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Over a century years old, Campbell Clinic physicians are the recognized national and international leaders in the field of orthopaedics. This Campbell Clinic podcast will highlight the Now and Future of orthopaedics. Our physicians are integrating the latest orthopaedic treatments and medical advancements in musculoskeletal care through their continued and ongoing clinical research, innovation, teaching, and the writing of the Campbell’s Operative Orthopaedic textbook.
That's what made me do my hip replacement. When I, my family wanted to go hiking out in Idaho and they went and I couldn't go because my hip was hurting too bad. That's essentially it. You want to give them functionality. Some of it's pain, but I think more people are frustrated by functionality than they are by pain.
Welcome to the now and future of orthopedics, a Campbell Clinic podcast. And I'm your host, Sam Coates. Campbell Clinic is over a century years old and its physicians are recognized thought leaders in the field of orthopedics around the world. On this podcast, you'll hear the latest treatments and advancements in musculoskeletal care through research, innovation, teaching, and the writing of Campbell's operative orthopedic textbook.
For more episodes, please search the now and future of orthopedics wherever you get your podcasts. Now let's get to this week's episode.
Hey everybody. Our guest today is Dr. James Guyton, an orthopedic surgeon with over 30 years of experience here at the Campbell Clinic. Since 1991, Dr. Guyton has been at the forefront of innovation in hip and knee replacement, transforming patient care through cutting edge techniques and technology.
In this episode, Dr. Guyton shares his journey from the evolution of orthopedic surgery to lessons learned as both a surgeon and a patient. We'll also explore Campbell Clinic's unique patient center model and how innovation continues to shape the future of orthopedics.
So here's today's episode with Dr. James Guyton. Dr. Guyton, thanks for doing this.
Oh, you're welcome. Thank you for having me.
Okay. So you've been here just over three decades, right?
Correct. Started in 91.
Could you share why you moved to Memphis and why you came to Campbell Clinic in 91?
Well, I was originally from Jackson, Mississippi, and I'd gone off to the Northeast to train and then was in Iowa for five years and then in Chicago.
And this was my way of getting back to the South. I also interviewed in Jackson, but this was a much better job.
I liked the structure of the whole institution here better, but it seemed much more congenial.
I like to be in resident education. Always wanted to do that.
Last month, I did an episode with Daniel, CEO here at the Campbell Clinic, and he talked about how the model is almost a socialist model from a standpoint with the surgeons, with the team.
And he said that's unique. Is there anything, given your experience, your education, options you've seen, how would you describe the model here at Campbell Clinic and maybe why it stood out to you back when you first came here?
It is kind of a socialist model. It's gotten a little more incentivized over time, which has probably been a good thing.
But the thing about being a socialist model is the patient that needs a particular surgeon gets to that surgeon without any sort of impediment because there's no downside to giving that person to the best person to handle it.
The best outcomes for the patient, right?
Structured that way. And are you saying that was unique to you?
That's unique to us. There are a few other places like that. I think Cleveland Clinic is a lot like that.
So, three decades in, you're an orthopedic surgeon here, right?
What hasn't changed from a standpoint of quality of work, service to the patient, and excellence?
It's still very time-demanding, and it's still all one-on-one. There's no remote orthopedic surgery, you know? And so, it's a service industry, you know?
And from that standpoint, you have to compartmentalize, and at one moment in time, you just have one patient.
You know, the technology, the medications, our understanding of the diseases, all that's changed a ton.
But the patient care aspect is still very much the same.
We have other pressures on us, just from the standpoint of we try to be extremely efficient,
and sometimes that eats into the doctor-patient relationship because you're trying to go too fast.
And I don't like that.
Could you speak more on that, like how you hold that and maybe cling to what you believe in from a patient care standpoint?
Well, you just have to, I mean, you got to follow some general principles.
When you come into the room, you sit down. You don't continue to stand up.
You shake their hand, you know, and you make eye contact.
And one of the things that I learned in medical school is you always, you know, right when you come in, you touch the patient.
You know, you want to establish a communication with them.
So given the fact here as an orthopedic surgeon that you specialize in hip and knee replacements,
could you maybe just share, go into the background of it and maybe where we've come from, where we are today,
and where we're headed within your space?
Yeah, well, when I started, we had some very large limitations on the materials that we were using
because some of them would wear significantly during time.
And so there was a very limited lifespan of a hip replacement.
And what that does is it also changes who you should be operating on.
So as a result, the initial hip replacements were very elderly because you didn't want someone to outlive their hip replacement
and then have a very difficult time for the rest of their life, right?
You can do redo hip replacements, but they don't work as well, or at least, and those have gotten a lot better too, right?
The other thing, when I started, we would admit the patient the night before.
The internist would come see them in the hospital and do a clearance on them.
We would have two units of blood ready to transfuse them.
And then we'd do their surgery through a much more invasive type incision.
Typically, they would get a transfusion and typically they would be in the hospital for about a week.
And that is so different now.
How is it different today?
Well, I would say currently I'm doing 60, 70% outpatient surgery.
And these people come in on the morning of surgery, having been cleared as an outpatient or maximized or optimized as an outpatient.
And then under, we do spinal anesthesia instead of general anesthesia.
At least we try to so that they are able to function right away.
And then we get them up walking about two hours after we operate on them.
And the surgery itself has gotten a lot more precise.
Also, we learn to do it through smaller exposures too.
But yes, also the implants we're able to place much more precisely.
And the injury to the body is less.
All those things have been really, really, really good.
And something that is happy and proud to have been a part of.
I can't say that.
I'm not saying that I was a monstrous innovator in this.
But I certainly adopted things as they came along and really enjoy it.
You have a very strong reputation here within your space.
What can you say with your own passion?
How have you been able to keep up with the changes?
How have you been able to learn all the progress but then still maintain this really strong commitment to the patient?
Well, I tell you, one of the things that has been really good is teaching residents.
Because as a result of teaching residents, they're always asking you questions.
And it's a two-way street.
But the other thing is you have to be committed to your continuing education, which you've just got to do.
And some people don't like to do that.
But I feel that if I don't do that, you don't want to be the guy who doesn't understand something or doesn't, can't offer the patients the best possible outcome because you have somehow fallen behind.
You just had one of these, didn't you?
I just had, well, I've had a lot.
I've had a hip replacement.
Then I've had a knee replacement.
Then I had to have a re-operation on a knee.
And so I've kind of seen a lot of it.
Who did yours?
Dr. Harkus did my hip replacement.
How'd he do?
He did fine.
Okay.
Yeah, I feel sorry for him because I templated it ahead of time.
In other words, you have x-rays and you put overlays over it.
And I made a preoperative plan for him.
And I made him use an implant that he'd never used before.
And I trusted him to do it.
And he did it.
So earlier, before we were recording, is it true that Campbell Clinic was the first organization, first clinic in this Mid-South area to offer the outpatient hip replacement procedure?
Yes.
What was that like?
It was terrifying in the beginning.
Okay.
Because the first one that I did was in 2014.
I'd had some partners do it before that.
And I was always a little afraid of doing a major procedure in an outpatient setting where I didn't have a certain amount of backup, meaning blood bank and intensive care unit.
But what happened is people proved that it could be done.
And there was a lot of things that went into that.
One is spinal anesthesia.
One is using procedures that were less invasive, so less blood loss.
We also started using a medication that limits blood loss.
Right?
And that was a big, big, big one.
And so then all of a sudden, our transfusion rate went from 30% down to 1%, right?
And then we also learned that as long as a patient had a hemoglobin above a certain amount, that the chance of them being transfused was minuscule.
All right.
So even within that 1%, we were able to, or it might be 2%, but we were able to limit those to the hospital.
But it seems like there's a trend here that when something becomes available or it becomes an option, chemo clinics, a lot of times at the beginning of that, at the forefront of it.
Well, we'd try.
Sure.
I mean, there's a fine line there.
Innovators are sometimes big risk takers, okay?
And so, such as, you know, we went through the whole metal, metal, total hip problem.
I don't know if you know what I'm talking about, but do you remember 10 years ago, there used to be advertisements on television about, did you get your hip replacement?
Do you have a such and such hip?
Call this lawyer.
And what happened was there was a period of time from 2007 to 2010 that we did metal, metal hips, meaning the ball was metal and the socket was, the bearing surface was metal, right?
And they were FDA approved.
This was something that had gone through all the channels.
And then what happened was is that the metal debris ended up being toxic, locally toxic, meaning the implant could loosen from the bone, hurt the muscle, and then remotely it could actually hurt the patient, meaning other systemic problems, right?
So, we went through a period of time.
And if you were first in line on that, you had a tremendous number of patients that had these implants in.
I waited.
I think I did 34 metal on metal hips.
Ended up having to revise 28 of them, right?
And you take them out, change them to something else, right?
I know a fellow in Chicago that did 800.
And so, his whole rest of his career, all he was doing was that.
And I'm sure he had all sorts of other misery associated with that.
What did you learn from that?
Well, I think what you learn is you want to be close to the leading edge.
But if there is a significant risk, you might want to let the person – in other words, you want to be sure before you start experimenting on people.
Could you share a little bit about the types of hip replacements that are currently being used today?
The primary ones, there's non-semented total hips, which are titanium stems with titanium cups.
And then the bearing surface, which is the ball and the liner of the cup, typically is a ceramic ball and a very hard plastic liner, right?
And that is kind of shown over time to be the most durable, extremely durable.
There are other ones, such as ceramic on ceramic, which I have used in the past, particularly on very young patients, when I want to try to get a 50-year lifespan out of it.
As we've gone through time since the plastic got better in 2001, we see that there's very little plastic wear.
And so, as a result, the amount of ceramic hips down in the United States has gone down to about 1%.
It used to be as high as about 5% at one time.
So, that's sort of the standard, all right?
And also, what we're seeing, we are seeing the return of some cemented femoral components, the femoral component being the one in the thigh.
And the reason for that is that people with extreme osteoporosis, if you do a non-cemented hip on them, then they have a slightly higher chance of having a fracture if they were to fall or a fracture during the operation.
And so, we're getting into making changes or decisions about implants based on 1% differences, right?
Which is great because in the past, we had 20% differences, right?
And there's even some people that still do what's called resurfacing.
And that's a metal, metal hip developed in England.
And that's a metal socket with a metal ball that's just like a cap that fits on top of the bony ball.
But very few places in the United States do that, and it's only indicated for young men.
And even on top of that, I quit doing that because I didn't want to have to worry about metal, metal toxicity in people.
And having said that, I probably did 25 and have not redone a single one.
Because going back to that earlier experience that you were talking about, could you talk through maybe how you see or how you understand which one to give to the patient depending on what they may need?
It has to do primarily with what their level of osteoporosis is, okay?
And so a 50-year-old or a 60-year-old man with extremely hard bone has a different type of implant, one that fits very, very, very tight inside the bone.
And the bone will grow into porous titanium or grow onto rough titanium and secure it long term.
And that's ideal.
And that's what I have in my leg.
And then when someone's a little bit more osteoporotic, we have a different type of implant that when we prepare the femur, it actually compresses instead of cuts out the osteoporotic bone.
So it makes it stronger in a way.
Not stronger, but let's just say it doesn't sacrifice the bone that's there.
It compresses it up against the wall and then utilizes it as a transition zone between the hard implant and the softer bone.
All right.
So if a person falls, it has less rigidity, so less chance of breaking.
And then if we have an extremely osteoporotic person, then we go back to cementing the implant because that's the most flexible construct because you have a thin metal part and then a flexible cement mantle and then the bone.
The problem with that is that if it ever has to be redone, it's much harder.
All right.
And this, my generation spent hours and hours and hours in the operating room taking out cement mantles from hips that had failed for one reason or another.
And it was extremely hard.
And it also tended to injure the bone when you were taking it out.
And I think the pendulum is swinging.
I don't want it to swing too far because you don't want to relive that experience.
I know you talked through this a little bit earlier, but just the way you laid that out there, all the different options, all the different situations that people may be in, and then the different solutions that people have.
How far has technology innovation and these ideas and these different types of materials progressed to where people can be met where they are?
Oh, it's incredible.
And again, the main thing was the plastic getting much tougher.
And that had tremendous science behind it that plastic is not used in anything else other than medical implants.
And it's highly cross-linked polyethylene.
And then we've experimented with different ways of making different amounts of cross-linking, okay, because that makes it tougher, all right?
So it doesn't wear as much.
And experimented with what the right dose of how we cross-link it.
It's typically a radiated plastic to make it cross-linked.
And then also we've made it very oxidation-resistant, okay?
When I say that, it's like having a rubber band that's on tension.
Over a while, it becomes brittle.
You don't want to have a plastic component do that in the body.
And they very much used to do that.
And now they've gotten much better from that standpoint.
And that's why, as I said before, we've gone to the standard being a ceramic ball on top of a cross-linked polyethylene liner.
The ceramic has gotten a lot better.
It's gone through four generations.
Now it's hard enough that you can hit it with a driver, a golf driver, and it won't break.
And so when we first started doing ceramic hips, there was a fracture rate of maybe one out of 100.
And now it's one in 10,000.
Wow.
About these different options, can you share about how long they last?
Yeah, we really don't know.
Okay.
When you do that, you talk in percentages, all right?
And so what we know is that approximately 94%, 95%, 96% will last up to 20 years.
But the thing is we don't know the endpoint.
And the reasons for failure have changed.
So now people fail because of fractures or because of dislocation, meaning the ball popping out of the socket.
But we don't see implants failing because of plastic wear.
When the plastic used to wear, the body would react to it and make an inflammatory membrane that would eat down between the implant and the bone and cause it to loosen up.
So we don't see that anymore.
And so fixation, meaning the connection between the implant and the bone, has become extremely durable.
And so mode of failure has changed.
And what did you say?
What percentage?
20 years?
Somewhere around 95% should be still, or 90 at least.
And what do you think it was in 91, if you had to guess?
Oh, in 91, at 20 years, maybe 20%.
Wow.
And we still would see a few of those.
And that has to do with individuals' bodies not being reactive to the wear debris because all of them would wear.
Okay.
And every once in a while, you'd see somebody who would wear their implant or wear their plastic, but they wouldn't form that reaction to it.
And the reaction typically is generated by a certain rate of debris generation.
And what's happened is the rate of, and even cross-linked polyethylene wears, but it's cut by a factor of 10.
So it's at a level where the body can handle it.
How many patients do you see on a weekly basis normally?
In a clinic, a full-day clinic, I see about 60 patients, and that's with help.
And then I see a half-day clinic, and the rest of the time I'm operating.
So somewhere around 90 patients a week.
And you're doing how many procedures a week normally?
Somewhere about 12, 14.
Okay.
You extrapolate that out over a three-decade-plus career.
What have you seen, what have you learned about patients when they're coming into your office, when they're meeting with you?
What are they concerned about?
What's most important to them?
Well, they want their life back, you know, because they come in and they are extremely limited in what they can do.
It's like you can't take your trash to the street.
You can't go walking with your spouse, you know.
That's what made me do my hip replacement.
When my family wanted to go hiking out in Idaho, and they went, and I couldn't go because my hip was hurting too bad.
That's essentially it.
You want to give them functionality.
Some of it's pain, but I think more people are frustrated by functionality than they are by pain.
And so what does it look like when you think about all the cases, all the procedures, the patients that you've seen, where it's been a successful outcome and they want their life back?
What does that journey look like when they're coming in and they have no idea what to expect?
I can't play four hours of tennis anymore, you know.
And those people, number one, I think they have to do some activity modification before you're willing to do that because they don't realize that even though we sit here and talk about how wonderfully replacement has gotten easier, all this.
It's still a big surgery.
There's still risks to it.
And you don't want someone to have an infection or a blood clot or something like that.
And you took someone who was playing four hours of tennis and being a little sore at night.
And somehow that happened to them, right?
It's very rare that stuff happens.
But again, you've got to figure that into the equation.
But I was getting at it that people are different.
And then some people are so scared of being operated on that they come in and they're on a walker on the verge of going into a wheelchair.
And you've got to take that person and you've got to look them in the eye and say, I can make you so much better.
You know, and they've got to trust you.
But the thing is, you treat all those people.
And I used to play a ton of tennis and I had a large number of people who their life was tennis.
And when they couldn't do it anymore, it's like they got depressed.
And I operated on a large number of those people, particularly knees, and gave them back the ability to play tennis.
And that's very, very satisfying.
From my standpoint, from their standpoint, you know, you have to factor in, you know, you don't want to do them at age 40 where they're going to have potentially wear out their knee at age 60, 65.
You want to find the right time.
And what you're saying is everybody's different.
And there's certain people that are super early on it that live a very strenuous lifestyle.
That's right.
And then you might have to reset the expectations.
And then there's others that maybe they wait way too long.
Yeah.
And then you just really, you want to meet them where they're at.
I tell you, over time, I have become a lot more of a, I've let the patient direct me more.
In other words, if someone feels a severe limitation, I will look at them and decide whether I can give them back that functionality, you know, and whether it is reasonable.
Is there anything that you can share about for someone that may be thinking about this, maybe looking at it, or also may have recently had one on an implant?
How do you think about longevity?
Well, you want to avoid reasons for failure.
All right.
And so what is it?
That's fracture.
So you don't want to be doing anything that will twist your leg violently.
I always tell people, you really ought to avoid high ladders.
Don't jump out of the back of your pickup truck.
Don't jump out of your deer stand.
We are in the south.
And I also tell people I would rather they not water ski.
All right.
Don't play pickup basketball where you've got to have someone cut out your legs.
In other words, those are the things.
Okay.
Having said that, I used to do a lot of water skiing, and now I still wake surf because I think it's great.
I want to be out there with my family.
I'm going really slow and can do that with my artificial joints.
And it's allowed me to do that.
And then from the other standpoint of how can you make them last a long time, I've become a big, big, big, big, big believer in exercise as I've gotten older.
And that is not just from an implant standpoint.
That's from an everything standpoint.
If anyone hasn't read, there's a couple of books I'll read, Outlive by Peter Attia.
And then there's another one called Younger Next Year, and I've forgotten the author on that.
But particularly somebody in their 50s and 60s, they ought to read those things.
And talks about how exercise in particular can affect neurodegenerative diseases, meaning dementia, cardiac disease, diabetes, and metabolic syndrome.
All right.
And it has sort of the medical science behind that, but it also is very lay friendly.
You're a very busy man.
How have you integrated exercise?
And just what does that look like practically, given all the things?
Yeah, I get up at 5 a.m., drink my coffee, go through my email, and then I've got to get on the elliptical by about 5.45.
And then sometimes I do things in the evening.
But I always try to get in 45 minutes in the morning.
I'm not an expert in your space by any means, but I've understood that there's a couple different ways to go about procedures and surgeries, one being anterior and one being posterior.
For people that look into this, could you maybe address that and your thoughts on it and how to really handle this for those that might Google their own solutions at home?
Sure.
There are a lot of different ways of getting into the hip joint to do hip replacement, right?
The two major ones are anterior and posterior.
We call it posterior.
Some people call it posterior lateral.
The anterior is called direct anterior approach, so a DAA.
And there's, in other parts of the country, people do other things.
There's an anterior lateral approach.
There's one called a super path.
I mean, that's very big out in Phoenix.
But there are all different ways of getting into the hip joint.
But anterior hip became very popular between about 2010 and over the next decade.
And from a patient's perspective, you get over it more quickly, right?
In which it's seen as a less invasive surgery.
Now, I'm going to have to tell you that, you know, on the inside, this is still cutting the bone.
It is still preparing the bone.
And it's still using a, you know, a device to prepare the pelvis.
So all of those things are still the same.
It is true, I think, that you're able to be careful with the muscles of the hip so that you don't have to injure them as much going through the front.
You have to have the right body habitus, all right?
Meaning some people that are extremely muscular, it's hard to do.
Some people that are very heavy, it's hard to do.
And have a little bit of increased risk doing it that way.
I started doing the anterior hip, I think, in 2014 and did it because I saw the trend going that way, all right?
And I wanted to offer that to my patients because I started thinking that it might be a better way.
And I would guess that for the first four years, I was pretty ambivalent of whether I thought it was truly a better way or not.
And then over time, I've come to think it truly is a better way because the true advantages of it are there's a little bit lower chance of dislocation, meaning the ball pop out of the socket.
And when at our national meeting, it was so interesting because there was a question, they always go to who's doing what now survey.
And currently in total joint trained orthopedic surgeons, meaning fellowship trained orthopedic surgeons, 5% use the anterior approach as their primary hip approach.
They tend to be folks under 50, just because people weren't trained on the anterior approach back 30, 40 years ago.
And so there are a fair number of people like me who made the transition during their career, but there was a learning curve to that, all right?
And so the anterior approach also got a little bit of a black eye during that time because during the learning curve, people would have problems, long surgeries, fractures during surgery, that sort of thing.
If you're extremely careful, those things are minimal, all right?
But, and then now that it's become my go-to, I think it is as easy as doing a posterior approach unless you have an extremely heavy person.
But there are also certain shape, bony morphologies, meaning shapes of bones, all right?
And if those are a certain way, then it's easier to go posterior.
I had a posterior hip, by the way, and that's just because the person I wanted to do it, that's all he did, all right?
If I were to do that again now, I might opt to do an anterior hip.
You've been here three plus decades.
You went to Harvard Medical School.
You were in Iowa.
Mm-hmm.
And then you came back here, correct?
One year in Chicago in between.
So, you've had a pretty diverse set of experiences leading up before Campbell Clinic and obviously since you've been here through the medical school, through your work nationally, and all the research.
What do you see for Campbell Clinic today, and where do you see it headed into the future?
I think we are still committed to being a place where people bring their problems.
In other words, you don't want to become so interested in just high output that you don't take care of the difficult stuff.
And so, I think as long as we remain committed to that, then I think that that is great.
I say all that, you know, you have to pay attention to your business, otherwise you don't have the opportunity to do that.
And so, we've been very fortunate to have good business people.
What are you most excited about for your specialty for the future?
Well, then joint replacement in particular becomes so durable that people are able to get it at a much younger age.
And with the expectation of it lasting decades, all right?
And the other thing that we have done is to put a lot of technology into it.
So, now a lot of, like, neighbor placements are done with the computer assistance.
That helps with the education because, and that's not inherently obvious, but what happens is the computer can show you what you're feeling.
Okay, and so, it helps you develop touch, right?
And then, the other thing that we've done is we've let technology help our accuracy, both in hip and knee replacement.
And presumably, that's going to affect number one function and longevity, right?
It used to be that, in particular with a knee, a good result was just somebody who didn't hurt.
But now, we are much more concentrating on functionality.
In other words, let them get back to playing tennis.
Let them get back to hiking.
When will you be hiking again?
Oh, I hope in about two months.
I had my knee worked on seven weeks ago.
So, let's say at the end of the day, somebody that's listening to this, maybe what you've shared with them or maybe what they've heard, that a hip or knee replacement would be in their best interest, but they're scared.
What would you say?
Well, the main thing is just come in and talk about it.
In a healthy person, the risks are very low.
Don't want to sound like I'm selling anything here, but the risks are very low, and you can improve your quality of life dramatically.
I see people who have limited themselves for two, three years and then come in.
And sort of the usual comment is, I really wish I'd done this a year ago, or I really wish I'd done this two years ago.
And that's true.
I mean, you know, it's my job to sit there and sift through this because, you know, you've got to compare it to everybody else you've done and what their experience has been.
Thank you, sir, for spending time with us this morning.
You're welcome. Thank you.
Thanks so much for listening to this episode of the Now and Future of Orthopedics, a Campbell Clinic podcast.
Be on the lookout for a new episode coming soon each month.
And for more information about Campbell Clinic, go to CampbellClinic.com and also search The Now and Future of Orthopedics wherever you get your podcasts.
If you love this episode, please do us a favor, tell a friend and leave a review.
As your host, Sam Coates, thanks so much for listening, and we'll see you soon.
Thank you.