot of patients who might be affected by cardiac amyloidosis.

And in addition, you know, heart failure is a huge problem in the U.S. Health system, affects many, many, patients. And in older patients, older than 82 years of age, 13% of these individuals who suffer from heart failure with normal ejection fraction are found to have cardiac amyloidosis. And what does it mean? A heart failure with normal ejection fraction? The hearts squeeze well, you know, normal ejection, normal squeeze. But they can't relax, because the amyloid fibrils deposit in the heart, making the environment too crowded to relax.

So when patients have symptoms of heart failure, and when you take an echocardiogram, your doctor says, "OK, the heart squeezes. Wow." But what's the reason to cause heart failure? Consider cardiac amyloidosis. Before, in the past, we didn't really have the awareness, so we didn't do the screening.

Another evidence I can tell you, Amber, in several postmortem studies, patient died and their hearts were looked at. It was noted that 25% of these older individuals have amyloid buildup in their heart. So all these data suggest in the aging population, in the current era, we are dealing with patients who might be affected by cardiac amyloidosis. We just need to have awareness. We need to diagnose them and hopefully treat them early before they go down to end-stage heart failure realm.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Cynthia Taub. She's a cardiologist and professor and chair of medicine at Upstate, and we're talking about cardiac amyloidosis.

Let's talk about how this is usually detected. You described, it sounds like, some people have this but don't know it, and it's just discovered incidentally when they have other medical procedures. Are there symptoms that someone might have that would bring them to the doctor, and this would be discovered that way?

Cynthia Taub, MD: Yeah. These patients with amyloidosis tend to have very non-specific symptoms. They might have fatigue, weakness, shortness of breath. Who doesn't have fatigue, right? And they used to have a high blood pressure, and later on they notice they don't need to take blood pressure medications. And they might develop orthopedic problems, bilateral carpal tunnel syndrome, spinal stenosis, numbness, pins and needles (feeling in) their foot and fingers, sensation, those polyneuropathies that we described. These patients tend to see at least five specialists, trying to figure out the mystery. And then once you see the right doctor who has the awareness that they were able to put together the diagnosis. And the delay of diagnosis can be very long, five to 10 years. Again, awareness is important, and the symptoms can be quite nonspecific.

Host Amber Smith: So do physicians, primary care doctors, do they refer patients to Upstate's cardiac amyloidosis clinic to get diagnosed, or do they get diagnosed and then they get sent to the clinic?

Cynthia Taub, MD: I have to say when I first arrived here, I noticed that there was really no good pathway for physicians to refer patients to make diagnosis. And thanks to Dr. Mary McGrath from the nuclear medicine department who spearheaded the PYP (pyrophosphate) scan -- that's a nuclear scan that can pick up signals in the heart that's been infiltrated by amyloid fibrils. And this service is the first for the city of Syracuse. And patient doesn't have to travel to Rochester to get the diagnostic testings done. So this is progress I envision in the next few years: Upstate will become a center of excellence for the diagnosis and treatment of cardiac amyloidosis.

Currently, it takes astute primary care physicians, orthopedic surgeons and hematologists to refer patients to cardiologist for the diagnosis and potentially treatment of cardiac amyloidosis. We're far from perfect. We're still trying to make sure our pathway is being worked out. The goal is to provide the best patient care possible for early diagnosis.

Host Amber Smith: Well, let's talk about treatments. What treatments are available?

Cynthia Taub, MD: The No. 1 thing is treatment of heart failure. That's very important,- heart failure management -- decongestion by diuretics, beta blocker, ACE inhibitor, SGLT2 inhibitor, people have heard of some new kids on the block -- Jardiance (the drug empagliflozin) -- and manage atrial fibrillation by blood thinners, by beta blocker, by ablation sometimes. And the new medication that employ advanced biotechtechnology are transthyretin (TTR) stabilizers. An example is tafamidis. That medication can reduce patient's heart failure hospitalization and improve survival.

And there are other medications, such as silencers, a (a genome editing tool), CRISPR technology- facilitated medication that can help our familial amyloidosis patients to manage their neuropathy. So these are all exciting new medications on the horizon that we look forward to prescribing them to our patients and help their symptoms.

Host Amber Smith: Do any of these new treatments or medications, do they work on the protein that is misfolded, that is at kind of the root of all of this? Are there any treatments that can reverse the damage?

Cynthia Taub, MD: Very good question. Right now these medications are used to slow the progression of disease. We don't really have enough data to say that we can reverse disease. Of course, if you make the diagnosis early, you are hoping that the damage is not done yet; we can reverse disease.

You know, this is something that I would love to think about. I was at Dartmouth, and we had a very thoughtful hand surgeon who performed carpal tunnel release surgery. And we formed a team, a multidisciplinary team, where every time he had a suspicion of amyloidosis where patients have bilateral carpal tunnel syndrome, spinal stenosis, men older than 50, women, older than 60, and they come to his operating room, and he would take a little biopsy. And if there is amyloid deposition on the biopsy, he would refer these patients to me.

OK, so 25% of these biopsies were found to have positive amyloid deposition. And several of these patients don't even have cardiac involvement. So most of these patients, when they get referred to me, they already have evidence of cardiac involvement, but some of them did not have cardiac involvement.

What does it mean? We are capturing these patients early. They have amyloid deposition in their tendon, in their bones, but they haven't reached a point it will affect the heart. So can we use our treatment early to stop the deposition of these amyloid fibrils to the heart? Can we do that? Right now, FDA (Food and Drug Administration) has not approved this indication, but we're hopeful with clinical trials, with research, we're able to answer your question, Amber.

Host Amber Smith: Well with the treatments that are available now, if you're able to slow the progression for someone, have you seen that help people? Do their symptoms get better?

Cynthia Taub, MD: Oh, absolutely. That's why FDA approved the medication tafamidis. They've tested this medication in patients with symptoms. You have to have symptom before you can start the medication. And after six months, these patients feel much better, and there's fewer hospitalizations for heart failure, and these patients live longer.

You know, years ago when I learned about cardiac amyloidosis, once you have the diagnosis, your survival, it is six months, and now you know, people live five years after diagnosis, or even longer.

Host Amber Smith: Well, I appreciate you making time to tell us about it, Dr. Taub.

Cynthia Taub, MD: Oh, it's my pleasure.

Host Amber Smith: My guest has been cardiologist Cynthia Taub. She's professor and chair of medicine at Upstate, where she leads the cardiac amyloidosis clinic. I'm Amber Smith for Upstate's "HealthLink on Air."

"Next on Upstate's "HealthLink on Air" -- joint replacement surgery after traumatic injury.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Sometimes after a traumatic injury, people may be recommended to have a joint replacement. I'm talking about what's important to know about these surgeries with Dr. Zachary Telgheder. He's an orthopedic trauma surgeon at Upstate, where he's an assistant professor of orthopedic surgery.

Welcome to "HealthLink on Air," Dr. Telgheder.

Zachary Telgheder, MD: Thank you for having me, Amber. I'm happy to be here.

Host Amber Smith: Now, which of the joints are most commonly affected by traumatic injuries?

Zachary Telgheder, MD: Almost any joint in the body can be affected by a traumatic injury. We see, very commonly, fractures around the hip, especially in the elderly population and especially this time of year, in the winter. We see fractures involving the joints around the knee and the ankle very commonly as well.

A little less common, but still a large part of my practice, are fractures about the shoulder and elbow as well. And then a lot of the fractures around the wrist and fingers are taken care of by orthopedic hand surgeons.

Host Amber Smith: How are these type of joint replacements different from the regular scheduled joint replacements?

Zachary Telgheder, MD: So a joint replacement after a traumatic injury is a little bit more difficult and a little more complex than, say, a standard joint replacement for something like arthritis. We do both joint replacements acutely at the time of the injury as a definitive method of treatment to help treat, say, a fracture on the hip with a hip replacement in the patient who's appropriate for that.

And occasionally, part of my practice is treating the post-traumatic effects of a joint injury. Sometimes we see what's called post-traumatic arthritis, where after an injury to the cartilage of the joint, the arthritis and the joint itself can degenerate rather rapidly. And sometimes the best option for that is a joint replacement down the line.

It's a little bit different than, say, a standard arthritic joint replacement in the sense that there's often hardware and implants in place or other large deformities. But the complexity of those and the rewarding satisfaction of giving a patient their life and function back is sometimes even greater than that, after an arthritic hip or knee replacement.

Host Amber Smith: Is it harder on the patient because they've gone through this traumatic accident that they are healing from or have to heal from, but then they also have this surgery that they really weren't planning to have to have. Is it harder to heal that way, or is it easier because it's all happening together?

Zachary Telgheder, MD: It certainly can be more difficult. I would say the most common joint replacement I do in the setting of a traumatic injury is a hip replacement for a fracture of what's called the femoral neck. And if you think of the hip as a ball-and-socket joint, it's relatively common, especially in patients over the age of 50, to break right below where the ball is. And many times, based on the fact that those fractures don't heal as reliably as other fractures in the body or even the femur itself, a joint replacement is usually the best option in terms of the most reliable outcome, and of course the fact that patients can get up and walk right away, right after they would with a standard hip replacement.

The big difference is that when you're having a hip replacement for arthritis, which is usually the most common way of having a hip or knee replacement, that's something you plan for. You can adjust your schedule. You go to preoperative physical therapy. You see your doctor. Whereas this all happens through the emergency department, so it's certainly a bigger psychological shock and recovery for patients.

One of the things I take a lot of pride in is being with patients at that time through the emergency department, getting them taken care of quickly and seeing them recover fully and have an excellent outcome as if they were to have an elective hip replacement. But it definitely is a little more traumatic and a little more challenging for patients just because it's certainly not something that they plan for.

Host Amber Smith: How do you determine whether a joint needs to be replaced or if it can be re repaired or reconstructed?

Zachary Telgheder, MD: It depends on both the injury itself as well as patient factors as well. Like I mentioned, fractures right below the ball of the ball and socket of the hip joint or the femoral neck... in patients who are young, generally less than 50, we often do our best to try to fix that with plates and screws. Even doing that, we find that sometimes they don't heal properly or have post-traumatic effects that need a hip replacement later.

Whereas in a patient who's, say, over the age of 50 or 60 who's pretty active, a hip replacement is a much more reliable surgical option right at that point to allow them to get up, walk right away, have no restrictions or limitations, and seem to recover better.

Many fractures, especially around the knee and shoulder, we can fix with plates and screws and try to reconstruct them. And that is my first specialty -- traumatic injuries and reconstruction and fixing broken bones like that. But occasionally, like I said, we try to tailor each surgical option to each patient based on both what their fracture looks like and what their quality of life was like before the injury.

A lot of people are candidates for joint replacement, but that depends a lot on their age, their functional level, and what we can do to best get them back to their baseline level of function as quickly as possible.

Host Amber Smith: Is there anything that would disqualify a person from having a joint replacement?

Zachary Telgheder, MD: I wouldn't say there's anything that totally disqualifies them. Again, based on patient age, we try not to do definitive joint replacements in patients who are really young and may require another joint replacement in their life, if we can happen to avoid that.

The only thing that would absolutely disqualify a patient from a joint replacement would be an active infection near that joint, but that's very rare, especially in the setting of trauma. What we sometimes see -- and this is very rare -- is someone who's had a previous surgery around the joint and there's an infection there, and first we would, of course, treat that before doing a joint replacement. But rarely is there something that would totally disqualify a patient from a joint replacement.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking with orthopedic surgeon Dr. Zachary Telgheder about traumatic joint replacements.

So what do patients need to know about joint replacements? What are the replacement parts made of, for instance?

Zachary Telgheder, MD: The replacement parts are often made of special metal alloys, most often cobalt and chrome, and in either a hip or a knee replacement between the metal components that replace the bone or resurface the bone, there's a plastic liner made of polyethylene.

The technology for joint replacements continues to evolve, and the technology we have now is certainly the best we've ever had in history, and we find that our joint replacements are lasting longer and are more functional than ever before.

Host Amber Smith: Does the human body ever reject the new joints?

Zachary Telgheder, MD: It's very, very rare, and it's a somewhat controversial topic in orthopedic surgery, but there have been reports of patients who have allergies to certain metals that sometimes have difficulty with joint replacements. That's very rare, and we haven't actually found a perfect way to test and evaluate for that. We do have, particularly in knee replacements, new components that are made without nickel, which is the most common allergen we see in joint replacements, and we can often use those if patients have a history of a previous nickel allergy.

Host Amber Smith: How long do the joint replacements last?

Zachary Telgheder, MD: With the modern technology and implants that we have now, we're finding that joint replacements are lasting longer than ever. Some of the registry data, which is where all of the surgeons throughout multiple countries in the world collect their data and submit that, show that some hip and knee replacements are now lasting 25 to 30 years.

Everyone is different, and everyone has a little bit of a different experience. Some patients last longer than that. Some patients, depending on their functional level, will have components have some wear prior to that. But we're finding that with our new components, most notably the new plastic liners that we have in place for our hip and knee replacements, that patients are having these last significantly longer than ever before.

Host Amber Smith: Can they feel the device underneath the skin, or does it feel like what their bone used to feel like?

Zachary Telgheder, MD: For the vast majority of patients, the goal of the surgery is to feel as though you never had a hip or knee replacement. The term we use is a "forgotten joint," and we see that very commonly with hip replacements. You can't really feel a hip replacement. The nice thing about hip replacement is it very perfectly resembles your normal hip anatomy, so patients can do very well with that. With the knee replacement, sometimes patients say they feel a little bit different when they're kneeling directly on their knee, but in general they cannot feel the implants themselves. It more just feels maybe slightly different from their knee normally prior to when they had arthritis or an injury.

Host Amber Smith: Does it change a person's gait?

Zachary Telgheder, MD: It can, oftentimes, especially with a knee replacement in the setting of deformity, actually improve a gait. Many times we see patients with deformity related to arthritis or a prior traumatic injury where their knee is bowlegged, or knock-kneed from the arthritis and wear in the joint. Many times in surgeries, particularly with the technology we have at Upstate where we use robotic technology and preoperative CT (computerized tomography) scan, we can correct a patient's alignment very nicely. And it can actually help improve their gait.

Host Amber Smith: Do these new replacement joints set off metal detectors, like at the airport?

Zachary Telgheder, MD: I have been told that the metal detectors that we have now are very advanced and can often see the joint replacement under the skin. In many airports around the country now they're creating separate lines and questionnaires to expedite the scanning of patients with orthopedic implants such as joint replacements. So I guess the correct answer is yes, they do set off the metal detectors, but it doesn't seem to cause much of a delay or any issue in that, particularly as hip and knee replacements and other joint replacements are becoming much and much more common.

Host Amber Smith: If a patient had osteoarthritis in the joint, and you removed that and replaced it, does the osteoarthritis redevelop on the replacement joint?

Zachary Telgheder, MD: It does not. Once we do a joint replacement, particularly a hip or knee replacement, the arthritic or traumatized bone is removed, and that's replaced with the new metal components. The idea of the metal components is to be very well fixed to the patient's normal bone so that there's no chance of arthritis developing ever again.

Host Amber Smith: What are the risks of having a replacement joint that you go over with patients before the surgery?

Zachary Telgheder, MD: The most common risks are, generally speaking, pretty standard surgical risks.

We always worry about infection and wound problems, which can happen after any open surgical procedure. We worry about the joint replacement wearing out or potentially needing a revision down the line. And again, that's very difficult to predict. Some patients last forever. Some patients need one in 10 to 15 years. And everyone's a little bit different with that.

With any surgical procedure we do on the bones and joints, there is a chance of injury to the nerves and vessels, but that's very, very rare with any kind of hip or knee replacement.

When we do a hip replacement, there is a risk of having a difference in the limb lengths, particularly because in the setting of arthritis, patients feel as though their arthritic or affected limb is a little bit shorter than the other limb. And we try to restore that normally. And with the robotic technology we have at Upstate, we now have the capability of matching a person's leg lengths perfectly and verifying that in surgery. And that's a very nice new technological update we have and we like to use on our patients.

Other risks we see after joint replacements are things like stiffness, particularly after knee replacements; needing some physical therapy after; and then blood clots can also happen after any surgery in the lower extremity. And we've gotten very good at minimizing that risk by working with our medical colleagues and also having patients optimize a blood thinner use usually for around six weeks after a joint replacement.

Host Amber Smith: Well, let's talk about what's involved in the surgery. How do you actually attach the joint to the existing bones?

Zachary Telgheder, MD: So, many times in joint replacements, particularly like what we do at Upstate, we utilize robotic technology to optimally position the components based on a patient's anatomy and to give them the best reproducible result. Instead of actually cutting away the bone, we actually resurface the bone, particularly around the knee, cutting very little bone away and just removing all of the arthritic and disease cartilage.

The joint replacement is then attached to the bone, either using metal that the body's bone will actually grow into, or with bone cement, which allows the bone to adhere. And again, the goal of both a hip and knee replacement is allow a patient to walk on it right away after surgery.

Many times in hip replacements, we rely on technology that the body grows bone into the implants as opposed to using cement. But occasionally, particularly in the setting of a broken bone, we will use cement to help fix the components, once again to avoid complications related to that.

Host Amber Smith: What happens to the nerves and tendons in that area?

Zachary Telgheder, MD: In the hip or knee, we often use approaches that are somewhat muscle sparing. And we try to do that to optimize and allow for quicker recovery.

Many times the nerves, tendons, and muscles in the region of the surgical approach for a hip or knee replacement are often safely retracted and mobilized to allow for exposure of the bone, and we try to do that in as minimally invasive a way as possible.

As I mentioned before, we do have what's called the Mako robot technology. And, in utilizing this we've been able to really minimize our dissection to the soft tissues, the nerves and the tendons around the hip and knee to allow us to optimally place components and hopefully give patients not only improved longevity of their implants, but also a quicker recovery after surgery.

Host Amber Smith: Now, what keeps the new joint lubricated?

Zachary Telgheder, MD: The body's normal joint fluid often is reproduced into the knee joint itself or the hip joint itself. And the modern plastic or polyethylene components we have actually form a very normal fluid type lubrication barrier, allowing for full range of motion.

Another thing that we tend to do, particularly around the knee replacement, is preserve all of the native ligaments that we can. We often preserve the ligaments on the inside and the outside of the knee, which helps the knee feel much more like a normal native knee. Between the normal joint fluid and joint lining, the modern polyethylene components and preservation of as much native soft tissue and muscle as possible, it allows the joint to stay lubricated and move in a full range of motion.

Host Amber Smith: Well, I want to ask you about what recovery is like, and I'm assuming it's probably variable depending on what the initial injury was, but in general, how soon do people walk?

Zachary Telgheder, MD: When we do a joint replacement, either for arthritis, for deformity, or for a traumatic injury, we get patients up and walking the day of surgery.

We have a very coordinated team, not only with the surgeons and the operating room team, but also our nursing staff, our recovery room staff, our anesthesiologists, physical therapists and occupational therapists in coordinating to help expedite and enhance recovery in all of our joint replacement patients.

Patients are up and walking with physical therapy the day of surgery, many times utilizing a walker or crutches to help assist with mobility. But we start range of motion and mobility right on the first day of surgery. Like you mentioned, Amber, everyone's recovery is a little bit different, but in the hospital, we have patients get up and moving right away with the goal being enhanced and expedited recovery.

Many patients for elective joint replacements, such as for arthritis, are going home either the day of surgery or the day after surgery now. In the setting of a traumatic injury, like a hip fracture, that requires a hip replacement, the recovery can be a little bit longer, especially in the acute phase, because like I mentioned before, patients don't always plan for something like that to happen.

In addition to working with physical and occupational therapy in the hospital, many patients require home physical therapy for a couple days after they get home to safely mobilize within their own home, with the goal, of course being to get patients home and in a comfortable environment as soon as possible.

Host Amber Smith: Particularly with knee replacements, we often utilize outpatient physical therapy as well to work on range of motion and strengthening, and that usually starts around one to two weeks after the surgery. A lot of patients report feeling very well around four to six weeks after surgery, but continue to make progress with their recovery for up to a full year after surgery regarding strength, range of motion, and return to their normal activities that they enjoy.Well, Dr. Telgheder, thank you so much for making time to tell us about traumatic joint replacements.

Zachary Telgheder, MD: Thank you very much for having me. It was a pleasure.

Host Amber Smith: My guest has been Dr. Zachary Telgheder. He's an orthopedic trauma surgeon at Upstate, where he's an assistant professor of orthopedic surgery. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Mick Cochrane is a writer and professor at Canisius College in Buffalo, New York. His poem "His Back Pocket" is dedicated to Dr. Joseph Leach, an oncologist in Minnesota, but it celebrates all physicians who keep patients hopeful and engaged through the roughest patches and yet stay realistic and honest and bear witness with their patients.

"His Back Pocket"

Don't worry he always says I've got

something else in my back pocket

he's got clinical trials he's got

off-label he's got stuff from Sloan

Kettering he's got what Lance

Armstrong juiced his team with

he's got more milestones he

tells you he's got your twins'

graduations he's got some new

theories his back pocket has

back pockets who's your tailor

you ask and he just laughs he has

your next birthday he's got Gamma

Knife and gene therapy and some

cocktail the Mayo Brothers don't

know about yet he's such a modest

magician he's got your trip

to California he's got stories

about remission like you

wouldn't believe he's got something

for nausea and pain and numbness

and tingling in your extremities

but you both know there's always

a last thing even in the deepest

pocket "time is an ocean"

you know what he's got

to show you "but it ends at the shore"

not today but soon you can see its outlines

almost feel the weight of the last

thing he will produce from his back

pocket

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," why are young adults with diabetes not taking their medications?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.