Hi, everyone. This is Lucas Voss with the
Becker's Healthcare podcast series. Thanks so much for
tuning in today, and I'm very excited
to be joined by 2 great experts today,
doctor Keith Behrendt, chief medical development officer at
Ortho Alliance and surgeon partner at JAS
Orthopedics,
and doctor Wilburrd, surgeon partner at Atlantic Orthopedic
Specialists.
Doctor Behrendt, doctor Boyd, thanks for being here
today. Great to have you.
Great to be here. Yeah. Thanks so much.
Looking forward to it. Absolutely. This is a
fascinating conversation.
Before we get into the weed of things
here, doctor Behrend, would you mind introducing yourself,
and then we'll follow that up with doctor
Burd. Can you talk a little bit about
your yourself and your work?
Sure. Thanks. So my name is Keith Behrend.
I am a hip and knee surgeon,
in New Albany, Ohio outside of Columbus.
Been here,
a little over 20 years in specialty practice.
Did a fellowship here, with JIS Orthopedics, Adolf
Lombardi, Tom Mallory, and and stayed on as
a partner.
And,
I've been down the road of really
jumping into the partial knee
pool, and then the anterior hip pool, and
then sort of my midlife crisis has been,
that kinematic alignment with the medial sphere concept.
And so I'm excited about the discussion today.
Absolutely. Doctor Byrd?
Yeah. Thank you. Yeah. My name is Will
Byrd. I'm a joint replacement surgeon out of
Virginia Beach, Virginia.
Been in practice for about 5 years now
and specialize in hip and knee replacements.
I have a focus in outpatient surgery with
rapid recovery protocols. And for my knee replacements,
I'm doing a unrestricted caliper verified kinematic alignment
through a subbasis approach.
That sounds very complicated.
It's a lot of words. Yeah. We'll talk
about that in a second. And I it
was very interesting. As I was doing some
research and looking into these questions, writing these
questions, I had actually heard of kinematic alignment,
we'll call it k a, throughout the conversation
here, because I follow, you know, athletes a
lot and and injuries and how they recover,
etcetera. So I had heard of kinematic alignment,
and and it has certainly gained some popularity,
because of its accessibility
for a lot of different patients. Doesn't matter
if you're high performing athlete or not, whatever
it may be, and, certainly, the compatibility
with, the implants on the market, etcetera.
We'll start with, with doctor Behrend here. Can
you walk us a little bit through what
PACE
and elaborate
on
why it's seeing sort of a popularity spike
and why physicians are gravitating towards it?
Sure. I I I think that's probably the
the biggest crux of the discussion
around KA
worldwide, and that is, you know, what what
is it? So kinematic alignment really goes back
about 20 years, maybe maybe 18 years to,
the work of Stephen Howell.
He was working off of some concepts that
were brought forth by,
researcher named Eckhoff,
looking at the cylindrical axis of the knee.
And so fast forward now, again, almost 2
decades, and Steve Howell, it turns out, was
correct
in his assumptions and and in his science
and and clinical,
application of the concept where,
basically, in order to do what is real
kinematic alignment, you can call it anything you
want, but the only true kinematic alignment
is resurfacing the knee
back to its original surfaces.
And so by definition, you have to take
out the exact same amount of diseased bone
and cartilage
that you're replacing
with metal and metal and plastic.
The only really way to do that is
with caliper verification. It's been proven, multiple times,
as doctor Byrd
And so we can talk about inverse k
a and gap balancing
and restricted k a and and sort of
k a and robot this and blah blah
blah.
Resurfacing the knee back to its pre arthritic
state by removing the same amount of bone
and cartilage is being replaced by
the implant.
That is kinematic alignment, and it has to
be unrestricted,
and it has to be verified with a
caliper.
Yeah. And doctor Byrd, you you mentioned as
you mentioned been talked a little bit through
that as well.
Why why are more physicians gravitating towards it
right now?
Yeah. I think that's a good question, and
you are seeing kind of a cultural shift.
And,
you know, historically, we've always had this alignment
strategy, this mechanical alignment strategy.
And that's kind of been the dominant force
in joint replacement. And
that has
been around for, you know, multitude of, reasons,
whether it be implant longevity
or just comfort level. But as we as
we learn more, we learn that, you know,
every patient has a unique alignment. There's plenty
of literature out there showing that
everyone has their unique alignment strategies, and they
can be grouped into, like, 9 different phenotypes.
Right? So not everyone falls on this plumb
line. Mhmm. There's about only about 15% of
patients that are truly in this mechanical alignment
strategy.
And so when you look into that and
you realize, well, gosh, man, that's 85% of
my patients that I'm incorrectly replacing.
You start to realize,
okay. There's gotta be some better way to
do it. And the more we learn, the
more you're seeing surgeons drift away from this
MA or mechanical alignment strategy.
Is that what most appeal to you too
in terms of of going gravitating towards it
and and really leveraging it?
Yeah. I mean, there's a ton of reasons
why I kinda gravitated
away from MA, but yes. So it just
makes sense. The more you sit down and
think about what you're doing
and how you're doing it, it just makes
sense to give a patient specific alignment strategy
versus kind of more of like a cookbook.
Everyone's gonna get the same Mhmm.
You know, standard angle fixed angle that's predetermined.
I mean, when only 15% of those patients
are gonna be happy or fall into that
alignment,
it just makes sense to give a patient
specific alignment.
Yeah. Doctor Baron, you I I loved your
introduction on on sort of the how this
emerged. Right? The sort of the historic piece
to this, where did this come up. When
you first started using it and after first
starting using it, what were your what were
your thoughts, and and why did you decide,
okay, this is this is the way to
go and and leveraging this more and more
in terms of the appeal to certainly
the doctor itself, but also the patients?
So I I had the opportunity to work
with Steve Howell, again, almost 2 decades ago,
and
he and I really diverged in our in
our principles of knee replacement. I I continue
to believe in mechanical alignment regardless of the
technology used,
and we had really good results. And we
looked at a very large series. It was
published in a a very reputable
journal,
and what really stood out to me was
there were a certain percentage of patients that
are dissatisfied. And you can call it 20%,
which is what everyone argues. It might be
8%, whatever,
but not everyone's really happy. And even those
that are happy are the yeah, buts.
Are you better? Yeah, but. How's your knee?
Well, it's good, but
the yeah, buts,
are a huge percentage of our patients, especially
those that come in complaining of the knee
feeling tight Yeah. Or the high activity level
patient who's not able to comfortably return to
those high activity levels.
And so I was just watching the literature,
watching the science, trying to figure out what
can I do to improve the situation? I
I really believe that partial knee replacement is
very helpful in that space for the right
candidates.
Obviously, anterior hip was incredibly impactful
in patients, but that's hip replacement.
And so I I decided
to go all in. And so Friday, I
did mechanical alignment.
And starting on Monday, I did kinematic alignment
with a medial sphere knee on every patient
regardless of if they had a knee before,
regardless of deformity, regardless of, you know, any
of the other demographics of the patient.
And I immediately noticed that patients were no
longer complaining of the knee feeling tight.
I am not suggesting that I have a
100% satisfaction or a 100% survivorship or anything
like that. What I did notice immediately
was the patients did not complain of the
knee feeling tight.
And we started to watch those early outcomes,
and we saw the rate of manipulation
for stiffness
went down in my hands by almost 6
fold.
And so early recovery was significantly better.
The pain relief was significantly faster.
We've published on this, in peer reviewed literature.
And so
it was a it was a blind leap
for me,
and then we quickly started seeing those results,
benefiting the patients early. And now we've got
2 plus year data on our series, and
it shows the same thing.
Less complaints of tightness, better range of motion,
less manipulation,
higher knee scores,
and most importantly,
higher forgotten joint scores, which is really the
the gold standard of of what we should
be measuring,
knees by. So I jumped in full tilt,
and then started looking quickly at the early
results and now the midterm results, and I've
been super happy with it.
Yeah. I'm gonna be the yeah, but here.
Right? I love that term. I think that
was a good that was a great one.
I'm gonna be a yeah, but here if
I'm the if I'm a I'm a physician.
Doctor Byrd,
what what should I be looking towards
if I want to if I'm not doing
it right now and I want to start
doing it, what do I need to look
into? What do I need to do if
I want to start implementing KA?
Yeah. That's a great question. I
I did not jump whole hog like doctor
Barron. You know, I was early in my
practice.
Doctor Barron's had a, you know, storybook career.
He's got a great reputation out there. And
so I was building mine, and I didn't
want to,
just jump all in. As I wanted to
kinda dip my toe, see how patients did,
and kind of,
build up from there. And I would say
that was about 3 years ago, and at
this point, I'm all in. I do,
unrestricted on everybody.
But the way to get going is,
you know, be thoughtful.
Do your research.
You know, it's all about homework. Right? Do
your reading. There are thousands of
ViewMedi videos out there. Definitely start with doctor,
Steven Howe's videos, and they're just a master
class in how to get going on KA
knees.
And if you really
pick the appropriate patients and stick to the
recipe,
It's remarkable
how well these these, cases turn out.
And then, of course, go watch somebody do
it.
I actually traveled up to New Albany and
watched doctor Baron do one. And,
this was prior to me doing my first
case, and so it was just you know,
I've read a lot, was intrigued by the
whole philosophy.
And I went up and watched him, and
it was like, woah. It was like a
light bulb went off. I was like, wait.
That
that's k a?
It's it's pretty cool, actually. You know? There's
there's kind of,
you know, like doctor Barron says, like, what
is it? And so when you actually see
it being done, it simplifies the whole process,
and that's the beauty of it. It's not
a complicated process. It's a simplified process, actually.
And by going and watching,
you can take that home to your own,
hospital and really get going. And, you know,
it's just not, as daunting as it might
seem at first.
Doctor Barrington for you here. I'm I'm assuming
you would encourage folks to to do the
same thing and and just see one for
themselves, see how they work, etcetera. What what's
your take on on what practices should do
and and what physicians should look at?
I agree with doctor Berg completely, and I
think one of the important things is
something that that I've come more accustomed to
saying to surgeons who ask about it.
When you start out, consider restricting
who you do the procedure on. But when
you do the procedure, don't restrict how you
do it.
Meaning, there are restricted alignment principles. There's inverse
principles, all this. Those are not kinematic alignment.
Kinematic alignment is exactly what we've defined.
If you are not comfortable doing it, then
restrict who you do it on and use
your standard technique on those patients,
and you will become more comfortable both with
the technique
and sort of with the degree of difficulty
by which you you deploy that technique.
I as was mentioned, I jumped all in
on in one day, but you you don't
have to. I mean, you certainly know how
to do a knee replacement the way that
you've always done it.
So take some of those patients, and then
watch them, and compare them to the outcomes
that you're seeing today. And you may think
you've got wonderful outcomes, and and most surgeons
do. Most patients do phenomenal with this operation.
But compare them in your own hands, in
your own clinic to
true KA
caliper verified
medial spherical knees,
and you're gonna see a difference. The high
activity level's different, The patient's complaints or the
patient's yeah, buts are different.
And so, again, if you're not comfortable doing
it in everyone,
restrict who you do it in, but don't
restrict how you do it.
Yeah. Absolutely.
And and seeing it again, like you mentioned,
I think that that's that's really a key
that both of you identified. That's that makes
a lot of sense to be able to
see the procedure and and see how it
works and and see how how the patient
benefits at the end of the day.
Doc doctor Barron, with with so much experience
in in the field itself and and certainly
so much exposure to what's going on
in the world itself,
where are you seeing this go?
As a lot of folks are talking about
automation,
of course, AI is a is a big
talking point for everything. Is this going to
come into play for k a, and and
how are you seeing that develop?
You know, I I'm I'm not sure yet.
I I think that
there is
with everything, we're we're throwing AI.
As long as you use that term, then
it's gonna be successful, is what it
seems.
Certainly on LinkedIn, that's what I see.
The, I I don't know. I mean, I
think that there's an argument that is made,
and and I just hosted a podcast where
there was a discussion,
about alignment
strategies. And there's an argument to be made
that, oh, we don't know the target.
In AI, you know, we get enough big
data and get AI to figure it out
for us, and it'll tell us where the
target should be.
That that's kind of an interesting philosophy
when we already know where the target should
be. It's where the patient's knee was
Mhmm. With the exception of some other deformity
or some other condition that's changing
the knee other than arthritis.
And so
I kinda feel like, yeah, maybe we'll have
some increased benefit from technology.
If you feel more comfortable using a robot
or,
augmented reality,
and and certainly all of that's available with
almost any of the manufacturers,
The principle of this operation is even simpler
than that. It's using a a caliper from
Home Depot and measuring the cuts and making
sure you put back the same amount that
you're taking out,
and the results are improved. Now can we
can we improve them even more? Probably.
Do we have a a incredibly unique implant
that we're using now with the with the
sphere that's specifically designed for this technique and
this and this idea? Yes.
And so these sort of incremental,
additive, accretive changes,
maybe AI is in there somewhere in the
future.
I don't see it as being probably anywhere
in in the remainder of my career, maybe
doctor Byrd's career, but
I think that it's it's pretty darn good
the way it is, and I don't know
that AI is gonna
make it much better than just doing it
the way that it's supposed to be done.
Yeah. Doctor Byrd, same for you here. Where
where are you at on on some of
this technology that's emerging, and how is it
influencing or how do you think it's going
to influence your your work or work in
general? Yeah. You know, I I completely agree
with doctor Baer, and I think I think
the AI and robotics is very interesting, and
it's
pretty fun. It's a fun toy. It's a
cool tool, but as an added value, I
don't see it right now.
Basically, what kinematic alignment is is just a
true resurfacing of the bone.
And you can achieve that without the use
of technology. And it's funny. I saw this
question come across. And when I was first
learning k a, you know, someone was trying
to convince me. I was like, oh, but
you need a robot to do it. And
Mhmm. You need this. You need that. And
it it couldn't be more
opposite. Right? So it's it's just get your
caliper from Home Depot, probably aisle 14 or
I'm not sure. But, 16, actually. 16. 16.
And it's you know, I think and I
think doctor Howell and, they
there's literature out there to,
demonstrate that the caliper is more accurate than
the robots. And and the standard error that's
built into the robots is higher than what
you can actually measure with a caliper.
And so if you verify every cut that
you're doing, you can more accurate
accurately resurface the bone,
and you don't need the distraction of the
of the
technology.
And, you know, I don't know. I hope
by the time,
I retire in 25, 30 years from now,
I'm doing something different than now because how
I mean Mhmm.
How boring would that be if I'm doing
the same thing? Right? Like, because from a
scientific standpoint, we're gonna have some innovation, and
I'm I'm just not quite sure what it
is. But at the current state of the
art, I cannot see how technology is gonna
be an added value for this technique.
Yeah. And, again, everybody, you know, now need
to stop by at Home Depot to grab
the the helper. I think that's a that's
that should be that should be the move
after this episode.
But also, as we talked in the beginning,
a lot of folks don't know or didn't
know what kinematic alignment was. I recommend you
have to listen because now I know certainly
a lot more about the technique, and and
that was it's very interesting in terms of
how this is going to develop and how
it's impacting patients.
Doctor Barron, doctor Byrd, thank you so much
for your time. This is very interesting.
Yeah. Thank you. I had a great time.
Thank you. Thank you. It's a great conversation.
We appreciate you guys
listening
and hearing about KAA.
Absolutely.
Thank you again for joining us, and I'd
also like to thank Medacta as well for
sponsoring this episode. You can also tune in
to more podcasts from Becker's Health Care by
visiting our podcast page at beckershospitalreview.com.