Duke Health Referring Physicians


Joint Replacement Surgeon Highlights Growing Demand for Direct Anterior Approach

Q&A highlights Duke’s range of treatment options, current trends in hip and knee research

Xray of knee replacement

As one of the newest joint replacement surgeons to join Duke’s growing adult reconstruction group, Sean P. Ryan, MD, offers a full range of nonoperative treatment options as well as several medically optimized surgical approaches to give each patient the best outcome possible.

In this Q&A, Ryan talks about his award-winning fellowship research while at Mayo Clinic, tailored approach to hip and knee replacements, and current work on postoperative fracture risk and knee flexion that may impact patient outcomes.

What research have you published recently in hip arthroplasty?

Ryan: Patients are often referred to bariatric surgery to lose weight prior to a total hip replacement, but in a retrospective study I led while in fellowship at the Mayo Clinic, our team found that patient outcomes are actually worse after bariatric surgery. Ultimately, we believe patients should be encouraged to engage in self-directed weight loss for medical optimization prior to a joint replacement surgery. The paper recently won the Hip Society's Frank Stinchfield Award, a prize given to a resident or fellow in training for a significant contribution concerning hip pathology.

What is the focus of your new practice at Duke?

Ryan: At Duke University Hospital and Duke Health Center Arringdon, I primarily work with patients with hip and knee pain who need total hip and total knee replacements, but I see a wide spectrum of patients presenting with everything from chronic knee pain and mild arthritis to complex arthritis, to those who have failed initial conservative treatment options. I also manage patients who previously had an arthroplasty elsewhere and are unsatisfied, considering revision, or those needing major revision procedures who are referred by other surgeons.

What specialty expertise do you offer in adult reconstruction for hip and knee replacements?

Ryan: At Duke as well as nationally, the most common surgical approach for hip replacement is a posterior approach.  In addition to that approach, I also offer lateral, and direct anterior approaches, depending on the patient’s medical history and risk factors. The direct anterior approach for primary total hip replacement is a muscle-sparing approach which, for select patients, may result in a faster recovery with a smaller incision, and patients are seeking this out. For knee replacement surgery, I utilize a variety of techniques for primary and revision surgeries, including robotic or computer-assisted techniques, when appropriate.

What else are you working on to advance the field of joint replacement? 

Ryan: I'm on the American Academy of Orthopaedic Surgeon (AAOS)’s American Joint Replacement Registry (AJRR) publications committee, and we're investigating fracture risk perioperatively based on implant design utilizing this powerful registry with millions of patients. With so many different implant designs and surgical approaches, there are likely varying risks for fracture based on bone quality, medical comorbidities, and surgical approach. For hip and knee replacements, it's all about trying to minimize complications and trying to maximize patient benefit from the surgery.

One of my other areas of focus is on knee flexion instability, which is a significant contributor to patients who remain dissatisfied after a total knee replacement. I’m working to create more objective diagnostic criteria for flexion instability, as well as developing indications for revision surgery in those patients.

When is the best time to refer a patient with hip or knee pain?

Ryan: If a provider is unsure of the workup required or wants to explore appropriate nonoperative treatment options for their patients, I always recommend placing the referral sooner rather than later. I’m happy to discuss what their treatment course will likely be and put them on a path towards pain improvement with nonoperative measures to start prior to surgery.

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