How To Keep Your Joints Jumpin,' With Leading Orthopedic Surgeon and Sports Medicine Expert Alan Beyer, M.D.

What if we're not stuck living with weakening bones and painful knees or hips as we age? Join host Jan M. Flynn in conversation with Dr. Alan Beyer, the Executive Medical Director of Hoag Orthopedic Institute in Newport Beach CA  and host of radio show "Doctors in the Dugout" as he talks about heading off osteoporosis, what to do if joint pain starts limiting your life, and his journey through his own hip replacement. 

Show links:

Dr. Alan Beyer “On the Other Side of the Scalpel” video blog

Or watch on YouTube

Hoag Orthopedic Institute, home page

Alan H. Beyer, M.D., Hoag Orthopedic Institute

Doctor in the Dugout Radio Show (AM 830)

Music on this episode includes Weathervane and Chafftop by Blue Dot Sessions.

Transcript

Jan, host: 

Hi, I'm Jan M Flynn, your host for this episode of crow's feet life as we age. And if you've clocked enough decades here on Earth, your joints and your spine, or maybe both, have probably gotten your attention. And if you haven't had a joint replacement yourself, you probably know one or two people who have and maybe you're facing that possibility yourself. So I'm really excited to have orthopedic surgeon Dr Alan H Byer as my guest. 

He is the executive medical director of Hogue orthopedic Institute in Newport Beach, California, and he's not only performed hundreds and hundreds of joint replacement surgeries himself, but has also undergone a hip replacement, and he's produced a video log of his experience. He's also a leading sports medicine specialist who hosts a weekly Saturday radio show, “Doctor in the Dugout” on AM 830, the home of Angels baseball — where he and his guests take deep dives into all things sports, while adding an entertaining twist on sports related medicine. And you'll find a link to that show in our episode notes. 

And luckily for us, Dr Beyer is passionate about educating folks about how to maintain or regain our mobility and quality of life as we face things like arthritis and osteoporosis and other challenges of our aging bodies. 

So Dr Beyer, welcome to Crow's Feet. 

Dr. Alan Beyer, guest:

Thank you. It's absolutely a pleasure to be here today, Jan. 

Jan:

Well, it's wonderful to have you, and besides being a sports medicine and joint repair specialist, you have a lot of expertise in osteoporosis, and that, of course, is a big concern for at least half of our aging population. So what would you like people, especially women, types to know about keeping our skeletons healthy? 

Dr. Beyer: 

Well, this is a great topic to start off with. First of all, as you alluded to, more than half of our population is going to have significant encounter with osteoporosis. Everyone knows that women become more susceptible to osteoporosis post menopause, when their hormone levels start to go down and continue to go down, and estrogen and progesterone protect our bones, keep them well calcified and keep the body from letting the bones decalcify. So it's a natural for women to get more osteoporotic as they get older. 

But it affects men as well. Testosterone is somewhat of a protector of bones too, so it really affects a very, very large segment of the population as they're aging. You know, a number of years ago, the kind of current concepts in medicine were anti hormone replacement therapy. We were encouraging women not to go on hormone replacement when they hit menopause because of the associated cancer risks. Certain cancers are fueled by estrogens, breast cancer, uterine cancer, ovarian cancer, so many, many physicians in those days were pushing women away from taking hormone replacement. 

That pendulum has swung a little bit, and now physicians are becoming a bit more liberal in terms of encouraging women to take low dose hormone replacement therapy, sometimes with bio-identicals, sometimes with actual hormone replacement, and some men as well, when they take a dive in terms of how dense their bones are. 

Now, how do we measure that? We use a tool called the DEXA scanner, which I think should become a part of people's annual regimen when they hit their 50s and 60s and older, just like you get your colonoscopy every five or 10 years, women get a Pap test almost every year. 

They get a mammogram every year or two, and a DEXA scan should become part of people's preventative health program as well, because that shows us how the density of the bones are in certain critical areas. The lumbar spine, the hips and the wrist are typically the three areas that are honed in on because we have large amounts of data that let us compare the patient’s scan to a known population and assess their risk of an insufficiency fracture — fracture that they sustain because their bones are osteoporotic. 

So I think the first steps here are prevention and detection, which is through the use of DEXA scans on a regular basis, and a first line therapy is to take vitamin D, to take supplemental calcium, to add to your diet. And talk to your physician about the possible use of of hormone replacement therapy to keep your bones up to snuff in terms of their their calcium levels. 

Jan:

Yeah, that's all really good to know. And just for people that aren't so used to the nomenclature “DEXA scan:” I have had a couple of DEXA scans. And really I think what confuses us, is people tend to call them bone density tests. It really means the same thing, right? 

Dr. Beyer:

That's correct. And there's no significant amounts of radiation, like there is with a CT scan or certain other PET scans that we do. So it's really nothing to be fearful of in terms of it having a downside risk. 

Jan:

Oh, no — basically you lay on a table and nothing happens. It's, it's very, very un-scary. And I, like I said, I've had a couple of them, but I have not had them recommended yearly. And I agree with you. I think that would be something that would be great to add to the normal practice. Because it's a big deal. 

My mother had osteoporosis. I was one of those who was kind of guided away from taking hormone replacement, although I do take my vitamin D and my calcium and I'm very careful about doing weight bearing exercise, which I understand is important too, for keeping our skeletons strong. 

Dr. Beyer:

That can't be overstressed. I mean, you know, the bone is actually a crystal. Those of you who remember your days of inorganic chemistry back in high school and college, it generates an electrical current whenever there's force applied to it. So when you're walking or weight bearing, doing any weight bearing activity, your bone is actually laying down more bone in response to the stress that you're placing on it.

 So it's very, very important to do weight bearing activities to keep our bone health. Swimming, unfortunately, though it's a fabulous exercise for muscles and joints because it eliminates gravity, it's actually not a great activity for preventing osteoporosis. You need that weight bearing to really get the effects of on the bones of doing that exercise. 

So weight bearing activities, be that as little as just regular walks, are very, very good at stimulating bone to lay down more calcium being deposited in the bones, which is what we're fighting for when we're trying to prevent osteoporosis. 

Jan: 

And I love that mental image of the bones as crystals, sort of laying on more crystal as you are lifting weights, which I do, or walking, or doing anything that is has some impact. So I'm going to keep that in mind. When I'm feeling like I don't feel like a workout, I'm going to remember I’ve got to add to my crystal collection. So that's a good tip. 

So moving on from osteoporosis, then — oh,  by the way, actually, I did want to ask you about medication for osteoporosis, because I know several people who are on it. My mother was on the daily dose, but now I believe they've moved to a weekly or monthly pill that people take. Is that correct? 

Dr. Beyer:

There are some injections or pills that are even monthly. We've come a long way in the in the medical treatment and reversal of osteoporosis. The early releases of these drugs had significant side effects. They caused a lot of esophagitis and gastritis, stomach problems, and it was even recommended in the original days, when people were on Fosamax, which is one of the first ones that came out, that you take a holiday from Fosamax every year year and a half, just to let your system overcome the effects of it. 

The drugs today are far more sophisticated, far more specific, have far less side effects. You know, every medication has side effects. If aspirin was invented today, it would be a prescription drug because of the side effects of aspirin. 

But I think that this is a topic that you need to sit down and discuss with a lot of gynecologists. I have a lot of expertise in osteoporosis. There's a whole cadre of endocrinologists who are now very, very interested in the study and treatment of osteoporosis. So I think sit down with an expert. Find someone in your area who's an expert, and if you are diagnosed with it based on your DEXA scan, your bone density scan, by all means, find the expert. 

Sit down and discuss the pros and cons of each of these things. For many people, just the calcium and the vitamin D and the exercise are enough to get them by. But some people are resistant to that and do require the pharmacological intervention. 

Jan: 

You mentioned reversal. So is it possible that osteoporosis can actually get better?

Dr. Beyer: 

 Absolutely. Sometimes, just the calcium and the vitamin D and the exercise is enough to get improvement in the calcification of the bone. So it doesn't necessarily need the pharmacological adjunct. I think that's dependent on severity and on, the resistance to treatment with the less invasive methods.

Jan: 

 That is really, really encouraging. Okay, so now let's move on to our joints. What's with our joints as we get older? What do we do when they get creaky and cranky, and are they all going to give out, and are they all going to limit our movement? What can we do?

Dr. Beyer:

 Well, you know, we're all just basically the human machine, and like any machine, a machine wears out when you use it enough. Some people are more prone to getting arthritis in their major joints: their hips, their knees, their shoulders. 

Look back and kind of try to remember if your mother or father or both had osteoarthritis, because that's a pretty good predictor that you are going to be at risk for osteoarthritis. 

But what can you do to try to prevent its effects? One would be to eat a healthy diet, a balanced diet, not just because it prevents arthritis, but it prevents you from gaining unnecessary weight. And weight is a definite impact on our joints wearing out. 

The data that I like to use is telling patients that for every pound that you weigh, that's three pounds of force on your knee with every step you take, just because of the geometry of the way our lower extremities are constructed. So if you drop 20 pounds, you're putting 60 pounds less force on your knee with every step you take. So that's an easy way to people feel they're getting three times the benefit for their buck when they're losing some weight. That's one good thing to keep in mind. 

Some osteoarthritis is genetic. Nothing you can do about it, but try to decrease the severity and the incidence by controlling things you can control, like your weight. Exercise is a very, very good way to keep your joints moving. Our joints need lubrication, just like the bearings in your car, by using them. 

And here's when swimming is a great activity, because you're not fighting gravity in the pool, and you get the resistive effect of the water against your muscles when you're using your arms and your legs. It’s like you're using thera-bands: you're getting more bang for your buck with every stroke or every kick that you take in the pool. So that's a great exercise. 

The exercise you want to decrease to the lower your instance of arthritis would be impact activities: jumping, running, marathons, skiing, double black diamonds. Those kinds of things kind of wear your joints out a bit faster. 

Now, sometimes your joints can wear out because of an old fracture that you might have had. So you get a post traumatic arthritis, which is really an osteoarthritis, a wear and tear arthritis. 

And there's a whole class of arthritis that are inflammatory, the old rheumatoid arthritis, lupus arthritis, psoriatic arthritis. These are all the body's autoimmune responses to itself, and we're actually seeing a lot more of these of late. So there's got to be something environmental going on that's causing us to see more and more patients with these disease, as you can tell by the number of ads you see on television for the drugs to treat these inflammatory arthritis problems. 

But be that as it may, arthritis is still just a wearing out of the joint. It's loss of the cartilage that cushions your joint and often winds up leading to a hip or knee or even a shoulder replacement when we're at a point where the pain is unbearable. 

Jan:

It sounds like, in terms of prevention, it's all the things we should always be doing anyway: eating the right kind of diet, keeping moving, and maybe mixing it up, maybe some swimming and some weightlifting. But it's  really up to us to follow that lifestyle.

But let's say we're doing all the right things and then it seems like we really can't do what we want or need to do because our joint pain, or our lack of range of motion, is limiting us. 

What are our options? Because I know that a lot of people really want to put off surgery for as long as possible, and is that always the best approach?

Dr. Beyer:

Well, I always say that my definition of minor surgery or surgery on anybody else but me, and that should kind of be everybody's definition of surgery. You don't want to have surgery, unless you have to have surgery. 

So let's go through quickly what the algorithm is for how we treat somebody who has who presents at the office with arthritis, let's just say, in their knee. 

For simplicity's sake, we'd start out with a just some mild anti-inflammatories, be that a non-steroidal like Advil, Aleve, Motrin, those kinds of drugs. Tylenol is not ant-inflammatory. You can use it to treat pain, but it doesn't have any anti-inflammatory effects. So that's not one of our first line drugs. 

So oral anti-inflammatories, loss of weight, and motion using the joint which lubricates it better. You know, in the old days, we should tell somebody with a hot, swollen joint to just sit it out and just lay there with your leg extended. We'd even put them in a cast in the old days sometimes, but now we're 180 degrees the opposite. We want people to move their joints, because the more they move the joint, the more the joint lubricates, and that's important. 

So the first step is just those simple things. Some therapy, strengthen up the muscles a little bit so the joints can move better, and you can do a little bit more exercise. The next step would be go into some injectables, which are sometimes steroid injections,  or sometimes lubricant injections — which are hyaluronic acid, the same thing you see advertised on TV to kind of plump up the face a little bit, because they do provide lubrication. They're like WD 40 for the knee, for want of a better term. 

And now we're starting to get into some of the stem cell things like PRP plasma, platelet rich plasma, and stem cell injections. Although that still has a way to go, there's still not great data on that stuff. 

So when all that has failed, arthroscopically treating arthritis of the knee or hip or other joint is not really highly recommended anymore. Most of our studies have shown that when you stick a scope into a knee that is very arthritic — not just a torn meniscus or a torn ligament, but rather full on arthritis — you can often make that joint react poorly, and it actually gets worse after you've scoped it. 

You think you're just going to go in and “clean it up.” People will say, “Clean up my knee for me,” but that doesn't work. That's not a long term solution, and it can actually hasten the development of the disease even further. So arthroscopic surgery for arthritis is not really, in today's times, a way to go. 

Finally, when you get to the point where either the pain is so bad that it's waking you up when you turn over at night (that's what drove me to have my hip replaced. I’d turn over bed and the pain would wake me up), or the motion becomes so limited that you can't put your socks on and  you can't do just activities of daily living comfortably. 

That's when you have to have the conversation with the surgeon about, is it time for a joint replacement? And you know, we've come a long way with these joints in the 40-something years that I've been in practice. We used to tell people they (replacement joints) would last 10 or 12 years. Now we think they'll that a well-placed, total joint emplacement will last 25 or 30 years. 

So it's not that you have to get (patients) into their 70s before you think about it anymore. We’re doing plenty of them on people in their 50s and 60s, when the degree of symptoms has gotten to the point where there's no other conservative therapy left. 

Jan: 

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Now back to my conversation with guest, Dr Alan Beyer, a renowned orthopedic surgeon and sports medicine specialist who's here to share his expertise on how we can keep our bodies moving and thriving as we age. 

So Dr. Beyer, you were talking about your own hip replacement, and I watched the vlog, or video log, that you created on YouTube of your experience, and I have to say it was very reassuring. So it's been about what, 11 or 12 years since then, and what would you want our listeners to know? 

Dr. Beyer: 

So yes, my hip replacement was 11 years ago. We have come such a long way, even in that 11 years. And my post-operative course was so benign. I mean, from the time I woke up after the surgery I needed nothing stronger than a Tylenol for pain. The whole time after the surgery, I never took any opioids or narcotics. 

That's not always the case. Some people are going to need a short course of some pain medication. So I don't want to you know over promise and under deliver. 

But we've come such a long way, even in that 11 years, with our techniques of anesthesia. Some of the anesthetic blocks we're able to do are long lasting: they last the first few days after surgery. The less anesthetic that we use because of these blocks,  people don't wake up with that anesthetic haze like they used to.  

Over 50% of our joint replacements now go home the same day. At most, they stay one night. We can thank Covid a lot for that — that got people out of the hospital faster because they didn't want to be in the hospital during the pandemic.

 So it's really, come a long, long way, and it's life changing. I mean, I could not play golf two days in a row before I had my joint replaced. I was limping up and down the halls of my office to the point where I look worse than the patients did. So it really made a huge, huge difference in my quality of life. 

And then that's the decision maker. None of these are — this isn't cancer. You know, you're not going to lose your life if you decide not to have this done. But you have to decide, how do I want to live the rest of my life? And my feeling is, you want the highest quality of life that you can have for whatever number of days the good Lord has granted you. That's to me, the mantra that I go by. 

So the thought process of, I'll put this off till I'm 70 or 75, well, you've just taken away five or six years of the enjoyment and benefits you could get out of this by doing it. Now, if I tell you that having it at 65 it's probably going to be the last time you ever have surgery on that joint, it's going to last you the rest of your life. So why deprive yourself being able to get on the ground with your grandkids, or, you know, play two rounds of golf in two days, or whatever? 

So quality of life is the mantra here. What is your expectation for your quality of life? And these days, I 180 degrees go in the direction where, if I never write another opioid prescription for a patient, that's too soon. We need to get out of the opioid business. Doctors had the wool pulled over our eyes with that whole opioid thing ten, fifteen years ago, where everybody thought, oh, pain is the sixth vital sign. I should have no pain. And we were sold a bill of goods by the manufacturers of opioids. 

We’ve got to get off of that train and just never write opioid prescriptions if we don't have to.

Jan:

 I think that's a good point too, because I do think that one of the fears people have about going into surgery is that, you know, surgery is scary enough because you're so out of control and then people are afraid that they're going to get hooked on painkillers. And you're telling me that not necessarily are you even going to have that much pain, and if you do need some support to get through it, you're not going to end up, you know, addicted to oxycontin or something like that. 

Dr. Beyer: 

Exactly correct. 

Jan: 

Okay, great.

So you've talked about your hip replacement, but I know that you yourself do knee surgeries a lot, and I'm just wondering if you can kind of walk people through quickly: what they can expect if their orthopedist is telling them, you know, it's maybe time to think about surgery for this. It might be time for a new knee.

What are they in for?

Dr. Beyer: 

So first of all, I will say that the recovery process from a knee replacement, and be it a partial knee replacement or total knee replacement — and I'll talk about what the differences of those are in a second — is a little bit more intensive than the rehabilitation from hip replacement.  Just as a function of the tissues that are involved, and there’snot as much soft tissue padding, and it's a slightly more painful experience.

That said, we do have a lot more ways in terms of the anesthetic blocks and things that I talked about, around the knee than we have around the hip. So we have tools to deal with that. There are some variations of knee replacement. There's partial knee replacement, where only a portion of the joint is replaced, if the arthritis is limited to half of the knee and the ligaments are intact. Then there's a traditional total knee replacement, where the end of the femur, the end of the tibia and the back of the kneecap are all replaced. 

There's a lot of talk today about robotics, and most of us use robotics. Some of us use it more than others. It's not necessary on every case; it doesn't necessarily turn out a higher quality outcome. A skilled orthopedic surgeon who's done hundreds or thousands of these doesn't need the robot for a straightforward knee replacement. 

So for people to say, “I'm going to this guy because he only uses the robot and that guy doesn't,” that guy who doesn't might be doing a better job than the guy who does. So you’ve got to just go with the surgeon. Don't go with the technology; that that's always been my kind of philosophy in life. 

But you do want to do the research about where you're having it done and who's doing it, because there are differences in outcome based on the facility and the surgeon. And this data is all publicly reported. You can see what a hospital’s infection rate is, what their readmission rate is, what their go-back, taking back because of a complication is. This is all publicly reportable data. 

And I will say Hoag Orthopedic Institute, which is where I work — you can go on their website, and they'll send you an outcomes book that actually shows you what their reported outcomes are. 

Any hospital that's going to be that transparent about their data, you should feel pretty good about because guys with good data like to report it. Guys with bad data try to, like, not be so transparent about it.

 So do the research: find the best facility where you can  get this done, where they do a high volume of them. And do the same for your surgeon. Never fear getting a second opinion, you're never going to, you know, kind of upset your surgeon. If you say, I want another opinion, any doctor who tries to talk you out of a second opinion, you should walk right out of their office and go with the second opinion. 

So those are, those are just rules of thumb that you have to take. This is, this should be a one-time operation, so put in the time, do the research, find the best place, find the best surgeon, and then go from there. 

Jan:

Well, that makes a lot of sense. And as you say, this is not an emergency surgery to save your life or something that you need to do before the tumor gets out of hand. So it's, I guess, incumbent on the patient to take the time to inform themselves and do the research, and, you know, access all that good stuff online that we that we can find out if we're at all resourceful. 

Is there a site, I mean, you said that Hoag, for instance, will offer patients a booklet of their own outcomes. Is there a site that that people should know about? One that they can go to, or a kind of site that they can look through to do that kind of research for any particular hospital or any particular physician? 

Dr. Beyer: 

Well, most of the major medical centers that do a lot of joint replacement and orthopedic procedures will publish it. Mayo Clinic publishes it. The Hospitals of Special Surgery in New York publishes it. We publish it. And a lot of states will publish the data for the hospitals in their state. California, I know does that.

 And I think most states have gotten to that point where they have a registry that patients can access and find that kind of data and outcomes that I alluded to. So like I said, do the research, put in the time. 

Also, put yourself in in a perfect prehab mode before you have it done. Make sure all your other medical conditions are well controlled. If you're a diabetic, make sure your diabetes, your hemoglobin is under seven. 

Make sure that you don't have something hanging over your head like, oh, I've got to be better six weeks from now, because I've got this cruise planned. Don't do that. Don't do that to yourself. Don't put those kinds of stressors on yourself. Do it when your calendar is clear, when you've got some help, some family or friends who can help you that first couple of weeks where you're going to need help. Don't bite off more than you can chew. It's tough enough to just concentrate on your recovery. Don't have a bunch of outside things glomming onto your brain and fighting for attention. Do it when the time is right for you. 

Jan: 

So a lot of the outcome really has to do with the patient setting themselves up for success. 

Dr. Beyer: 

Absolutely correct. That was very  — I couldn't have said that better myself. 

Jan: 

Well, cool — I have to say I find a lot of this encouraging and empowering. You know, it feels like we're less at the mercy of our aging bodies, and a little more in the driver's seat, especially with the medical advances and what we know about health and maintaining good health. 

So now we're going to move into the three traditional questions that we like to ask our guests, kind of towards as we close. And these are just quick, rapid fire questions that we just like you to sort of answer them off the cuff. 

Dr. Beyer: 

All right, yep.

Jan: 

So first, what surprises you most about your own experience with aging? 

Dr. Beyer: 

Wow. I think that once it starts to kick in and you realize your mortality, it's how fast it kicks in. You can fool Mother Nature, but you can't fool Father Time. And I think that that's what caught me a little bit off guard.

That, and when I had my first grandchild a couple of years ago; that's when I really began to feel my own mortality. And I said, you got to be around here for a long time so this kid can be impacted by their granddad. Yeah. 

Jan: 

Well, congratulations on your grandchild! I do not yet have the pleasure, so I'm a little jealous. That's great. 

And second question, if you could, what would you now tell your 25 year old self?

Dr. Beyer: 

The old If I knew then what I know now question!

I think the best — and I'm probably guilty of not following my own advice here; I'm not going to make myself out to be this perfect human being — develop healthy habits before they become too ingrained. 

And this runs the gamut from how you eat, whether you smoke or not. You know what, how much exercise you get, your work habits, the older you get, the harder it is to change. So try to develop as healthy a lifestyle as you can. Mentally, really, physically, emotionally, every single way when you're young, because it's much, much easier to keep that going then to try to change something and realize, oh, heck, I shouldn't have done that. 

Jan: 

Good advice, 25 year-old us —  and the last question is, what is it about aging that you are still trying to figure out? 

Dr. Beyer:

I think what surprises me the most is when the wheels start to fall off. They all fall off at once or very close together. 

I mean, suddenly you can't see as well, suddenly you can hear as well. Your balance isn't quite what it used to be. Your memory isn't quite what it used to be. It's like all of your senses kind of all get dulled, and it really takes a lot of effort to try to keep doing things the way you did them, when you don't have quite the same quality of tools as you had before. 

So I guess the key is to just find good ways around it, keep compensating and you know what? And also don't feel that you have to work till you drop dead. I mean, I think that, you know, we've all worked hard in our lives, and when you get to a certain point, say, hey, job well done. Now it's time for me to do some me time. 

Jan: 

Amen to that. I really do like that message. 

Well, thank you so much, Dr Beyer, for being with us today. This has been just so illuminating. I've learned a lot, and I find it very reassuring, and I'm so grateful to you for taking so much time out of your very busy schedule to visit with us. 

Dr. Beyer: 

Well, I like spreading the tonic around, take what I've learned over 40 years and spread the cheer so everybody can feel a little bit better about themselves and what the future holds. 

Jan: 

Well, that really makes a big difference. So thank you so much. 

Dr. Beyer: 

Thank you, Jan.

Jan:

And thanks for joining us for this episode of Crow's Feet: Life As We Age with our guest, Executive Medical Director of Hoag Orthopedic Institute, Dr Alan Beyer. 

For more information about Dr Beyer, Hoag Institute and Doctor in the Dugout, check the links in the episode notes. 

This episode was produced by me, Jan M. Flynn, with support from senior editor and founder, Nancy Peckenham, sound designer and engineer, Rich Halton, public relations and marketing expert Nancy Franklin and podcast team members, Betsy Allen, Jean Feldeisen, Lee J Bentch, Melinda Blau, Jane Trombley, and George “Ace” Acevedo.