Device Nation Podscript: An Interview with Leo Whiteside

Leo Whiteside: A Life of Innovation in Joint Arthroplasty

Interviewed by Kevin Brown, Device Nation

One person that I am so thankful was available for us is Dr. Leo Whiteside. We are in the presence of greatness and if you do not know who this is and I’ll give some of young whippersnappers a break here, you know, you do not know a lot of these founding fathers, but I strongly suggest this week just take a few moments to keyword search his name on the Internet and just look at who you are getting to here today. Just amazing stuff. I am so humbled that he took time out of his life to talk to our audience. We’re going to get so much from it. I know I did. So, let’s welcome to the show. Dr. Leo Whiteside.

Dr. Leo Whiteside: Well, thank you so much. It’s a pleasure to have the opportunity to talk to you and discuss orthopedic surgery and especially implant surgery.

Kevin: So Dr. Whiteside, when and if you choose to retire, I firmly believe that your jersey will hang from the rafters in this arena called Joint Reconstruction. Nobody’s ever going to be able to use your number again. [Laughter] Did you set out to do this to make this big of an impact on this business? or did it just kind of happen as you went along in years?

Leo: Well, you know, it’s hard to say for sure. I was passionate about arthroplasty and biomechanics very early. When I transitioned from my Neurosurgery pass into Orthopedics during my training. I did it because I was just fascinated by a few cases I was involved in in orthopedic surgery. I thought, if I could do that in my career it would just be a fabulous way to get up out of bed and go in and work like hell all day. So in the process of learning Orthopedics. It was just natural to get into arthroplasty because of the fascinating things that were going on in materials and in biomechanics of joints. It was so attractive to get into that. I figured that that’s where I focus my energy and then found some research avenues to look at and I must say you never think, “Well, I’ll make an impact.” You just think, “Well, can I get into this and learn something? Figure out new things about it and do the upshot of all that” Kind of never does hit you until your at this point in your career and then somebody says “We’re going to nominate you for a lifetime achievement award.” You wake up and say, “What the hell?” [laughter] It’s not over. My life’s not over yet with that.

Kevin: No, it’s not. So, the first time I ever saw your name and this is going to age me but I remember when the boxes said Dow Corning Wright…

Leo: Oh sure.

Kevin: And it was the Whiteside OrthoLoc Knee and…

Leo: Yes, that’s right.

Kevin: If my memory serves correctly, I got two questions. Number one, what was that whole project like? Number two, your system was the first to feature intramedullary instrumentation and a slotted guide for that femoral analogous cut. So how did you come up with that? And like I said, just tell me about the project.

Leo: Most people have forgotten that, but that– you are exactly right. I develop some intramedullary alignment instruments in the cadaver lab because I must say I was struggling with alignment in total knee replacement and my professor at the time, Fred Reynolds was funneling all and knee replacements to me because he was a hip surgeon and didn’t want to do these knees and this was a really great opportunity to me. I had to get these things in there straight. I still have to get in, in there straight and what I found was if I just put a rod down the center of the medullary canal of the femur and cut it a 5 [inaudible] valgus angle to that, I would get that femur right pretty much every time. Then another rod down the center of the tibia would save me the struggle of trying to fiddle with these external alignment guides, which were really not very good back then and give me a perpendicular cut on the tibia and then of course that lines the knee up and then you deal with the ligaments after that.

It seemed very natural to me, but it was too simple and straightforward for the then existing academic community and they resisted it. So that’s crazy. I remember Charlie [inaudible] got up at one of the important meetings that took to discuss my paper and said, “Well this just absolutely will not work.” That was pretty much what he said and sat down. I’ll tell you what, I found that you go into a skills lab and take fifty surgeons in that skill lab, all sharing of 2 per cadaver knee and every one of them would put that knee in straight with intramedullary alignment. Then as you mentioned the addition to that was slotted cutting guys, we had nothing of the sort, but we had these kind of eyeball things that you put on and pinned down and that sort of thing or have just a nurse hold while you cut with it?

Kevin: Sure.

Leo: I found that if you just attach a slotted guide to the intramedullary rod that you had on there and slide it up and down referencing the cortex and front and back of the femur. It would put your dead on. The next thing was figuring out kind of rotationally aligned that femoral component and it fell into my hands because I was working on unicompartmental knee a little bit later and then the AP Axis center the intercondylar notch posteriorly, center of the deepest part of the patellar grew and followed on up to the proximal edge would give you rotational alignment of the femur.

So that lighted up inflection. You just cut perpendicular to that. So you had medullary canal of the femur the medullary canal of the tibial and the AP axis. I’ll tell you what, that’s what I still use. I’m still certain that if you do not do that, you are going to have consequences that get to your patients sooner or later. Yes, and the other thing about the that knee system, the so-called Whiteside Ortholoc Knee was cementless fixation and that was integral to the whole thing. A porous coat on that and we were not allowed by the FDA to advertise it for cementless fixation, but I use it that way. We all do that with what we were going to do and kind of that became the way of getting our porous coated implants on the market in small print. It said “for cemented use only”.

I think we’re still using that ruse a little bit now. So that was a great project with Dow Corning Write. I really thank them and all the wonderful guys that I worked with back then and the young engineers that were fresh out and now are going deeply into this industry and have been successful and a lot of them have retired.

Kevin: What inspired you to go all in on cementless with that system? I mean, it wasn’t really the conventional wisdom at the time.

Leo: I know, it was not. You are exactly right. I was working on the hip and the knee at the same time. We had good example of cementless hip that had preceded Charlie’s work with cement. I knew on the 60s when I heard about Charlie and his pressure injected cement with the thumb pressurization and all that. I thought, it’s crazy to put this toxic material into bone and really expect that to last a lifetime. You know, I think Charlie agreed because he suggested nobody under the age of 67 and tell them it’ll last about seven years and that was that was his– This is a short-term solution and you are going to have to deal with a mess later too. I was in the in the process of watching that mess develop, and I was certain that bone would grow into porous coating.

We had clinical evidence with the [inaudible] and a couple of other things, the ring hip and the lower hip. A couple of things like that that were very clearly effective cementless. My feeling was, we should focus on and develop cementless in the knee. It was already kind of coming forward in the hip. You know, it took a big hit from marketing. I am convinced it was just a marketing issue that stopped growth of cementless total knee replacement after these big failures of the PCA knee I watched it and I watched the politics involved in it as well. That’s where I learned to have real skepticism for Orthopedic marketing. I am sorry to say that because the people who live on Orthopedic marketing, but I think it’s one of the biggest sources of misinformation in the work.

Kevin: In 1995, Smith & Nephew launched the PROFIX Knee System and that’s where I saw your name come up on my windshield again and that was the cementless knee that kind of launched you yet again and I know you’ve done that for a while. Is there any place for the smell of monomer in one of your cases today? or is it still cementless as much as you can?

Leo: Nope. No, it’s cementless except whenever I submit two dead things together. Occasionally got us some cement and augment onto a femoral component and the cement is very effective if you are good with your hands and if it’s– and you think and give enough time set and you have decent well-made implants for augmentation. It’s great to make a sort of a custom augment system at the bedside or it’s a operative table, but I will not pressurize cement into anything living. I just do not do that anymore. There are so many easy ways to do some cementless fixation of the hip and knee that I just maybe never but if I’ll tell you that, I’ll tell you one thing for sure, the last 25 years I haven’t used cement against living tissue once.

Kevin: Wow. So tell me tell me some tips and tricks here. Dr. Hoffman came on this show recently and was talking about his bone slurry that he likes to use to biological cement. Is there anything that you like to do to try to enhance fixation on the tibia side?

Leo: Yes, very important issues, fixation of the tibial component because that’s a flat surface. Aaron used this slurry and I think that’s fine if you do not have a cutting system that makes a good flat surface cut and you do not want to bother with that and you can then use a slurry of patients autograft under that surface and Aaron did a nice job of showing how that really does work, but one thing Aaron did was have an effective stem on that implant and also screw it down. He used screws to hold it down. Now, if you do not do what he did that is firmly fixed that implant to the bone, you are not going to be successful. Aaron’s a good technician too. You watch him operate and he does make a good cut and his slurry that he uses just fills in the little bit of gap that would cause toggle and then he augments that with screws. I tend to get on board with the rigid fixation and the viable surface. So I make a cut and then I put the trial on and test it with a four touch test with my finger right in the middle, one finger, one hand on the middle of that tray and the other finger makes four corner touch tests. If it visibly toggles that’s more than a hundred microns of motion. With that, I redo the cut until it does not toggle.

When I put that stem, that implant down, it has an effective stem. So this component that I use has a choice of stems. Big fat ones and little skinny ones and almost always that big fat ones that require pressurization. They require driving down and they’re tied well before it’s seated. Then it seats on porous surface– fully porous surface and partial porous coating of the pegs and then it’s held down with screws. Now, throughout my career go back and forth on screws. Every time I stop using screws, I look at my x-rays and I think, “Oh there’s a radiolucent line there.” and “Is that going to be bad?” and I haven’t found any of them without screws loosen, but I feel better about it if I use screws. I do not want to sit there and say, “Well, I’ll make a choice so your screws or not?” I just put screws in all of them.

If you have a well-designed system, you know that there’s no downside to using screws and there’s– and big upside here is an effective stem. If we did some work in the cadaver lab some time ago with one of my fellows and he found that if you have an effective stem and four screws, you can fix it well in the softest of bone. So that’s when I tell you, you better use an implant that has an effective stem and that generally means a taper on the under surface and choice of stamps. You better have one that allows you to use screws like the– like screws in the acetabular component of your total hip that maybe you do not always need them but better be ready in case the thing really is not tightly fixed soft bone. You have to be a decent technician and insist on a flat surface that you can screw this implant down to. This is a matter just being a good carpenter, good mechanic.

Kevin: Just got asked this real quick because it’s been a running theme lately but do you do any carpentry outside of the OR?

Leo: You know, I used to and I used to do auto mechanics too. I was an avid Porsche mechanic. Learned a bunch about how to take down a Porsche 911 engine before they became totally computerized and how to put it back together. I had every special piece of equipment that it took to tear down the Porsche 911 engine. I got pretty far along and learned how to weld and I had some early experience in machine shop work when I was in high school and learned that if [laughs] One thing, I learned how to work around grown men and then realize that if you piss them off you are going to get hurt. [Laughter] So that taught me how to deal with orthopedic surgeons.

Kevin: We have a similar pack ground. Mine was with a paint crew and I was a young guy with a bunch of old guys and I found out real quick if I rub them the wrong way, it made a man out of me. That’s for sure.

Leo: Yes. Yes, that’s right and another thing I learned up in the Machine Shop is to clean up after yourself. If you work in a clean shop, you are going to be doing good work and if you do not clean up as you go then you have a mess so you can’t clean up when you are finished. So that’s another thing I learned is as from those machinist was “clean up as you go” and you go in there and be a sloppy guy and try to clean up at the end, you got stuff and crevices that you are never going to get cleaned out of there. Somebody else is going to come in and clean up after you and I tell you if you do that in surgery. You clean up constantly as you work. That’s another very important issue, clean that with irrigation constantly and you mentioned press fitting and bone ingrowth.

If you cool and clean that surface as you cut it, you won’t be trying to get bone in grows out of a dead bone surface. You keep it cool and irrigated and you know, that’s another thing that Aaron Hoffman talks about too, is end up with a viable bone surface cool at blade as you cut and then and do this with care, and if you try– if you irrigate the trash out and add antibiotic to your irrigation fluid, you won’t have infections anymore. I mean, you’ll go 20 years without infection of a primary joint if you irrigate it with antibiotic irrigation solution throughout the case. If there’s one thing I could train young guys on would be learn to use antibiotic irrigation throughout your entire procedure and never cut bone to the point that it smokes and leave that dead bone and that patient with bacteria that you haven’t flushed and cleaned out throughout the entire operation.

Kevin: I’ve got to talk about ligament balancing for a second. It’s Ligament Balancing in Total Knee Arthroplasty: An Instructional Manual. You are the author of this book. I saw a copy of it on Amazon yesterday and you’ll be pleased to know it was priced at nine hundred and two dollars.

Leo: [Laughs] Is that cool or not? I got a bunch of it right there in my office.

Kevin: I didn’t check to see it. You are not the one selling that book, right?

Leo: No, I am going to have to start a new enterprise though.

Kevin: I remember Dr. Insole and I am so fortunate that I actually got to go in surgery with this gentleman and I’ll never forget him saying that a knee that is not balanced will fail. I have some questions for you, you know, we used to get in this whole back-and-forth about do we balance before the cuts? After the cuts? What’s your order of operations for doing your soft tissue releases?

Leo: Well, I think you must make your bone surface cuts first or I shouldn’t say first, but you must make your bone surface cuts based on anatomic structures on the bone not on deformed ligaments. If you let the ligaments guide your bone surface cuts, your just essentially putting the knee in crooked. The worst your ligament imbalance, the more crooked you are going to accept when you use those deform ligaments to guide your cuts. So you must find bone landmarks on the knee.

Now, some people find that they can’t get into the knee and let’s say release these tight ligaments, but you should remember that if you release tight ligaments, then you may over release because you haven’t gotten to the osteophytes yet. Here’s what I suggest. Get link and get Landmark that you can trust. Makes the bone cuts, clear out the osteophytes, then start to deal with the ligaments and then you can deal with ligaments with tensioners or with trials. I assume that the tensioners are going to be partially accurate and the trials are going to give me a three dimensional feel and access to do the ligaments once the trials in.

All right. So I would want to go directly to the trials, evaluate the ligaments and then release the ligaments that are tight. If you understand the knee, you’ll understand which ligaments are tight. The ligaments that are tight in extension or the posterior ones and the ligaments that are tight inflection are the anterior. With that, you can figure out what to release.

Kevin: So tell me about the periosteal elevator versus the spinal needle. I’ve seen this done both ways and I’ve been dying to ask you this question. Any thoughts on that?

Leo: Yes. I learned that pie-crusting technique from Johan Bellemans. I think he was the first to start talking about that and I was fascinated right away. I pretty much stopped doing periosteum elevation or ligament balancing and use the pie-crusting technique exclusively and you can get to most ligaments with a spinal needle safely and there are several techniques that I am on the process of putting together some videos that I’ll put on YouTube to explain how to do this Pie-crusting, but I think Johan Bellemans ought to be the guy that has pointed to– he’s the one, he’s the pie-cruster incharged here.

Kevin: One question I’ve always wanted to ask somebody of your stature is this, it’s going to seem kind of silly but I was in a case one time and the surgeon had made the distal femoral cut and made his tibial cut then put a spacer block to look at what is extension presented and said “It’s too tight. I’ve got to take more bone” and in my mind, I was wondering we haven’t removed any posterior osteophytes yet and there was a lot on that particular X-ray and we ended up using a thick surface. I always wondered, is that a little premature to be measuring that extension gap when you haven’t even gotten back and release the capsule or any osteophytes?

Leo: Yes. Absolutely. You are so right. You just said everything that needs to be said about how that works. If you do not take out the osteophytes, you still have deformities of the ligaments and they can lead you to make some pretty catastrophic bone surface cuts and it’s even worse than if you make those bone surface custom it get the knee to full extension and then go back and take care of the problem in the first place the posterior capsular and posterior osteophytes. Then you got the knee that goes into hyperextension and you have to add augments on it to keep it from hyperextending. So, you are so right. First, make the bone cuts. That gives you access to all the osteophytes. Then take all of the osteophytes down and get a pristine knee to work with then put in the trials or spacer blocks and balance the ligaments.

Kevin: I read an article recently about mid-flexion instability being less of an implanting issue and more of a soft tissue issue and I was just curious, do you think a proper balancing of the knee addresses a majority of that subject?

Leo: Yes. Absolutely, yes. It requires that you get the knee in in the right position in the first place and the best way to do that is with balanced anatomic surface cuts where you remove the thickness of the implant from the high side to the undeformed side of the joint. There’s always one that’s high and the other one low. Rarely both about the same. With that, you get to the basic bone anatomy established. So I said, it’ll hold your correctly inflexion and extension once you get the ligaments balanced.

Kevin: A couple more clinical questions doctor, I was fascinated reading a paper that you wrote detailing single stage revision for infected hips and knees and essentially reimplantation with poorest components and then a Hickman’s catheter for six weeks with some high dose antibiotics. Is that still your treatment of choice?

Leo: Absolutely. I am pushing that as hard as I can to the Orthopedic Community. They’re still fiddling around with intravenous antibiotics and with spacers and that’s all– that’s just enough to piss off the bacteria. Give them ammunition to– and intelligence. You are losing the battle with all of that. We learned in medical school, all of us did that small piddly doses of antibiotics given over a short period of time creates antibiotic resistance. The way to eliminate infection is with high-dose, long-term antibiotics. That eradicates the bacteria to the point that the patient’s immune system and other mechanisms of resistance of infection can then take over. You know that in urinary tract infection, that’s the way you get a chronic urinary tract infection with resistant organisms. Give them a couple of days of low dose antibiotics and then they–one after another, they keep getting these infections and get sicker and sicker.

But that’s what we still do in Orthopedics. For some reason the academicians are following along with the Infectious Disease guys who tell you that you can just use oral antibiotics oppressively for long period of time or that the spacer is going to be of some help to you and the spacer will release enough antibodies to give you maybe a hundred, maybe two hundred if you are lucky, micrograms per milliliter or milligrams per liter. That is about one tenth or maybe one thousandths of what you need to kill biofilm. We have to discuss biofilm if we’re going to talk about implant infection.

Biofilm is so resistant to bacteria that you have to increase the concentration of bacteria by a thousand times or more to eradicate biofilm. Any discipline that is dealing with infection of implants should be dealing with minimum biofilm eradication concentration MBEC, M-B-E-C. If you are not achieving M-B-E-C, MBEC with your mechanism of treatment, you are going to have a high failure rate. I’ll tell you that antibiotic spacers loaded with cement and that cement impregnated with antibiotics are ineffective. A hundred micrograms per milliliter is ineffective on biofilm. So you are going to fail at a high rate.Infusion can give you fifteen thousand micrograms per milliliter and I guarantee you, that’s effective.

Kevin: There was an article out years ago, and I’ve got it somewhere but it was talking about the therapeutic level of antibiotics that you had to have to at least do something. It was astounding when they plot it in on a graph as to how many antibiotics cements were basically one and done within 24 to 48 hours. I was surprised by that.

Leo: The antibiotics have leased out and even at that, their highest point, it’s still ineffective against biofilm but direct infusion– when you do the debridement in the first place and also when you do the primary joint, you should be irrigating with high dose antibiotics, broad-spectrum. So I use a thousand– excuse me, 5,000 milligrams of vancomycin per liter and 500,000 units of polymyxin per liter in my irrigation fluid so that when I am finished operating, that’s a sterile joint. I do not care if you operate on it for five hours. You irrigate throughout the procedure, just like I said in the Machine Shop, you clean up after yourself throughout every step of the way. You end up with a sterile joint that has antibiotic closed up inside it. When you close it, it stays sterile. When you got an infected joint, you do that plus you start infusing antibiotics directly into the joint. If you do not know what’s in there, you start with broad-spectrum. I start with vancomycin one day and gentamicin the next day. Alternate until I figure out whether it’s a [inaudible] super gram negative.

Kevin: Let’s talk about your wash outs for a minute. I was at one time seeing them used what they called Witches Brew, which was saline, Betadine and hydrogen peroxide when they were washing out an infected joint. Any potions that you prefer in your cases?

Leo: No, I think that’s horrible. The more the last thing you should do is use antiseptics in a joint. It damages every tissue that you are trying to get to heal. It damages bone cells, cartilage cells, synovial cells, skin cells. I think it’s just horrible. Using that stuff in a human wound is crazy when we have antibodies. Now, maybe that sort of thing would be okay back in the Middle Ages. Middle Ages is when they would put a goat shit compress on a fresh burn because it stimulated transformation, similar sort of logic I think.

Kevin: Nickel allergies, I remember giving surgeons many years ago these discs to put on their patients skin to check for that and then we discovered that was really an incomplete picture. I’ve heard three camps over the years. I’ve heard that it’s not an issue. I’ve heard it is an issue and then I’ve heard other people say, well really it’s just a legal issue because if the patient says they didn’t do well and I didn’t acknowledge it with a change of implants then I am going to get sued. I was just curious where you come down on this debate?

Kevin: Well, I’ve been studying that every day for years and I assure you that metal sensitivity is real and it’s serious business. If you look through the orthopedic literature, it’s loaded with problem with metal sensitivity. Sometimes just cobalt chromium alloy plate will cause total body metal sensitivity and even things such as neurotoxicity and strokes and the patient not cured until a plates taken out.

Back in the 70s, we had these metal on metal hips that were put in and huge epidemic among arthroplasty surgeons of metal sensitivity illness loosening and pseudotumor formation. It disappeared when the metal on poly came out and by the way, I think that’s Charlie’s greatest contribution is metal on polyethylene because it didn’t cause this metal hypersensitivity. So the metal on metal came back. Metal sensitivity because of the dosage level came back. It was a vengeance and almost everybody who dealt with metal on metal hips quit and their patients paid a great price for that.

So since metal on metal hips is pretty much gone now. In fact, it’s ceramic on polyethylene, and I am sure we’re headed for a ceramic femoral surface in the knee. That’s where I am putting my greatest emphasis right now. The femoral component in the knee distinctly releases metal. No doubt about it. There are all sorts of studies that show that metal is released by the femoral component. There are also lots of good studies in the literature that show that metal sensitivity increases, doubles its percentage after you put a total knee replacement in the patient. There are patients in every major Medical Center that have metal sensitivity and are severely disabled from it. I’ve got patients that have been sent to me from all over the world with metal sensitivity after total knee replacement.

It’s a big issue, but it’s hard to deal with now because we do not have an inner femoral component that’s reliable to use without cement and then I’ll tell you what, that’s what’s going to come and that’s what going to change our approach. You hear a lot of people say well 10%, maybe 15% of patients with total knee replacements are dissatisfied. They have intermittent swelling and you can’t really find anything wrong with their x-rays and they say well it’s because of some subtle ligament imbalance or maybe the wrong size implant. My feeling is if knee replacements are not so good because of that toxic femoral component that we have in there. I’ll tell you where the pressure is going to come from, European version of the FDA has already required labeling of any cobalt chromium metal as putting the body as potentially carcinogenic. It’s getting people’s attention and we’re going to have to stop putting this toxic femoral component into the knee. We’re going to have to stop doing that. The dentists have stopped long time ago putting cobalt chromium metal into people’s mouths because so many people reacted to it. So we better get on this and that’s where I am focusing everything that I am doing. That plus infection issue as you know.

Kevin: The CeramTec is pretty much owned the ceramic world I think if no matter what company you are with if a ceramic head is called for, it’s a pink one. Tell me about these whiteheads I saw the other day, magnesia-stabilized zirconia.

Leo: Yes. That’s the key to success is magnesia-stabilized zirconia. That’s among the ceramic engineers known as the super alloy of ceramics. It’s got enough flexibility that has great fracture toughness and you can make things out of it that you ordinarily couldn’t make out of something as brittle as alumina ceramics. Magnesia-stabilized zirconia is flexible enough to be even be used as a femoral component in total knee. It makes an excellent femoral head. These implants actually outperformed the CeramTec, ZTA zirconia ceramics. The CeramTec ceramic is called ZTA, Zirconia-toughened alumina. It’s actually sort of a conglomerate like the conglomerates that you studied in geology. It’s a bunch of different crystalline structures packed together primarily, alumina and zirconia and that gives it a certain toughness but it’s not so tough that they can make these without a metal inner liner.

So most of them have a metal inner liner that they rely on for toughness. Magnesia-stabilize zirconia if it’s made correctly does not require metal inner liner and it is heat resistant and water resistant and is pretty much a lifetime implant. Zirconia-toughened alumina that CeramTec uses does roughen in an aqueous environment and is not heat stable enough for biological use. I do not think– So, I think–ceramic is looking for an alternative to that and I do not think they’re looking in the right spot.

I’ve been using these magnesia-stabilized zirconia implants or years. I mean, close to twenty years without a failure. No failure of these implants have ever been reported with over 20,000 implanted and on the process of working on a femoral component for the total knee. I think that is going to make a big difference.

Kevin: I talked to a surgeon this morning who followed up on one of your cementless uni’s out in Arizona that was 18 years out and doing awesome. I can understand back in the 90s, there were some reticence to do a uni because some of the designs weren’t faring well and honestly, we were still figuring out the technique. You do not balance it like a total knee, you leave a little slack. I can understand all that but now that we’ve worked out a lot of those kinks, why do you think they’re still reluctance in some quarters in the presence of isolated compartment arthritis to do a uni?

Leo: Yes, because it’s harder to do it just right. I am telling you, unicompartmental knee replacement is a real technicians operation and you’ve got to be patient and slow down and do it absolutely right. We’re talking about millimeters as opposed to centimeters [laughs]. When you do this we do the uni knee. It’s one of the hardest operations in Orthopedics. Maybe the hardest operation is a unicompartmental knee and then of course you leave the rest of the joint that may or may not perform well for the rest of the patient’s life and so you might be embarrassed by late failure due to progressive arthritis. You have to do a good job of selecting the patients and counseling the patients on what to expect after a uni knee and what I tell them is, uni knee would be most likely to give you a knee that’s going to function like your own knee. It has lower infection rate, lower complication rate in terms of the primary operation at least in the literature but it may fail due to failure of the rest of your knee that the loosening rate can be almost zero in a good technical surgeons hands but big downside is the rest of the joint and some of them will look at you and say, “we’ll just do it all then” and ones that say, “no” I want you to save every bit of my knee as you possibly can and that kind of makes the decision.

Kevin: Yes, I can only imagine. I mean, I’ve never had one but the perception would be a lot better with a uni than a total.

Leo: Yes, I’d love to have–if I had a medial compartmental issue, I’d love to have a very excellent technician do a uni knee because I know they can give you an knee that functions well for years, but I wouldn’t want a cemented uni. It’s interesting that the Oxford Group has already shown that their cementless uni is outperforming their own cemented uni, interesting.

Kevin: You brought up a UTI earlier and passing and it took a while for that to get through my head. A question that I see come up. I have some surgeons, if there’s a presence of a UTI that morning, they will just do the case anyway, and then there’s some surgeons that say “absolutely not”. What’s your thoughts on that?

Leo: Yes, if they have an active urinary tract infection. I do not operate. I do not operate on them because they are bacteremic if they’ve got a UTI and I do not take that chance. I’ll send them home. If they come in with painful urine and they’ve been on antibiotics for a couple of days, I send them directly home and get that all cleaned up. Now, if they got a chronic ongoing urinary tract infection, that’s another decision to make, whether or not they are a candidate for total joint replacement and I must say I almost never have to make that decision.

Kevin: So Dr. Whiteside, two hundred publications, you’ve invented three knee systems, two unicompartmental systems and three hips. What’s next?

Leo: Well, I am working on an infusion system that can be made that the FDA will accept. A direct infusion into the knee and will give people some confidence that this is not just off label use and you are some kind of a cowboy for doing it. So that’s a big one, I think. The other is a ceramic femoral component for total knee replacement. A cementless implant that will give you a lifetime of service. All the advantages of ceramics and get the toxic cobalt chromium out of the knee.

Another one is reconstruction of the abductors of the hip. We didn’t talk much about the hip and over the last fifteen years or so, I’ve learned a lot about the abductor muscles and have really focused on reconstructing or at least identifying and fixing what you have to look for at a total hip replacement and then reconstructing using gluteus maximus flat transfers and sometimes tensor fasciae latae flap transfer for addressing this important issue. Of course, you know I am going to be continuing to press on the ligament balancing [chuckles] in total knee replacement. I refuse to give up. [laughs]

Kevin: Well tell me about Costa Rica. I was reading an article recently about this Wildlife Sanctuary you are involved in and tell me what’s going on?

Leo: Well, you know I have been fascinated by the tropics since I was a kid. I mean, I can’t remember a time that I wasn’t just fascinated by palm trees and tropical jungles. I kept that interest all through my childhood and adulthood. For a while, I thought it’s almost an impossible dream, but I’d love to have a place on on the Pacific Coast in Costa Rica with a biological team to look at some of these interesting questions like Marine Turtleswhere they actually go and what makes that life cycle work. So about fifteen years ago, I took one of these little tours where they advertise the Wall Street Journal for five hundred ninety-nine dollars they give you a air fair to Costa Rica, five days of rental car and five nights in hotels with food and thought, I can’t pass that up.

So I took this thing and went to Costa Rica and worked my way down to the Southern Pacific Coast of Costa Rica and started looking around and I stumbled on a place that was a hundred acres or it was easily expandable to a hundred acres. Their on the Pacific coast with a couple of strings running through it into the ocean and it was just perfect for what I wanted to do. Had a couple of buildings on it that I could rehab and so I started working on it and it took about four years before I got it where I could take my family down there. Now, they’re really delighted to go. We have a Wildlife Reserve that brings people in from all over the world to volunteer and do a marine turtle project or we have now a crocodile project and a tropical mammals project and they spend a week to a year with us. Sometimes doing graduate work. We have a full-time biology staff that works there all the time and on a permanent Wildlife Reserve. Very important endeavor in my mind. We are actually doing some significant work on Marine Turtles and also on the effect of urbanization on water runoff and in tropical environments.

Kevin: Maybe you could host a conference down there for device reps that host medical device podcast?

Leo: Yes [Chuckles]

Kevin:I know a guy. [Chuckles]

Leo: [Laughter] We do not allow insect repellent on the premises. So you’d have to be ready to [crosstalk] a couple of bugs.

Kevin: Oh, I imagine. I imagine there’s some big ones down there.

Leo: Yes.

Kevin: So lastly– and this is just to resolve you know in music it’s the song that has never resolved for me. I tried to remember, for years the presentation that I saw you do with the [inaudible] meeting, those meetings were wonderful by the way.

Leo: They were, yes.

Kevin: I always enjoyed hearing different voices, always enjoyed yours, especially if it didn’t line up with what I believed at the time. I thought you know, every idea needs a challenge and helps us understand everything a little better and you were talking about a revision hip that you would come up with and I’ll never forget the rasp on your slide show, it was a square long stem and you were talking about the rotational stability of that square rasp and a round hole. It always stuck with me that that made total sense. What was that? What was it? What was I looking at?

Leo: Well, it was the Quattro lock and Cointreau M revision system and you know, I still use that concept in primary hip. It’s just that the FDA has been so difficult to deal with, with a fully porous coated monoblock stem. That project is on hold but you know, that was our great stem. Simple, easy to work with and very easily understandable and you could revise the entire spectrum with a total of nine different stems and that took care of that little tiny folks and great big people with catastrophic bone loss. You had to have a good cable system, but with that sort of technology, we could we could get any surgeon to handle a really tough revision femur.

Kevin: So, how many years you been doing this sir?

Leo: Well, let me see. I got into Orthopedics in 1970. How long has that been? [Laughs] Too long I bet.

Kevin: Fifty years

Leo: Last couple of years.

Kevin: Wow. So, what are you the most proud of? I mean if you had to hang your hat on a couple things that kind of jump out at you over your career, what’s the thin you said, “You know, I am so glad I did that” or “That was a lot of fun.”

Leo: Well, I must say I am glad that I took a few years of my career early on to really focus hard on biomechanical research and that sort of endeavor. It gave me a background that I could use the rest of my life to–taught myself how to manage statistics and to understand scientific method a little bit. So that’s I think the best decision I made. It’s a little stressful on my family but it was it has definitely made a difference.

I guess the other thing is I am so glad that I choose Orthopedics as a specialty. It’s been a wonderful trip and give me more than I can do right now. Will tell you that if you expect to learn Orthopedics forget about it. I mean, there’s more than that you can learn in a lifetime just to be good at it. I am always disappointed in myself and I am not good enough yet and I’ve been doing this all my life. So it’s one of those things that’s a curse and a blessing. It’s a blessing to have something so fascinating to do all the time but it’s a curse to have to put up with the frustration of not being good enough at it yet.

Kevin: Well, you’ve certainly been a blessing to this industry and has certainly been one of the preeminent voices in the Joint Reconstruction space for now 50 years.

Leo: Yes. [Chuckles]

Kevin: Thank you so much for your contributions to it and for sharing your life with my audience. I just really am grateful.

Leo: Well, it’s very much a pleasure to talk to you and thank you very much. I am flattered to have this opportunity.