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    Dr. Salvatore Pacella – When Surgeons get Surgery

    Dr. Sam Jejurikar: Good morning, everyone, and welcome to yet another episode of 3 Plastic Surgeons and a Microphone. I’m Sam Jejurikar, and as always, I am joined by my host Doctor Sal Pacella at San Diego Plastic Surgeon and Doctor Sam Rhee, at Rasmus New Jersey, Ramus New Jersey, at Bergen Cosmetic. Good morning gentlemen.

    Dr. Sal Pacella: Hello. Good morning, everybody.

    Dr. Sam Rhee: Good morning.

    Dr. Sam Jejurikar: So, before we get into the meat of our discussion today. First, we’re going to have Doctor Rhee. Little Disclaimer. Just covering the legal basis.

    Dr. Sam Rhee: Yes, this show is not a substitute for professional medical advice, diagnosis, or treatment. It shows for informational purposes only. Treatments and results may vary based on circumstances, situations, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or another qualified health provider with any questions you may have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something in this show.

    From Surgeon to Patient: Dr. Sal Pacella’s Journey Through Total Knee Arthroplasty

    Dr. Sam Jejurikar: Great. Well, today, we’re going to go on a little bit of a tangent. Typically, we talk about plastic surgery-related issues, but one of our co-hosts has had a very interesting development in the last few months, which actually caused our show to go on hiatus. Instead of being the surgeon, Doctor Pacella was actually a patient, and he went through total knee arthroplasty, and so we’re really interested in learning about what he’s been going through, what it’s like for the surgeon to be a patient. So, Doctor Pacella, let us know how the last few months have been.

    Dr. Sal Pacella: Well, thanks, guys. So, it’s been an exciting time for me. I’ve been out of work for about two months and then halftime for about a month after that, and so I’m going on my fourth month right now after surgery, and it’s been interesting, to say the least. I would say overall; it’s been an exceptionally positive experience. I was in a bit of pain before this total knee replacement, and it was really affecting not only my work life but my personal life as far as doing all that I love. So, really it was, I’m 49 years old, and I was sort of pushing off this for a couple of years, and mentally I thought to myself, well, if I could just make it to 50 with this bad knee. I kind of go from there, but I just had to get it done.

    So, I’ve got a little power point here. I’d maybe want to share a little bit. So, I’ll just dive in and tell my story a little bit about how I came about this here. So, just share, okay? So, I heard this quote probably 20, 25 years ago, and I had difficulty finding the origin of who said this, but I think it really kind of resonates very well with me. “Embrace every scar as a lesson learned.” And I think not only for me personally but for our patients. I try to sort of life and learn this and teach this to my patients because as we make choices in our life, those choices make, and so this is really, this knee injury that I’ve had on my left knee really is a direct result of choices that I’ve made as a young man continue to make and as a middle age. So, this story first starts with a sport that is well-endeared to my heart. It’s the sport of rugby.

    These are a couple of pictures of me throughout my years. I mean, down at the bottom here, you can kind of see this guy with long hair standing up. That’s me in college. This picture here up above is me in medical school, and then this is my residency towards the end at the University of Michigan. If you look at the space right here, the guy hiding underneath here that’s a former guest host on our show, Dr. Trustler. I grew up playing football in high school and kind of transitioned to rugby in undergrad just because I didn’t play college football. It’s kind of a sport that is really, I think, been a very important part of my life, as I couldn’t play anymore after several injuries. My first injury was when I was 19. I tore my ACL, and then I’ve had about 5 or 6 other surgeries, including another ACL on the same knee and then multiple cartilage injuries.

    So, it’s really just my left knee that has been affected. My right knee is fine, and as I stopped playing from my last injury, I sort of transitioned into a somewhat different role in the sport. I started to become a referee. I’ve done many college matches and semi-pro matches throughout the years, and then, of course, I started coaching when I couldn’t referee anymore because of my knee. So, these are my kids on the side. Just a couple of years ago, we won the Southern California Cup for their Under 18. So, it’s been an important part of my life, and these are just some of the organizations that I’ve been involved with throughout the years. Just various teams I’ve played with and various organizations that I’ve been involved with. Rugby in and of itself is not necessarily just a sport, but it’s really a community, and I’ve gained a lot of friends and acquaintances and sort of a lot of philosophy of life just from being on the rugby field. And it’s been an important part of my life that has been very difficult to give up. But those scars, every scar is a lesson learned, and this is, unfortunately, what my left knee looked like prior to surgery.

    So, you can see here that each of these screws and each of these scars tell a story. So, this first screw that’s right in the femur here is for my first ACL reconstruction that was a patellar tendon graft when I was in college, and that worked really, really well for a number of years very. Quick rehab after that. I went back to playing just about four or five months later, and it lasted me for an additional 10 to 12 years. Then when I was a resident at the University of Michigan, my chief residency year, I tore my ACL again playing. And the folks at Michigan, the orthopedic surgeons, put me back together here, and that was a total of three surgeries, one of which was in a fellowship. And that involved this kind of long screw, a washer here, and another sort of absorb screw down below, and that was the graft that they used to reconstruct the quad tendon. Just an exceptionally painful surgery.

    But the difference between these two surgeries, when I was 19, it was a massively easy recovery. But when you’re 35 and going through something like this. It’s a much different scenario. Plus, adding in a few cartilage grafts are cartilage tears here. Just exceptionally problematic. So, what kind of really made my decision was if you just look at the difference between my right leg and my left leg here. This right leg is unaffected, and if you look at the axis of the bow here, if you look at this right side compared to the left side, you could see there’s what we call a varus angle. So, the angle of the bone is really off by about 3°, and I never noticed this until it got too late.

    Dr. Sam Jejurikar: Just for our listeners, when you say varus, are you meaning that you’re basically bow-legged?

    Dr. Sal Pacella: Bow-legged, that’s correct. That’s absolutely right, and one thing I didn’t necessarily realize until several years ago was that my surgeons were telling me that when you’re bow-legged like I am, it’s very good for athletics. It’s great for balance. It’s great for speed and explosive movement, but it’s horrific once you sort of have your first meniscus injury. And most people, most athletes who are varus or have a varus deformity in their bones, are sort of predisposed to getting meniscus tariffs. Because if you look at how the physics of this is, it’s really grinding on the inner surface of the knee, and once that meniscus is torn, the setup of the physics and the grind is just exceptional. So, it’s just once you have a first injury; in fact, some of the studies show that once you have your first ACL injury, regardless of whether or not you’ve had any cartilage injury. Within 15 years, you have demonstrated what’s called arthrosis on your X-ray.

    Arthrosis is not arthritis. Arthritis is just simply an inflammation, and if you look at the X-ray, there or may not be a change in the joint structure. Arthrosis is when there’s a visible change on the X-ray, and if you look at my X-ray on the left side, you can see these kinds of out these little bony outgrowths here. So, this is just extensive not only arthritis but arthrosis, actual joint changes. So, I do hope that most of our viewers out here and our two surgeons on the podcast here don’t ever see this in their own X-rays.

    Surgery Journey of Dr. Sal Pacella: Deciding to Undergo Orthopedic Procedure

    Dr. Sam Jejurikar: Awesome. All I was going to say is that even though we’re contrasting your right from your left. You do have some changes on your right side too. Yeah. You got some arthritis and some arthritis on the right side too.

    Dr. Sal Pacella: Yeah, but that’s not as bad.

    Dr. Sam Jejurikar: No.

    Dr. Sal Pacella: But the right one doesn’t hurt. So alright, so this was me the morning of surgery. This was on March 9th this year. So, here’s me as a patient. You can see the exceptionally happy look on my face here, and this is the scar that I already had a big massive scar. So, it’s not I necessarily don’t care how the scar looks, but they just went through the same incision.

    Dr. Sam Rhee: So, Pacella, let me ask you real quick. How hard was it for you to get to this point where you’re sitting in the OR? Like I know you waited a really long time. What finally drove you to decide I need to have the surgery? I can’t live without the surgery at this point.

    Dr. Sal Pacella: So, it was really interesting. My orthopedic surgeon Bill Bugby said, when you, and this is what every single orthopedic I’ve known throughout my life told me was, when you make the decision, you’ll know it’s the right time. And I thought to myself, you know, that’s just ridiculous. That doesn’t make any sense. There’s got to be some objective criteria to tell you when to do this. But he was 100% right. And things such as parking, you park in a parking lot, and there are no spaces, and you find yourself getting irritated because there are no spaces closer to the store or the facility you’re going into. So, you have to walk 30 yards, and it’s like that process of walking just became annoying and just like put you in a bad mood. Every single time I go outside to play basketball with my daughter or Frisbee with my son, it’s like, oh my God, am I going to make a wrong step, and it’s going to irritate me.

    So, just all the things I’d like to do in my life, refereeing and co-surfing became problematic. Surprisingly I would say that surfing anything was the least affected, believe it or not, because with the exception of trying to stand up, which takes a lot of work. But surfing is a relatively low impact on your joints, but for everything else, I stopped running, I stopped hiking, I stopped mountain biking, and it just became obvious that this needed to be done.

    Dr. Sam Rhee: Got it.

    Dr. Sam Jejurikar: You don’t have a typical 9-to-5 job though. Was it hard with all your patient care responsibility, the fact that our jobs never really sort of end when at the end? Was it hard to carve out the time in your schedule? Patients are responsible.

    Dr. Sal Pacella: Yeah, so good question. So, I wanted plenty of time to prepare my practice and my patients, and my partners for this. So, I started the process about eight months. So, I made a decision somewhere around the autumn of the year before knowing that I was going to go out in March. My two partners, Doctor Campanero and Dr. Aria, were just exceptional. They said, whatever you need, get yourself healthy, etcetera, and my patients, I sort of told them I was going to be out on medical leave. I would say a majority of them were very understanding. Some were not so understanding, but the key here is if I’m not healthy, I can’t make you healthy. So, I think once I’m kind of up and moving around, that’s the time for surgery, and for me, the act of standing in surgery was problematic.

    I mean, we do a lot of cases where we’re standing. I thought, at least for the facial cases, I would try to sit down a little bit more. For some of the breast cases, in the end, once you’re sewing, it’s a more appropriate time to sit down or sit on a stool during surgery. But all of that just became much more challenging in my work life. Okay, so this is me the day of. This is also my team here. So, the gent on the right is Doctor Todd Austin, a very good and close friend of mine who did my anesthesia. I was essentially pain-free. They did a block called an inductor block, which is done right before surgery. Pre-operative holding area. And then you’re essentially pain-free for the entire time during the hospital. So, it was just a great positive experience.

    The gent on the right is Bill Bugby, who is a trusted orthopedic surgeon. I chose Bill not only because he’s got an outstanding reputation in the community both in Southern California and nationally but also intends to care for many younger patients with cartilaginous injuries. He’s got an extensive lab where he does cartilage transplants and cartilage growth procedures for young patients who have cartilage injuries. And by nature of his practice, he tends to do a lot of joint replacements on younger people like myself in their 40s or even 30s and a lot of ex-athletes. So, he was it became pretty obvious he was the choice I wanted. So, Bill is just a master technician. Just an exceptionally talented surgeon.

    So, here are a couple of pictures here. So, they snap these photos during the surgery, and for our viewers here, this is a slice open of my knee here, and my knees sort of cracked open like a celery stomach here.

    Dr. Sam Jejurikar: That is terrible.

    Dr. Sal Pacella: Yeah.

    Dr. Sam Jejurikar: That is awful. That’s awful.

    Dr. Sal Pacella: So, just to kind of go over what this looks like. So, imagine your knee opened here. Okay, and what we’re doing on the left side is we’re looking at the undersurface, the joint surface of the fever, the big long bone in the leg. And normally, the surface is very white and shiny, and what you can see here is that the bone is very yellow, meaning that bone should not be there. There should be a white surface thereof cartilage. But you can see that kind of that redness in the bone and the yellowness to the bone; that’s what’s called sclerotic bone. So, that’s when a bone is injured to the point of losing blood supply. It looks very hard and thick. It’s sclerotic, and the whiteness on the white appearance on the outside is the remnant of cartilage, okay?

    So, like that rim of cartilage looks very abnormal, very diseased, very ground out. So, this should normally be white cartilage on a very shiny surface, like a chicken bone. You could see here it’s just kind of amorphous. It’s granulated and sort of irregular in shape, and that’s just a bad disease. I was running around and walking on this for many, many, many years, and obviously, you can’t tell that this looks the way it does, and it’s a surprise. My surgeon told me; I can’t believe you weren’t in more pain from what you described. If you look at the right side, that scoliotic bone is looking at the surface of the tibia. So, that’s the bottom bone of the leg, and that looks even worse. So, that’s where the majority of the cartilage injury is where the bucket handles tears of the meniscus. So, that’s a really, very bad disease surface. So, we’ve said about 96%, 97% of the joint surface was gone.

    The Precise Nature of Joint Replacements

    Dr. Sam Rhee: Dude, that looks like stalks of cauliflower. That’s amazingly bad. Holy man. Wow.

    Dr. Sam Jejurikar: I was going to say cottage cheese. I’m going to the same place. Yeah.

    Dr. Sal Pacella: So, it’s funny as a plastic surgeon, when we work with orthopedic surgeons in the operating room, we often see the worst of the worst, right? Infected joints, we’re often times doing salvage procedures to salvage joint repairs, and we don’t have a lot of understanding of routine orthopedic surgery like this, right? So, the last time I scrubbed in on a joint replacement case was in medical school.

    Dr. Sam Rhee: Same.

    Dr. Sal Pacella: Go ahead. Comments?

    Dr. Sam Rhee: No, go ahead.

    Dr. Sal Pacella: Okay.

    Dr. Sam Rhee: I was just about to say the same thing.

    Dr. Sal Pacella: Yeah, and so we have this kind of joke with the orthopedic surgeons that they’re just this kind of carpentry meat hit kind of guys that they just go and drill with saws and both, and drills, right? But it’s actually exceptionally precise so, and it has to be because if the precision is not there when you do the joint replacement, that joint replacement won’t last very long. So, these on the left side are the cuts that are made to remove the joint surface. So, this is all done with 3D mapping. So, what they do is they put this jig on the femur and the tibia that has kind of a laser-guided surface that tells the surgeon in order to get the absolute mechanical central access of the bone you cut here, okay. And so., the surgeon is responsible for the cut, but it’s all mapped out three-dimensionally, and that was just fascinating for me to hear that.

    Then on the right side, here is my new shiny joint. The prosthesis that I have is something called a Zimmer persona. This is, it comes in 12 different sizes. I had size number eleven, so I had some pretty big bones and big muscles, so it had its surface that it’s like…

    Dr. Sam Jejurikar: How disappointed were you?

    Dr. Sal Pacella: Does exist. So, it’s actually a prosthesis that comes in four parts. So, they first work on the fever, and they put this cap on the fever that’s that shiny metal surface you see here. Then they do the tibia, which is the bottom bone, and then to recreate the joint surface, a ceramic spacer goes inside. So, it’s all very precise how they sort of calculate how big the spacer should be. So, the spacer locks into the tibial’s bottom surface and essentially is your new joint space. So, this is important if you ever need revision surgery. Usually, the part of the prosthesis that wears away is the central portion, the ceramic portion. And then the fourth part of the prosthesis is the inner surface of the knee. So, that is shaved off, and then that that portion is with another ceramic type of prosthesis. So, pretty interesting view here.

    Dr. Sam Rhee: Our computer-guided cuts have really revolutionized this joint replacement. It’s made it so much more precise, I feel like, and I’m glad these guys are using the most advanced technology for joint replacements.

    Dr. Sal Pacella: It’s really fascinating, and it really is; I just have so much respect for these surgeons, both men, and women. The precision is arguably much more precise than our job. I mean, when we are doing plastic surgery, it’s for measuring things in millimeters, etcetera, and to some extent, we do. But there’s inherently a lot of giving in soft tissue. You could stretch things; you can get a feel for it. You don’t have to be exceptionally precise with sewing a muscle flap into a wound because that tissue will grow. But bones are a much different story in that bones don’t change; they don’t stretch necessarily, so they need to be exceptionally precise. So, this is me not in recovery but in my room afterward, and a couple of interesting comments here. So, after the surgery.

    Dr. Sam Jejurikar: Check out that.

    Dr. Sal Pacella: Yes. So, this is actually from a view of the Tory Pines Golf Course. I want to say that this is on the fourth floor four west of Scripps Green Hospital, which sits right on the bluff of Tory Pines. These are exactly the rooms that my breast cancer patients go to for post-operative recovery. So, I was physically in the same room that I have been in for over 12 years where my breast cancer patients go. Room 419. So, I felt very special that they put me in a room with such a great view here. So, in recovery, I have absolutely no recollection of the recovery process. And it was funny, the other day, I ran into a nurse I know. His name is Doug. And he asked me if I hadn’t seen him in a couple of months, and he said, ‘Oh, how’d your surgery go?’ I said, ‘Oh, really good. I didn’t feel anything in recovery.’ He said, ‘Yeah, I heard you cried like a baby in recovery.’ I’m like, ‘You’re absolutely right. You’re probably right.’ I have no recollection whatsoever. The bigger they are, the harder they fall, right?

    And so, this was actually a photograph that my wife took in the room a few hours later. So, the surgery was at 7:30 in the morning. I was in my room by about 9:45, and I was up walking by 11 AM, believe it or not. You can see Walker in the background here. So, now this is an interesting picture here, so, if you recall from these pre-op photos here.

    Dr. Sam Jejurikar: Those are your, yeah.

    Dr. Sal Pacella: These are a screw and a post to screw, and a washer. And so, I was able to keep these here. So, I specifically asked for these, and I don’t know what I’m going to do with them. They’re in an envelope in my dresser drawer, and I think this is kind of an important thing for me to hold on to throughout my lifetime. So, I was happy that these were able to be salvaged. So, the interesting thing is with the recovery, that post-operative recovery is very accelerated. So, years ago, they used to keep you in bed for a week or two. They’d use this passive motion machine to get your leg moving, and that just doesn’t occur anymore. They want you up and walking within hours. And one of the main reasons why I chose my surgery was to be at 7:30 in the morning, not only because it was the first surgery but because you get the benefit of doing a PT session that same day. So, it’s one night in the hospital, and then PT starts just a few hours afterward.

    So, I got to tell you I was completely pain-free at 11 o’clock, and I got up with the physical therapist walking around with a walker, and I said, ‘This is easy? I’m going to work tomorrow, okay? This is nothing.’ So, I was just absolutely amazed at how quickly you could start walking on this prosthesis. Once the cement cures to fit that prosthesis in your femur and your tibia, it is essentially indestructible, and so they want you up walking to get that swelling down and get the soft tissue mobilizing in it, and I was just amazed at how quickly you can get up.

    Dr. Sam Jejurikar: Now, you mentioned that they had done some sort of block.

    Dr. Sal Pacella: Yes, that’s right.

    Dr. Sam Jejurikar: And so, did that contribute to your pain-free existence in a lot of pain?

    Dr. Sal Pacella: Exactly. And I completely forgot about that afterward. I’m like, oh, I’m moving around. No problem. Right? And so, by the next morning, I still was pain-free, and I was like, wow, I expected the block not to last this long. But a couple of days later, the block goes away. You’re left with kind of what is seen on the left side. So, you could just see the tremendous amount of bruising and swelling from this, and so that’s what it looked like, I think, about post-operator today number three. So, the pain just dramatically gets worse from there, okay, and the swell gets dramatically worse. So, I basically was sitting on the couch, getting up, and walking around every couple of hours. This is my dog Hawk, so he was a good recovery for me.

    A little bit about the rehab. So, the rehab starts, and they actually send a therapist out to your house a couple of days a week before you start driving and moving around, and that was just fantastic. I mean, this therapist would come over in the morning and do a PT session for about 45 minutes, and I thought this was going to be a big vacation for me. But it was 100% work for two months because you have to do two PT sessions a day. And the key is getting the end range of motion, both flexion and extension. For me, the extension was the biggest issue. I could not fully extend my leg for probably close to about ten years. I probably had about a two-degree flexion contracture because the extension’s end surface was impeded by arthritis.

    So, if you think about that, what happens is your gastrocnemius muscle, your calf muscle, and your hamstring muscles tighten up, and they shorten over those years. And so not only is it tough to try to get the joint out to length but to stretch out those muscles that are tight. And when you’re a thick fat Italian guy like me with big muscles in your legs, that’s a much harder scenario to do than if you’re 90 years old with no muscle mass. So, younger patients tend to do a bit worse regarding the range of motion than older patients. So, that was kind of a surprise.

    So, let’s go here. So, as far as getting back to like what a full-time job this is I would get up in the morning and do an hour of PT and then I’d ice for another hour, and then, like, by nap time, it’s 11 o’clock in the morning and I’m just completely wiped out. You got to take a nap for an hour or so, and then by the time you sort of settle in, get something to eat, and then you do the afternoon session by about 3 or 4 in the afternoon, and then it the whole process starts over again. And then the first four weeks or so was very difficult to get comfortable at night and sleep. So, you’re on narcotic medications and anti-inflammatories, and you just kind of can’t sleep at night, and then the next morning, you’re just whipped out. So, it is a massive process to get through.

    I would say I was on some narcotic medication. Mostly off of it during the day on about the fourth day after surgery, but I still needed it at night for a good couple of weeks just to get comfortable. So, really, I was sort of not prepared for this all that well based on my experience in the hospital, which is so good.

    Alternative methods for post-operative pain control

    Dr. Sam Rhee: Does this lend insight into your own patient’s recoveries? Because they always say that being a patient yourself makes you understand your own patients.

    Dr. Sal Pacella: Oh, no question, and I think I’ve undergone some major surgeries throughout my lifetime. I’ve had these a few ACLs, and meniscus tears were not easy either. So, I have a very good understanding of post-operatively. So, this only reinforced it for me for myself and my patients just because I kind of know what they’re going through. And the types of surgeries we do, there’s a gradient of pain. So, breast reconstruction in general is very painful. Facial surgery often times is not usually as painful as breast surgery. So, I really try to taper my expectations of the patient’s post-operative recovery.

    But there’s a between using medication and kind of doing other things to help with pain control. I would say that I had a very good understanding of alternative methods for pain control such as ice, ice is key exceptionally important. I had an ice cooler in my bathroom. I would buy bags of ice every two days and constantly keep ice on this thing. I think that was a huge step in recovery. So, the same thing I tell patients is ice is really kind of the main thing to help you with control. Reduces inflammation and reduces inflammatory mediators. It’s just a key concept for post-operative control in any surgery.

    So, I’m happy to report that. I did not necessarily require a walkover very long after surgery. So normally, I think what my therapist was telling me is it’s about two to three weeks that people are on patients are on walkers. And I was able to transition to a cane very quickly within the first week. So, I had a lot of residual strength. I spent a lot of time prior to surgery trying to get a range of motion and strength before sorting of pre-habilitation, if you will, as opposed to post-rehabilitation, and was able to use a cane pretty quickly afterward. This is the good news a couple of buddies of mine actually bought me these canes, and I thought these were awesome. So, the one on the right is a shark which I thought is very fitting for some of my hobbies. And then the one on the left is, you guys recognize this.

    Dr. Sam Jejurikar: That’s a dire wolf.

    Dr. Sal Pacella: Exactly. So, I call this the cane of thrones.

    Dr. Sam Jejurikar: Exactly.

    Dr. Sal Pacella: These are kind of fun. So really interesting.

    Dr. Sam Jejurikar: Yeah.

    Dr. Sal Pacella: So, this is my post-operative view of my X-ray. So, for my first post-operative visit and you could see just the extent of what’s replaced here. So, this prosthesis fits like a cap right on top of the femur and fits like a kind of nail or plug into the tibia. And the thing that surprised me about this when I kind of looked into it was, I sort of had this vision that the entire end of the joint was amputated. But that’s actually not how it’s done; it’s just the articular surface that’s removed. And so, that leaves you a lot of good bony stock left behind, so if you ever needed a revision, you have the bone there to do it. The good news with this is it gains me about half a centimeter of height. So, now I’m actually a little bit taller than I was beforehand, so that’s a good thing.

    Dr. Sam Jejurikar: Yeah, 

    Dr. Sal Pacella: So, if you look at these here, these photographs. So, this was on the left; this was before, and, on the right, this is after. And what I wanted to show you here is just the angle of the axis of this bone here. So, you can see here on the pre-operative picture that’s a good 5 degrees varus. 5 to 7 degrees of varus, which is a huge deformity, and then afterward, it’s essentially straight within about one to 2 degrees of ferrets. So, the important thing is the surgeon will sort of dial in the amount of varus based on your existing genetics, right? So, you don’t want to be exactly 100% straight because the opposite side is still in varus deformity. And so, he accounted for that, and my knee feels very symmetric when I’m kind of doing my exercises now. I feel a little bit more stable. Don’t feel like I’m kind of shifting or listing over to the side. So pretty, pretty fascinating.

    Dr. Sam Jejurikar: What an interesting thing.

    Dr. Sal Pacella: So, those of you that are a little older like these two guys and me, you may remember this series from the 70s or 80s. It’s the $6 million dollar man, so this was Steve Austin, Lee Majors. Steve Austin had all of his essential joints replaced, and kind of became a superhuman. So, I’m not exactly the $6 million dollar man, but this is a copy of my bill, okay? I’m about to eat $110,000, man. So, you can just see here that this was just one joint. So, if I had my total body replaced, I’d probably be close to, what I calculated, probably be close about 10 million dollars to account for inflation. And so, this is just an exceptional cost obviously for patients if you’re paying out of pocket, and if you look at the surgical services here. So, $57,000 for the prosthesis. Actually, no, that’s not true. Supplies. So, $30,000 for the prosthesis.

    That’s an exceptional cost, but if you think about you know what that means for someone’s life and someone’s longevity. That’s a fraction of the cost of someone’s earning potential. If you cannot work or you cannot provide for your family because of arthritis, that’s it can add a few zeroes to there and lose potential income or lost support for someone. So, this is a huge advance in medicine that we’ve had throughout the years.

    Perspectives on Pain Management and Recovery after Major Surgery

    Dr. Sam Jejurikar: I’d like to actually call you the $14,100 man for your bills. I’m not even giving you $110,000, $95,000 in write-offs right there. So, but still impressive. So, let me ask you one question because I mean it’s interesting, I mean just fascinating how bad the disease was you were living with. You talked about the pain. You didn’t dwell on the pain, but it’s clearly a very painful recovery that’s going on. You’ve been through painful operations before, but out of this most recent operation, you have, which is by far and away the biggest one you’ve had. Like what new perspective do you have when dealing with your own patients? Are you prescribing medications differently? Like people are complaining because a surgeon sometimes will have patients that want to be on pain meds forever. How are you doing things differently as a result?

    Dr. Sal Pacella: Well, I would say I was always very intuitive to patients’ pain and discomfort. I would say that on the bell curve of things, I personally, as a physician had a bit of a challenge dealing with that subgroup of patients on the bell curve that may have had challenges getting off of. Maybe the pain is extensive. Maybe there are some underlying factors that are, of course, here. So, I think my experience now has really helped me a little bit more with that sort of subgroup that may have difficulty getting off their patients. And I’m a big proponent of sort of alternative methodologies of pain control. So, for example, I mentioned obviously the ice, the elevation, and acupuncture. I haven’t personally tried it, but I’ve heard great things about it.

    For years with our breast cancer reconstructive patients or breast cancer patients, I’ve advocated for utilizing THC or CBD, that’s Real big in California. I’m a big believer that that’s a great methodology as an adjunct for control that we haven’t really grasped onto or believed in as providers. I think that’s the ability of the providers to kind of utilize that in the regimen as one small piece, and I think that’s huge. I personally hadn’t used I did not use any PHC or CBD. No, that’s not true. I did use CBD but not THC during my joint recovery, and honestly, I’m a big believer in CBD. I think it really tremendously. It helped me sleep a bit at night. There’s no sort of high component to it at all. The CBD is legal in most States, I think. I think it’s not necessarily a regulated medication, but I think if you stick with recommendations and purity, it can be very helpful. So, those things I think are very important for patients to kind of make a multimodal approach to pain control.

    Dr. Sam Rhee: I think one of the biggest things we have as doctors is it’s hard for us to give up trust and control to another physician because we have been on that side. We’ve been in control, and I see time and time again when you have to give yourself up and put yourself in someone else’s hands, you have to do it. You have to go; we know you have to go all in and fully trust your provider. That’s the only way you’re going to get a good outcome, most of the time, is fully trust that provider. But that’s a hard thing to do.

    Dr. Sal Pacella: It is, and I will say that in time, what’s made this process easy for me is being a surgeon and knowing the reputation of the surgeons and anesthesiologists I work with. I sort of just completely gave in to the process, and because it was very easy for me because I personally know these people, right? Now if I had a medical problem that didn’t require surgery, I’m not be an internist or a medical physician. It’s a lot more difficult for me, even with my children. One of my children has medical issues, to put my trust in a pediatrician or an internist that I don’t necessarily know. That’s something I have to learn and deal with as a parent and as a human. But in surgery, it was really easy for me because Phil has an exceptional reputation. I know he thinks through things. He’s going to do the right thing. He’s got thousands and thousands of reps doing this operation, and to me, that was a tremendous amount of comfort.

    So, when I have these kinds of little spikes after surgery, oh my God, I feel this ache of pain here. Is this the prosthesis failing? I had to kind of grasp and stopped myself from that and say, well, this can’t possibly happen. Let’s just kind of wait for my disappointment and not freak out about it. It’s really easy as a physician to freak out about things. Yeah, and just a little bit about kind of the recovery now where I’m at. So, I’m about four months in, and I’m back to working full-time. I’m back at the gym. I’m doing Stairmaster. I’m biking. I’m doing inclined walking. I haven’t kind of run or jogged yet. I don’t plan on doing that to any extent. The more you sort of do a lot of higher impact sports that can affect the length of the prosthesis. It’s not prohibited. So, I do plan to kind of go back to a little bit of refereeing if I can.

    I actually was surfing this morning, and it was a little questionable as to my strength, but in the next few months, I think that’ll get better. But I was able to stand up, and kind of get a few waves this morning. So, I was pretty excited about that. So, back to everything for the most part.

    Dr. Sam Jejurikar: That’s amazing. Well, Sal, thank you so much for sharing that with us. It’s definitely nothing that Sam and I have been through such an extensive operation patient and so. Perspective and what we have to look forward to over the next few decades of our lives. That’s right.

    Dr. Sam Rhee: Thank you so much, Dr. Sam Jejurikar.

    Dr. Sal Pacella: Alright. Thanks. Appreciate it.



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