Episode 51: Thursday August 4

What happens when the plastic surgeon has to get surgery? Our very own Dr. Salvatore Pacella recently underwent total knee arthroplasty (total knee replacement) surgery, which prevented him from working for months. Why would a busy plastic surgeon choose to undergo surgery? How did Dr. Pacella plan for the surgery? Who did he choose to perform the surgery? What was the outcome?

We discuss all this with Dr. Pacella and find out his perspective on the other side of the operating table. find out more at https://3plasticsurgerypodcast.com/

#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetic #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S03E51 DR SALVATORE PACELLA - WHEN SURGEONS GET SURGERY

[00:00:00] Dr. Sam Jejurikar: Good morning, everyone. And welcome to yet. Another episode of three plastic surgeons in a microphone. I'm Sam Jejurikar. And as always, I am joined by my host, Dr. Sal Pacella at San Diego plastic surgeon and Dr. Sam Marie, a Paramus New Jersey, a Paramus New Jersey at Bergen cosmetic. Good morning, gentlemen.

[00:00:25] Dr. Salvatore Pacella: Hello. Good morning everybody. Good morning.

[00:00:29] Dr. Sam Jejurikar: So, uh, before we get into the meat of our, uh, discussion today, first we're gonna have Dr. Re little little disclaimer, uh, just covering the legal

[00:00:36] Dr. Salvatore Pacella: basis.

[00:00:38] Dr. Sam Rhee: Yes. This show is not a substitute for a professional medical advice, diagnosis or treatment. This show is for informational purposes, only treatments and results may vary based upon circumstances, situation, and medical judgment.

After appropriate discussion, always seek the advice of your surgeon or other 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.

[00:01:02] Dr. Salvatore Pacella: Great. Well,

[00:01:03] Dr. Sam Jejurikar: today we're gonna go on a little bit of a tangent.

Um, typically we talk about plastic surgery related issues, but, uh, one of our, uh, co-hosts has had a very interesting development in the last few months, which, uh, actually caused our show to go on hiatus. Um, but instead of being the surgeon, Dr. Pacella. Was actually a patient and he went through total Neo arthoplasty.

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, uh, with that, Dr. Patella, let us know how the last few

[00:01:31] Dr. Salvatore Pacella: months have been well, thanks guys. Um, you know, so it's, uh, it's been an exciting time for me. Um, and, uh, you know, I've been.

Outta work about two months and then a half time for about a month after that. And so I'm going on my fourth month right now after surgery. And it's, it's been interesting to say the least, um, I would say overall, it's been an exceptionally positive experience. Uh, I was in a bit of pain prior to. Um, this, uh, total knee replacement, um, and it was really affecting, um, not only my work life, but my personal life, as far as, um, you know, doing all the things I love to do.

So. So really it was I'm 49 years old. And, and I was sort of pushing off this for a couple years now. And, uh, you know, mentally, I, I thought to myself, well, if I could just make it to 50 with this bad knee, you know, I'll kind of, kind of go from there. But, you know, I just really had to. Had to go and, and, and get it done.

So, um, I've got a little PowerPoint here I'd maybe wanna share a little bit, so I'll kind of just dive in and kind of tell my story a little bit about how I, how I came about this here. So let me just share here. Okay. So, um, I try to, I've heard this, this quote. Probably 20, 25 years ago. And I, I had a difficult time finding the actual origin of who said this, but I think it, it really kind of resonates very well with me, embrace every scar as a lesson learned.

And, uh, I think not only for me personally, but for our patients, you know, I, I try to. Try to, um, sort of live and learn this and teach this to my patients because, you know, as we, as we make choices in our life, um, those choices make you. And so this has really been, uh, this knee injury that I've had on my left knee, uh, really is a direct result of choices that I've made, um, as a young man and continue to make as a, as a middle aged man.

So , um, and this, this story first starts with, uh, With a, a sport that is well endear to my heart. It's, it's the sport of rugby. Um, and you know, these are, these are a couple 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.

Um, this, uh, picture here up above is me in medical school. And then this is me in residency towards the end at the university of Michigan. If you remember, if you look at this face right here, the guy hiding underneath here, that's a, a former guest host on our show. Dr. Tru. And, you know, I, I grew up, um, playing football in high school and kind of transitioned to rugby in, in, um, undergrad, just because I, I didn't play college football and it's a, it's kind of a sport that is really, I think, Been a very important part of my life.

Um, you know, as I couldn't play anymore after several injuries, um, my first injury was when I was 19. Um, I tore my ACL and then I've had about five or six other surgeries, including another ACL on the same knee. And then, um, you know, multiple cartilage injuries. So it's really just my left knee that has been affected my right knee.

Right. Knee's totally fine. And as I stop playing. Um, from my last injury, I sort of transitioned into kind of a little bit different role in the sport. I, I started to become a referee. I've done a lot of college matches and, um, sort of semi-pro matches throughout the years. And then, um, of course I started coaching when I couldn't referee anymore because of my knee.

So, um, these are my kids on the side. We, uh, just a couple years ago. Won the Southern California cup for their under eight teams. So it's been an important part of my life. And these are just some of the organizations, um, 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.

And, you know, rugby in and of itself is not necessarily just a sport, but it's, it's really a community. And, you know, I I've gained a lot. Friends and acquaintances and, 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, those scars, every scar is a lesson learned.

And this is unfortunately what my left knee look like prior to surgery. So you can see here that, um, each of these screws and each of these scars tell a story. So this first, um, Uh, screw that's right in the femur here is for my first ACL reconstruction. That was a patella tendon graft, um, when I was in college and that worked really, really well for a number of years, very quick rehab after that.

Um, and you know, I went back to playing just about four or five months later and it lasted. Uh, it lasted me for an additional 10 to 12 years. Um, then when I was a resident at the university of Michigan, my chief residency year, I tore my ACL again, playing in a game. And, uh, the, the folks at Michigan, the orthopedic surgeons put me back together here.

And that was. Uh, actually a total of three surgeries that I had, uh, one of which was in my fellowship and, and that involved this kind of long screw a washer here and a, another sort of INSORB screw down below. And, uh, that was a, the graph that they used to reconstruct the ACL was the, the quad tendon, just an exceptionally painful, painful, um, surgery.

But the difference between these two surgeries when I was 19, it was an massively, easily recovery. Um, but when you're 35 going through something like this, it's a much different scenario. Plus adding in a few cartilage graphs or cartilage tears here, um, just. Exceptionally problematic. So, um, and the thing that kind of really sort of 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, the access of, uh, the bone here, if you look at this right side compared to the left side, you can see there's what we call a virus angle. So that angle of the bone is really. Off by about three degrees. And, and I, I never really noticed this until it really got too late. And, um, just for our listeners, when

[00:07:49] Dr. Sam Jejurikar: you say Veris, are you meaning that you're basically

[00:07:51] Dr. Salvatore Pacella: bow-legged bow-legged bow-legged that's correct.

That's absolutely right. And you know, one, one thing I, um, I didn't necessarily realize until several years ago, My surgeons were telling me, you know, when you're, when you're, bow-legged like I am it. It's very good for athletics. It's great for balance. It's great for speed and explosive, um, movement, but it's horrific.

Once you sort of have your first. Uh, meniscus injury and most the most people, most athletes who are virus or have a virus deformity in their, in their bones, um, are sort of predisposed to getting meniscal tariffs. Because if you look at how this, how the, the physics of this is, is it's really grinding on the inner surface of the knee.

And once that. Once that, uh, meniscus is torn, that the setup of, 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 AOSIS on your ex on your x-ray AOSIS is not arthritis. Arthritis is just simply an inflammation. And if you look at the, the x-ray, there may or may not be, um, a change in the joint structure. Arthrosis is when there's actually a change, a visible change on the x-ray. And if you look here at my x-ray on the left side here, you can see these kind of out, um, These little bony outgrowths here.

So this is just extensive, not only arthritis, but AOSIS actual joint changes. So I, 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 .

[00:09:36] Dr. Sam Jejurikar: So how I was gonna say, even. Even though we're contrasting your right from your left. You do have, uh, some changes on your right side too.

Yeah. A little bit ly. Yeah. You, you got some arthritis on the, uh, and some AOSIS on the right side too. Yeah. But

[00:09:50] Dr. Salvatore Pacella: not, not as bad, not as bad. no, but you know, the right one doesn't hurt. So all, so, so this was me the morning of surgery. This was, I believe March 9th of this year. So here's me with, uh, as a patient, you can see the exceptionally happy look on my face.

And this is the scar that, uh, I actually already had a big, massive scar here. So it's, uh, you know, not, I necessarily don't care how the scar looks, but they just went through the same incision.

[00:10:18] Dr. Sam Rhee: So Sal, 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, what finally drove you to, to decide? I need to have this surgery. I, I can't, I can't not live without the surgery at this

[00:10:36] Dr. Salvatore Pacella: point. Um, so it, it was really, uh, you know, so it's interesting. The, you know, my, my orthopedic surgeon, bill, buby said, you know, when you, and, and this is what every single orthopod I've known throughout my life told me was you, when, when you make the decision, you'll know it's the right time.

And I, I thought to myself, you know, that's just ridiculous. That doesn't make any sense to me. Like, there's gotta be some objective criteria to tell you when to do this, but, but he was 100%. Right. Um, you know, and, and things such as, you know, parking, you know, you park in a parking lot and you know, there's no spaces and you find yourself getting.

Irritated because there's no spaces closer to the store or the facility you're going into. So you have to walk, uh, 30 yards and it's like that, that, that process of walking just became annoying, you know, and just like puts you in a bad mood. Um, Every single time I go outside to play basketball with my daughter or play Frisbee with my son.

You know, it's like, oh my God, am I gonna make a wrong step? And it's gonna irritate things, you know? So, so just all the things I'd like to do in my life referee and coaching surfing became problematic. Surprisingly, I would say that. Surfing of anything, um, was the least affected, believe it or not because with the exception of trying to stand up, which is takes a lot of work, but, you know, surfing is relatively low impact on your joints, but everything else, you know, I stopped running.

I stopped hiking, I stopped mountain biking, um, and it, and it just, it just became obvious that this needed to be done. Got it.

[00:12:06] Dr. Sam Jejurikar: You don't have a typical nine to five job though. Was it hard to. You know, with all of your patient care responsibility and, you know, the fact that our jobs never really sort of end at the end of the Workday, was it, was it hard to, to, to carve out the time in your schedule

[00:12:20] Dr. Salvatore Pacella: and yeah.

So patients respond to it. Yeah. So, so good, good. Uh, good question. So, um, you know, I, um, I wanted planning a time to prepare my, my practice and my patients and, and my partners for this. So I, I started the process about eight months in advance. Um, and so I. I made a decision somewhere around, uh, the autumn of the year before knowing that I was gonna go out in March.

And, um, you know, my, my two partners, Dr. Champion and Dr. Aria were just exceptional. You know, they said whatever you need, get yourself healthy, et cetera. And, you know, um, my patients, I, um, I, I sort of told them I was gonna be out on medical leave and, you know, I would say a majority of them were very understanding.

Some were not so understanding, but you know, the key here is if I'm not healthy, I can't make you healthy. So I think, you know, once, once I'm kind of up and moving around, that's the time to have your surgery, you know? And, and for me, The act of standing in surgery was, was problematic. I mean, we do a lot of cases where we're standing.

I found myself, at least the facials cases. I would try to sit down a little bit more. Some of the breast cases, I, you know, at the end, once you're sewing, it's a more appropriate time to sit down, um, or sit on a stool during surgery. But all of that just became much, much more challenging in my, in my, uh, work.

Um, so, um, okay, so this is a me, the day of this is also my, my team here. So, uh, the gen on the right is Dr. Todd Austin, a very good and close friend of mine who did my anesthesia. Um, I was essentially pain free. They did a block, something called an inductor block, which is, uh, done right before surgery in.

Preoperative holding area. And then, um, you know, you're essentially pain free for the entire time during the hospital. So it was just a great positive experience. Um, the gent on the right is, uh, bill buby, who is, uh, uh, my trusted orthopedic surgeon. Um, I, I chose bill, uh, not only because he's got an extent, outstanding reputation in the community, both.

In Southern California, but nationally, he, he tends to care for a lot of younger patients with cartilages injuries. Um, he's got an extensive lab where he does cartilage transplants and cartilage growth procedures, uh, for young patients who have cartilage injuries and by, by nature of his practice, he tends to do a lot of joint replacements on.

Younger people like myself in their forties or even thirties and a lot of ex athletes. So he was, you know, it became pretty obvious. He was, he was the choice I wanted. So, um, and bill is just a master technician and, and just an, you know, exceptionally talented surgeon. So. Couple pictures here. So, so they snap these photos, um, during the surgery and for our viewers here, this is a, a slice open of my knee here and my knee sort of cracked open, like a celery stock here.

So this is, I thought is terrible. Yeah. So this is, that is, that is

[00:15:30] Dr. Sam Jejurikar: awful, awful.

[00:15:34] Dr. Salvatore Pacella: So, so just, uh, just to kind of go over what this looks like. So imagine your knee opened. Okay. And what we're doing on the left side is we're looking at the under surface, the joint surface of the femur, the big long bone in the leg.

And normally the surface is very white and shiny. And what you can see here is there. The bone is very yellow, which means that bone should not be there. There should be a white surface there of cartilage, but you can see that kind. That redness to the bone and the yellowness to the bone that's what's called sclerotic bone.

So that's when bone is injured to the point of losing some blood supply, um, it looks very hard and thick and sclerotic and the. The whiteness on the, the white appearance on the outside is the remnant of cartilage. Okay. So like this, that rim of cartilage looks very abnormal, very diseased, very ground out.

So this should normally be a very white cartilaginous surface that, that looks very shiny, like a chicken bone. And you can see here, it's, it's just kind. Amorphous it's granulated it's, it's sort of irregular shaped and that's just a bad, bad disease knee. And you know, I, I was running around and walking on this for many, many, many years.

And didn't, you know, obviously you can't tell that this looks the way it does. and, you know, it's, it's a surprise. My surgeon told me, you know, I, I can't believe you weren't in more pain from what you described. If you look at on the right side, that's sclerotic bone is looking at the, the surface of the tibia.

So that's the bottom bone of the leg. And that's, that looks even worse, you know? So that's where the majority of the cartilage injury is where the bucket handle tears of the meniscus are. So that that's a. Very badly, uh, disease surface. So he said about 96%, 97% of the joint surface was, was.

[00:17:32] Dr. Sam Rhee: Dude that looks like stalk of cauliflower.

That's amazingly bad. Holy man. Wow.

[00:17:38] Dr. Sam Jejurikar: I was, I was gonna say cottage cheese, but I'm going in the same place. thanks. Yeah.

[00:17:44] Dr. Salvatore Pacella: Um, so, so, you know, it's funny as a. You know, as a plastic surgeon, when we work with orthopedic surgeons in the operating room, you know, we, we're often seeing the worst of the worst, right.

Infected joints. Um, you know, we're oftentimes doing salvage procedures, salvage joint repairs, and, you know, we don't, we don't have a lot of understanding of routine orthopedic surgery like this. Right. So, so I, you know, the, the last time I scrubbed in, on a, on a joint replacement case was in medical school, you know?

So, um, and same, you. Go ahead.

[00:18:18] Dr. Sam Rhee: Comments. No, go ahead. No, I was just about to say same.

[00:18:21] Dr. Salvatore Pacella: Yeah. And so, um, you know, I just kind of, you know, we have this kind of joke with the orthopedic surgeons that they're, you know, they're just these kinda carpentry meathead kind of guys that, you know, they just go and drill with saws and bone and, uh, and, and, uh, drills.

Right. Um, but it it's, it's actually exceptionally precise. So, and it, and it has to be because if the. If the precision is not there when you do the joint replacement, that joint replacement won't last very long. So what, so these on the left side are the cuts that are made to remove the joint surface. So this is all done, uh, 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, um, in order to, to get the absolute mechanical central access of the bone, you cut. Okay. And so the surgeon is responsible for the cut, but it's all mapped out three dimensionally.

And that, that was just fascinating for me to hear that, you know, um, And then on the right side, here is my new shiny, uh, joint. Um, the prosthesis that I have is, uh, something called a Zimmer persona. This, uh, is a, it comes in 12 different sizes. I had size number 11. Um, so, you know, I got some pretty big bones and big muscles.

So it had to kind of surface at.

[00:19:45] Dr. Sam Jejurikar: How disappointed were you that you were

[00:19:48] Dr. Salvatore Pacella: exactly right. So, um, so it's, so it's actually, the prosthesis comes in four parts, so it's a, so they first work on the femur and they put this cap on the femur. That's that shiny metal surface you're seeing here. Then they do the tibia.

Um, which is the bottom bone. And then in order to recreate the joint surface, there's this ceramic spacer that goes inside. So the, um, and it it's all very precise, the way they sort of calculate how big the spacer sh should be. So this spacer actually locks into the bottom surface on the tibial surface and essentially is your new joint space.

So that, so why this is important is if you ever need a revision surgery, Um, usually the part of the prosthesis prosthesis that wears away is the central portion, this ceramic portion. And then the fourth part of the prosthesis is the inner surface of the kneecap, so that, um, that is shaved off. And then that, that portion is resurfaced with another, uh, ceramic type of prosthesis.

So pretty, pretty interesting, uh, view here.

[00:21:00] Dr. Sam Rhee: I think the computer guided cuts have, uh, really revolutionized this, um, this joint replacement that it's really made it. So. More precise. I feel like, and, and I'm really glad that these guys are using the most advanced technology for their joint replacements.

[00:21:15] Dr. Salvatore Pacella: It's, it's really fascinating. And, and you know, it really is.

I just have so much respect for, for these, uh, these surgeons, both men and women. I mean, they are, you know, the precision is, is arguably. Much more precise than our job. I mean, when we, when we are doing plastic surgery, you think it's, you know, we're measuring things in millimeters, et cetera. And to some extent we do, but there's, there's inherently a lot of give and soft tissue.

You can stretch things, you can get a feel for it. You don't have to be exceptionally precise with, you know, Sewing in a muscle flap into a, into a wound, um, because you know, that tissue will grow, but bones are much different story that bones don't change. They don't stretch necessarily. And so it's, it's important for them to be exceptional precise.

Um, so this is, uh, this is me not in recovery, but in my room, uh, afterwards and couple interesting comments here. So, um, after the surgery check out that view. Yes. So this is, this is actually. A view of the Torry Pines golf course. And what I wanna say is, so this is on the fourth floor, four west of Scripps green hospital, which sits right on the bluff of Torry Pines.

And this is exactly the rooms that my breast cancer patients go to for postoperative recovery. So I was physically in the same room that I have been in for, for over 12 years where my breast cancer patients go room four. So, uh, it felt very special that they put me in a room, uh, with such a great view here.

And so, um, so in recovery, I, I have absolutely no recollection of the recovery process. And, um, it was funny the other day I ran into a, uh, a nurse. I know his name is Doug. And he asked me, I haven't seen him in a couple months. And he said, oh, how'd your surgery go? And I said, oh, really good. You know, I didn't feel anything in.

And he said, yeah, I heard, I heard you cried like a baby in recovery. so

I'm like, you're absolutely right. You're probably

[00:23:17] Dr. Sam Jejurikar: right.

[00:23:20] Dr. Salvatore Pacella: I have, I have no recollection whatsoever. So the bigger they are, the harder they fall. Right. So this was actually a, a photograph that my wife took, um, uh, in the room a few hours later. So the surgery was at seven 30 in the morning. I was in my room.

By about 9 45 and I was up walking by 11:00 AM. Believe it or not. You can see this Walker in the background here. So. Um, now this is an interesting, um, picture here. So if you recall from, um, from these, uh, your preop photos, my preop

[00:23:54] Dr. Sam Jejurikar: photos here, those, those are your, these,

[00:23:56] Dr. Salvatore Pacella: yeah, these are that's a screw and a post are the, a post, a screw.

And a washer. And so I was able to keep these here. Um, so I specifically asked for these, and I don't know what I'm gonna do with 'em they're in an envelope in my, in my dresser drawer. And I, I think, you know, this is kind of an important thing for me to hold onto throughout my lifetime. Um, so I was happy that these weren't able to be salv.

Um, so, so the interesting thing is the recovery, the, the postoperative recovery is very accelerated. So years ago, they used to keep you in bed for a week or two. Uh, they used this passive motion machine to get your leg moving and, um, that, 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 to be at seven 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 afterwards. So I gotta tell you, I was, I was completely pain free at 11:00 AM and I got up.

And 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. right. So, and I was just absolutely amazed at how quickly you could, you could start walking on this prosthesis once the, once the cement cures to fit that prosthesis in your femur and U tibia.

It is essentially indestructible. And so you, they want you up walking to get that swelling down and get the soft tissue Mo mobilizing. And it, and I, I was just amazed at how, how quickly you can get up and the. Now you

[00:25:48] Dr. Sam Jejurikar: had, you had mentioned that they had done

[00:25:50] Dr. Salvatore Pacella: some sort of block on you that's the time that's right.

And so

[00:25:53] Dr. Sam Jejurikar: so, so did that contribute to your PainFREE existence at Mayo? Absolutely.

[00:25:57] Dr. Salvatore Pacella: Absolutely. You know, I completely, I completely forgot about that afterwards. So I'm like, oh, I'm moving around. No problem. Right. And so. So, you know, by the next morning I, I still was pain free and I'm like, wow, I expected to block not to last this long, but a couple days later, the block goes away and 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, uh, so that's what it looked like. Uh, I think about post-op day. Excuse me, number three. And so the pain just dramatically gets worse from there. okay. And the swelling gets dramatically worse from there. Um, so I, I basically was sitting on the couch, getting up, walking around every couple hours.

This is my dog Hawk. So he was a good recovery companion for me. Um, Little bit about the, the rehab. So the, the rehab, um, starts immediately and, um, they actually, uh, send a therapist out to your house a couple days a week, um, before you start driving and moving around. And, and that was just fantastic. I mean, this therapist would come over in the morning, um, and we do a PT session for about 45 minutes.

And, you know, I, I thought this was gonna be a big vacation for me, but it, it was a hundred percent. For essentially two months, because you have to do really two to two PT sessions a day. And the key is getting the end range, range of motion, both with flexion and extension. And for me, the extension was the biggest issue.

I, I could not fully extend my leg. Um, for probably close to about 10 years, I had probably about a, a two degree flexion contracture, um, because the end surface of extension was, was being impeded by the, the arthritis. And so, so if you think about that, what happens is your, your gas Strous muscle, your calf muscle, and your hamstring muscles, they tighten up and they.

Over those years. And so not only is it tough to try to get the joint out, to length, but stretching out those muscles that are tight. And when you're a, 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, you know, younger patients tend to do a, a bit worse when it comes to range of motion than, than older patients do. So that, that was kind of a surprise to me. Um, So, um, let's go here. So, um, so the, as far as getting back to like what a full-time job, this is, um, you know, I, I would get up in the morning, I'd do an hour of PT and then I'd ice for another hour.

And then like, by that time, it's 11 o'clock in the morning and I'm just completely wiped out. You gotta 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, the afternoon session. By about three or four in the afternoon. And, and then it, the whole process starts over again.

And then the first four, four weeks or so was very difficult to get comfortable at night and sleep. So you're on some narcotic medications, some anti-inflammatories and, and, you know, you're just kind of can't sleep at night and then the next morning you're just wiped out. So it, it is a massive process to get through.

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

[00:29:40] Dr. Sam Rhee: does this, uh, lend insight into your own patient's recoveries because they always say that, you know, being a patient yourself makes you understand your own patients

[00:29:49] Dr. Salvatore Pacella: better. Oh, no question. And I, I think, you know, I I've, I've undergone some major surgeries throughout my lifetime. I've had, you know, these, the, the few ACLS and meniscus tears were not easy either.

And so, you know, I, I have a very good understanding. Pain postoperatively. So I, and this only reinforced it for me, for myself and my patients, just because I, I kind of know what they're going through and, you know, the types of surgeries we do, there's a gradient of pain, you know? So like breast reconstruction in general is very painful.

Um, Facial surgery oftentimes is not usually as painful as breast surgery. So I, I really try to taper my expectations on patients, post-operative recovery. And, but there's a balance between, you know, using medication and kind of doing other things to help with, uh, with the pain control. I would say that, um, you know, I, I had a very good understanding of alternative methods for pain control, such as ice ice is.

Exceptionally important. I had an ice cooler in my bathroom. Uh, I would buy, you know, bags of ice every two days and constantly, constantly keep ice on this thing. And I think that was a huge, huge step in recovery. And so, you know, that's the same thing I tell patients it's ice is really kind of the main thing to help you with pain control reduces inflammation, uh, reduces the inflammatory mediators.

It's just a key concept for postoperative pain control and surgery. Um, so I'm happy to report that I did not necessarily require a Walker very long after surgery. So normally I think, you know, 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 range of motion and strength. Before sort of pre-habilitation if you will, um, as opposed to, uh, post rehabilitation and was able to use a, a cane pretty quickly afterwards, and you know, these are my, the good news is a couple buddies of mine actually bought me these canes.

And I, I thought these were awesome. So the one on the right is a, is a shark, which I thought was very, very, uh, fitting for some of my hobbies. And then the one on the left is, is you guys recognize this. That's a, that's a dire wool. Exactly. So I call this my, so I call this my cane of Thrones.

[00:32:19] Dr. Sam Jejurikar: exactly.

[00:32:21] Dr. Salvatore Pacella: So these, these are kind of fun.

So I really enjoy these. Yeah. Um, so this is my postoperative, uh, uh, view of my x-rays. So for my first post-operative visit and, you know, you could see just the extent of what's replaced here. So. You know, this, uh, this prosthesis fits like a cap, right on top of the femur and fits like a kind of a nail or a plug into the, into the, uh, tibia.

And, you know, the thing that, that, uh, surprised me about this when I kind of looked into it was, you know, I sort of had this vision that the entire joint end of the joint was amputated, but it that's actually not how it's done. It's, it's just the articular surface that's removed. And so that leaves you a lot of good bony stock.

Behind. So if you ever needed a revision, you can, you know that you have the bone there to do it. Um, the good news with this is it, it gained me about a half, a centimeter of height. So now, um, now I'm actually a little bit taller than I was beforehand, so that's, uh, that's a good thing. Say, Hey, you look straight.

Yeah. So, so if you look at these, here are these, 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, the angle of the access of this bone here. So you can see here, uh, on the pre-operative picture, you know, that's a.

That's a good five degrees of verus five to seven degrees of verus, which is a huge, huge deformity. And then afterwards it's essentially straight within about one to two degrees of verus. So the important thing is, um, you know, the surgeon will sort of dial in the amount of vari based on your, on your existing, uh, genetics.

Right? So, um, the, um, You know, you don't wanna be exactly 100% straight because the opposite side is still in various deformity. And so, um, so it, he accounted for that and you know, my knee feels very symmetric when I'm kind of doing my exercises. Now I feel a little bit more stable. I don't feel like I'm kind of shifting or listing over to the side.

Um, so pretty, pretty fascinating here.

[00:34:32] Dr. Sam Jejurikar: What an interesting, no, I got one more

[00:34:33] Dr. Salvatore Pacella: last line so, you know, so those of you that are, uh, that are a little older, like myself and, and these two guys, you know, you may remember this, uh, this, uh, uh, series from the seventies or eighties. It's uh, the 6 million man. So this was Steve Austin. Lee majors, right?

Lee majors, Steve Austin, who, uh, had all of his essential joints replaced and kind of became a superhuman. So I, I'm not exactly the $6 million man, but this is a, this is a copy of my bill. Okay. I'm about the hundred $10,000 man. So you can just see here and, and this was just one joint. So if I had my total body replaced, I'd probably be close to, I calculated I'd probably be close to about $10 million to account for inflation.

Um, and so, you know, this is, this is just an exceptional cost, obviously for patients. Um, if you're paying out of pocket and you know, if you look at the surgery surgical services here, so $57,000 for the. For the prosthesis? Um, actually, no, that's not true. Um, uh, supplies. So $30,000 for the prosthesis. I mean, that's, that's an exceptional cost, but if you think about, you know, what that means for someone's life and someone's, uh, longevity, you know, that's a, 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, um, you know, that's that that's, you know, It can add a few zeros to there and lost potential income or lost support for, for someone. So this is, you know, this is a huge advance in medicine. Um, that we've, that we've, uh, we've had throughout the years.

Yeah.

[00:36:18] Dr. Sam Jejurikar: I. I'd like to actually call you the $14,100, man. Cause that's

[00:36:23] Dr. Salvatore Pacella: paid according bill.

[00:36:26] Dr. Sam Jejurikar: I'm not even giving you were 5,000 in writeoffs right there. So, um, yeah, so, you know, But still impressive story. you know, so, uh, let me ask you one question because, um, I mean, it's interesting. Um, I mean, just fascinating how bad the disease was you were living with, and you talked about the pain.

You didn't dwell on the pain, but it's clearly a very painful recovery that's going on. And 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. What, what new perspective do you have when dealing with your own patients?

Are you prescribing medications differently? Are you, if people are complaining about, cause a surgeon sometimes will have patients that wanna be pain meds forever, how are, how are you doing things differently as a result of what you've just gone?

[00:37:15] Dr. Salvatore Pacella: Well, I would say, you know, I was always very in tune to patients pain and discomfort, and, you know, I, I would say that on the bell curve of things, I, 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 pain medication.

Maybe, maybe the pain is, is, uh, extensive. Maybe there's some underlying factors that are at, at course here. So I think my experience now has really helped me a little bit more with that sort of subgroup of patients that may have difficulty getting off their pain medications. And, you know, I'm a big proponent of.

Sort of, uh, alternative methodologies of, of pain control. So for example, Um, I mentioned obviously the ice, um, the elevation, um, acupuncture. I haven't personally tried, but I've heard great things about it. Um, for years with our breast cancer, reconstructive patients, our breast cancer patients, you know, if I've advocated for, um, utilizing.

Um, THC or, or C P D um, you know, that's real big in California and I'm, I, I'm a big believer. That is, that's a, that's a great methodology as an adjunct for pain control that we haven't really grasped onto it grasped onto or, or believed in as providers. And I think that's the, the ability of. Of providers to kind of utilize that in the regimen as one small piece.

And I think that's huge. I, I personally hadn't used, I did not use any PhD or CBD. Well, that's not true. Um, I did use CBD, but not THC during my joint recovery. And honestly, I'm a big believer in CBD. I think it really helps tremendously. It helped me sleep at night a bit. There's no sort of high component to it at all.

Um, the CBD is, you know, legal in most states I think. And I think it's, you know, it's. It's not a necessarily regulated medication, but I think if you, if you stick with recommendations and the purity, it can be very helpful. Um, and so, so those things I think are very important, um, for patients to kind of, you know, do a multimodal approach to pain control.

[00:39:29] Dr. Sam Rhee: I think one of the biggest things we have as doctors is, is the hard, 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 know, 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 gonna get a good outcome. Most of the time is fully trusted provider, but that, but that's a hard

[00:39:59] Dr. Salvatore Pacella: thing to do. It is. It is. And you know, I will say that, um, in times in my. What's what's made this process easy for me is being a surgeon, knowing the reputation of the surgeons and anesthesiologists I work with, I, I sort of just completely gave into the process, you know, 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 I'm not. An internist or a medical physician. It's a lot more difficult for me, even with my children, you know, my, my children's have medical issues to put my trust in a pediatrician or an internist that I don't necessarily know. Um, and, and that's something I have to learn and deal with as a parent and as a, as a human.

Um, but in surgery, it was really easy for me because bill has an exceptional reputation. I know he's he thinks through things, he's gonna do the right thing. He's. Um, thousands and thousands of reps of doing this operation. And, and that, to me, that was a tremendous amount of comfort. So when I had these kind of little spikes after surgery of, oh my God, I feel this ache and pain here is this the prosthesis failing.

You know, I, I had to kind of grasp and stop myself from that and say, well, you know, this can't possibly happen. Let's just kind of wait till my next appointment and not freak out about it. You know? And it's, it's really easy as a physician to freak out about things you. Yeah. And just, just a little bit about kind of the recovery now, where I'm at.

Um, you know, so I'm about four months in and you know, I'm back to working full time. I'm back at the gym. I'm, uh, doing StairMaster, I'm doing biking, I'm doing incline walking. I haven't kind of ran or jog yet. I don't plan on doing that to any extent. Um, the more you sort of do a lot of higher impact sports that can affect the, the length of the prosthesis.

It's. It's not prohibited. Um, so I do plan to kind of go back to a little bit of refereeing if I can. Um, I actually was surfing this morning and, uh, you know, it, it was a little questionable as to my strength, but you know, in the next few months I think that'll get better, but I was able to stand up and kind of get, you know, a few waves this morning.

So I was, I was pretty excited about that. So back to back to everything for the most.

[00:42:20] Dr. Sam Jejurikar: That's amazing. Well, Sal, thank you so much for sharing that with us. It's um, it's definitely nothing that Sam and I have been through, um, such an extensive operation being a patient and so perspective and what we have to look forward to over the next, uh, few decades of our lives.

That's

[00:42:35] Dr. Salvatore Pacella: right. Thank you so much, Sal. All right, guys. Well, thanks. Appreciate it.