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Part II: Examining Anterior Approach from Down Under · AHF Podcast

• 0:07
  Joseph M. Schwab: Welcome to part two of examining the anterior approach from down under.
• 0:12
  Joseph M. Schwab: Let's get back to our conversation with Australian hip surgeons, Patrick Weinrauch, Ilan Freedman and Jit Balakumar, as well as orthopedic sales rep Joe Scerri.
• 0:23
  Joseph M. Schwab: Which, which just raises my next question, and you started this conversation here a bit, Jit, so what do you guys see as the biggest challenges or controversies about DAA, within the landscape of Australia?
• 0:39
  Jit Balakumar: The biggest controversy, it's what you've said already.
• 0:41
  Jit Balakumar: I think the, creme de la creme in orthopedics for most, hip surgeons is arthroplasty.
• 0:49
  Jit Balakumar: you have a winning surgery.
• 0:52
  Jit Balakumar: very predictable outcome.
• 0:54
  Jit Balakumar: Patients are usually low maintenance.
• 0:55
  Jit Balakumar: So that's what most people want to do.
• 0:58
  Jit Balakumar: And so I think you have to be careful.
• 1:00
  Jit Balakumar: There's the private practice aspect and we've all seen LinkedIn videos, YouTube videos of patients walking day one post op 20 steps of stairs.
• 1:10
  Jit Balakumar: And, is the marketing, right?
• 1:12
  Jit Balakumar: And.
• 1:13
  Jit Balakumar: I think this it's no, it's not dissimilar to what my senior colleagues did with yellow pages.
• 1:19
  Jit Balakumar: So we shouldn't criticize people for that.
• 1:22
  Jit Balakumar: with it comes some risks because we all get complications and we all have problems.
• 1:28
  Jit Balakumar: So when you put yourself out there, it can also be the sword you die by.
• 1:33
  Jit Balakumar: let's look at the data.
• 1:34
  Jit Balakumar: The data shows anterior and posterior approach is.
• 1:38
  Jit Balakumar: It's exactly the same in outcomes at six months, and there's double the rate of dislocations with posterior approach, almost three times the increased rate of infection, twice the rate of fracture and loosening, early loosening in the anterior approach.
• 1:54
  Jit Balakumar: so there's, trade offs and I think we have to be cognizant when you do it.
• 1:58
  Jit Balakumar: But I agree with Dr Matta completely.
• 2:00
  Jit Balakumar: I think the market is the current market is very astute.
• 2:05
  Jit Balakumar: They know what they want they are all on social media.
• 2:12
  Jit Balakumar: Pat does a lot of resurfacings.
• 2:15
  Jit Balakumar: I have so many patients coming in saying, look, I want a resurfacing.
• 2:18
  Jit Balakumar: And I said, where did you hear about this?
• 2:20
  Jit Balakumar: I go, I'm on a Facebook website.
• 2:21
  Jit Balakumar: I'm a runner.
• 2:22
  Jit Balakumar: I'm a marathon runner.
• 2:23
  Jit Balakumar: I've heard that you've got to be loading your proximal metaphyseal bone if you want to run long distances.
• 2:29
  Jit Balakumar: And, I said, look, you're, absolutely right.
• 2:32
  Jit Balakumar: look, I'm going to send you to one of my partners.
• 2:35
  Jit Balakumar: But the market is way more well equipped to actually know and have the knowledge Then we give them credit for I think gone is the paternalistic era But you've got to play a role in this and say look I think Um in my hands, this is what the best approach is.
• 2:51
  Jit Balakumar: So I think it's Dr Matta's absolutely right the market's driving it and that's what's going to organically grow it.
• 2:58
  Joseph M. Schwab: Do you think we're moving the paternalism out of the clinic room and onto the internet when we're engaging with patients, that way?
• 3:07
  Joseph M. Schwab: is that, we're ceding that information a little bit, to our patients, ahead of time.
• 3:12
  Ilan Freedman: Yeah, it can be a bit difficult.
• 3:13
  Ilan Freedman: Patients come in now, asking for specific bearing surfaces or asking you about what particular polyethylenes or which, which exact metal have you used.
• 3:22
  Ilan Freedman: So it's, I guess it's the, the side effect of having all this information on hand.
• 3:28
  Ilan Freedman: patients can access all of that very easily, and many of them do.
• 3:30
  Ilan Freedman: So come in with good questions, but sometimes come with questions which, They don't really know what to do with the answers, they come in asking, what metal is it?
• 3:38
  Ilan Freedman: And you tell them and they look stunned.
• 3:42
  Ilan Freedman: yeah, but people are coming in, very informed and they read your bio, they read your results.
• 3:48
  Ilan Freedman: In some cases, they've read your papers.
• 3:49
  Ilan Freedman: So I guess that's the reality now.
• 3:54
  Patrick Weinrauch: I don't, mind, patients being well informed, I think that, I think it's, I think that it's good that they've we instinctively, I think sometimes they may be a little over informed, but, there's a, good balance there.
• 4:08
  Patrick Weinrauch: And, and I think, I think it's nice to be able to have a really robust sort of education of a patient prior to their surgery.
• 4:20
  Patrick Weinrauch: so I I don't, shy away from, a patient comes in and my heart doesn't sink when they come in with their, with their ream of papers, it's like, Yeah, sometimes it can be a bit tricky, our role is, as a responsible professional is to guide them, right?
• 4:36
  Patrick Weinrauch: And we're there to be able to educate them and to be able to put, what they've read into context and balance because we're the subject matter experts and, if they're relatively well read, then it's actually quite easy to direct them there and to be able to, give them a framework to be able to understand what they're reading.
• 5:01
  Patrick Weinrauch: And I suppose my, comment, bringing it back to anterior approach is, that, historically, I think when, anterior approach first came into Australia in any numbers.
• 5:14
  Patrick Weinrauch: There was very much a, it was really marketed hard.
• 5:18
  Patrick Weinrauch: That wasn't necessarily just, in fact, that probably wasn't so much surgeons who are driving that.
• 5:22
  Patrick Weinrauch: That was industry.
• 5:23
  Patrick Weinrauch: So industry was driving anterior really hard because there was one company in particular that was linking, anterior approach and, this is the implant and this is the table.
• 5:34
  Patrick Weinrauch: And so it was like a package and this, and from a surgeon's perspective, that was the easiest conduit to be able to get education in the space as well.
• 5:43
  Patrick Weinrauch: So it was a very successful marketing strategy, to be able to, educate surgeons, educate the community and build awareness around it all simultaneously.
• 5:56
  Patrick Weinrauch: And so that particular company, which was really a minnow in Australia at the time has really boomed, right?
• 6:02
  Patrick Weinrauch: So it's a very successful company now in Australia for that reason.
• 6:07
  Patrick Weinrauch: I think we've seen a bit of a correction now over the last sort of eight years where pretty much all of the companies have got an anterior offering now.
• 6:17
  Patrick Weinrauch: So instrumentation platforms and things like that.
• 6:19
  Patrick Weinrauch: And so, we're now starting to see a bit of diversity, amongst the ways in which we are doing surgery.
• 6:28
  Patrick Weinrauch: For instance, whether it's being put on a traction table or not on a traction table, there's quite a, I'm not sure what the, we can't capture that on the Australian registry.
• 6:38
  Patrick Weinrauch: My instinct is it's probably still dominated by table use, but then there's a quite a big component which are doing it off traction tables as well now, which is pretty much, and, very much being implant agnostic now as well.
• 6:56
  Joseph M. Schwab: Would you say that the industry based education, that you're talking about, was that a primary driver towards adoption of, of anterior approach or were people getting their surgical, education on this technique, it mostly in other ways.
• 7:13
  Patrick Weinrauch: So in Australia, like when I went through My residency, we call it registrar, but residency, the, there was really no exposure to anterior approaches.
• 7:28
  Patrick Weinrauch: So this is a technique that I've taken up post, qualification fellowship.
• 7:35
  Patrick Weinrauch: and We're very reliant on industry support to be able to get that education, right?
• 7:42
  Patrick Weinrauch: and this of course you do us nowadays if you can find a place to go and do fellowship, right?
• 7:46
  Patrick Weinrauch: Where you can learn those techniques in your fellowship, but you know a post fellowship orthopedic surgeon requires Industry support.
• 7:56
  Patrick Weinrauch: The industry is still very involved here in Australia in, surgeon education, not just an anterior approach, but in all aspects,
• 8:05
  Jit Balakumar: I run two fellowships, and my, all my fellows, they start their practice.
• 8:10
  Jit Balakumar: I have a local fellow and international fellow their practice almost instantly explodes because of anterior approach.
• 8:17
  Jit Balakumar: Um, look, obviously, I learned slightly differently, but I remember that actually the first anterior approach I saw was with a guy in Box Hill Hospital, public hospital, and, there was two of them actually there.
• 8:30
  Jit Balakumar: One guy who did it on the table.
• 8:32
  Jit Balakumar: Supine and another guy who did it in the lateral position anteriorly and I was blown away by it.
• 8:38
  Jit Balakumar: No one talked about it.
• 8:39
  Jit Balakumar: There was no marketing, but their recovery was very different to the rest of the, unit.
• 8:44
  Jit Balakumar: And then when I went to my, equivalent rural rotation, I convinced my boss there to do it anteriorly.
• 8:50
  Jit Balakumar: We had a ASR head, with an ASR cup with a Zweimuller stem, and, it was, a disaster, and I should never have convinced my boss to do that, But I would say, look, I echo Pat's points.
• 9:07
  Jit Balakumar: It's, changed very much in the industry has really been, people are very quick to criticize industry.
• 9:12
  Jit Balakumar: They have improved patient outcomes dramatically by championing high quality education, right?
• 9:18
  Jit Balakumar: And, they, the smaller startup companies use it as a point of difference.
• 9:23
  Jit Balakumar: The larger companies try to get ahead with it.
• 9:26
  Jit Balakumar: And now, fellowships that are attached to an anterior, because they can see the, the return on investment and how they can monetize it.
• 9:37
  Jit Balakumar: On the flip side, think every hospital, I'm sure it's the same in Queensland and in Australia, in Victoria to be credentialed.
• 9:46
  Jit Balakumar: So they classify anterior hips, robotic surgery as a tier B credentialing.
• 9:50
  Jit Balakumar: So not the standard that you finish in your training program.
• 9:54
  Jit Balakumar: And to be credentialed, they expect you to have done either a fellowship.
• 9:58
  Jit Balakumar: Or have done at least 30 cases with someone who's an experienced anterior hip surgeon and then be supervised by their local, whoever the hospital representative is.
• 10:10
  Jit Balakumar: there's some very robust credentialing process and I again tell trainees, look, you've got to be careful.
• 10:16
  Jit Balakumar: When you first start, you don't want to be, you've got to slay a few dragons to get your princess and we don't want to go through that process, right?
• 10:23
  Jit Balakumar: don't want to be slaying dragons.
• 10:25
  Jit Balakumar: That's not the process with this.
• 10:27
  Jit Balakumar: And, I think that's industry has done that amazingly here.
• 10:32
  Joseph M. Schwab: Joe, as the representative of industry in this conversation, what do you, what have you seen in the landscape of anterior approach in Australia?
• 10:41
  Joseph M. Schwab: What has been most striking to you?
• 10:44
  Joe Scerri: I think I'd like to answer that question a little bit historically, and that is in a lot of the points that the guys are making, certainly fellowships are really important.
• 10:53
  Joe Scerri: and I've done a number at, Wrightington and various places like that over the years.
• 11:01
  Joe Scerri: in France and, so forth and they have been, as has been mentioned in terms of the return on investment, excellent because quite often they're with a high volume surgeon who happens to be using obviously, the implant that is manufactured by the company that sponsors it.
• 11:19
  Joe Scerri: And then they come back as a devotee and, it becomes a nice circular return.
• 11:24
  Joe Scerri: Everybody wins.
• 11:25
  Joe Scerri: And, and that's been a worthwhile investment.
• 11:29
  Joe Scerri: And as far as I know.
• 11:31
  Joe Scerri: continue to do that.
• 11:33
  Joe Scerri: then you've got the existing fellowships.
• 11:35
  Joe Scerri: the one that, that you've mentioned Jit when Jit does the anterior approach, the people that become, proficient at that, have to learn somewhere.
• 11:46
  Joe Scerri: So if they decide that's for them in their private practice, then they'll continue to do that.
• 11:50
  Joe Scerri: So that goes on.
• 11:52
  Joe Scerri: And then you've got.
• 11:54
  Joe Scerri: people like Pat who, do visitations from various companies.
• 11:59
  Joe Scerri: and I think that there are selected people around the country who, perform direct anterior where there are medical companies that will send, surgeons to those, to those surgeons because it enables them to be trained on the anterior approach, but at the same time, presumably.
• 12:20
  Joe Scerri: If they like the implant at the time, then they go back and that becomes part of their private practice.
• 12:24
  Joe Scerri: And I think that's where, one hand, rubs the other and everybody wins as well.
• 12:30
  Joe Scerri: And, then there are other things that, I'd like to get involved in.
• 12:35
  Joe Scerri: And that is, we're not big enough to be able to sponsor those things, but certainly things like, cadaver workshops, where, you know, that can be learned on that approach.
• 12:45
  Joe Scerri: think, those go on as well, but I think the combination of fellowships, visitations, And certain workshops are probably the collection of things that surgeons are getting exposed to when registrars and senior fellows.
• 12:59
  Joseph M. Schwab: has the landscape for visitations in Australia, has it begun to include things like reverse site visits where a mentor will come and spend time with a surgeon as they're starting to do their cases?
• 13:13
  Joseph M. Schwab: And has there been any introduction of, virtual visitations, using, augmented reality, virtual reality, those sorts of things?
• 13:24
  Jit Balakumar: I've got to say something about that, though.
• 13:26
  Jit Balakumar: Look, I do have a problem with visitations.
• 13:28
  Jit Balakumar: And I think Pat and I were with J and J at this stage where they were trying to develop this mini fellowship and and reverse visitations.
• 13:36
  Jit Balakumar: I do think, the.
• 13:38
  Jit Balakumar: One of our all of our pet, interest is adult education, right?
• 13:43
  Jit Balakumar: And adults are very differently educated based on who you are.
• 13:47
  Jit Balakumar: There are some who can just do that and they'll come back and I'm sure Pat, you probably taught a lot of people how to do resurfacings, but there are some you would never let do a resurfacing afterwards just by watching you.
• 13:59
  Jit Balakumar: And some of these things require a lot more.
• 14:01
  Jit Balakumar: So you want the expert novice right at the end of that And that's not what you're getting.
• 14:07
  Jit Balakumar: I don't think with anterior who've never had it before.
• 14:09
  Jit Balakumar: So it's probably different for the next group of trainees, but I think that was one of the downfalls of the anterior early on was was high fidelity training on cadavers.
• 14:20
  Jit Balakumar: Then you came and saw someone, but they weren't the expert novice.
• 14:23
  Jit Balakumar: They weren't the airline pilot has done 10, 000 hours on the simulator, right?
• 14:28
  Jit Balakumar: They were essentially still going through their learning curve.
• 14:32
  Jit Balakumar: And hopefully that, so I do have a problem with visitations and reverse visitations for certain surgeries.
• 14:38
  Jit Balakumar: And I think anterior approach is one of them.
• 14:41
  Jit Balakumar: it has its place at a certain stage, not early on in their learning curve.
• 14:46
  Jit Balakumar: But it looked at everyone's different.
• 14:48
  Jit Balakumar: There are some people who are exceptionally talented.
• 14:50
  Jit Balakumar: And they'll be able to do that very easily, right?
• 14:53
  Patrick Weinrauch: I see, I see people at various points in their learning journey, and they might come up and visit to be able to, see a bunch of cases being done just to be able to know, actually, is this a, is this really a thing, is this something that's, that I would even contemplate bringing into my practice or is this something that, it doesn't stack up for me and then they see it and they can make their decision, right?
• 15:21
  Patrick Weinrauch: And and then they might go off and they might start learning a bit more and they might go and see another guy.
• 15:26
  Patrick Weinrauch: And the, what, I tended to, observe.
• 15:31
  Patrick Weinrauch: in that space, though, is that, they would sit in a, like a pre learning space or a learning space, but they would never actually start.
• 15:43
  Patrick Weinrauch: It would be like the conversion on that, that, that conversion into starting doing their own cases was a bit of a rocky, a bit of a rocky, road.
• 15:53
  Patrick Weinrauch: a transition and that's where, having a high quality long fellowship, I think, has the benefit because there's a lot more, there's a lot more sort of guidance in that transition zone and to try to bridge that with a reverse visitation is sometimes difficult because it's so it's one day, we've only got a couple of cases.
• 16:14
  Patrick Weinrauch: Yes, it is.
• 16:14
  Patrick Weinrauch: You have got an expert surgeon with you, but it's not like doing it for over a period of months, right?
• 16:20
  Patrick Weinrauch: And, reverse visitations for, us are, they're difficult because, you've got to get licensure, and accreditation in the receiving facility.
• 16:34
  Patrick Weinrauch: and and it's very, very time consuming as well.
• 16:38
  Patrick Weinrauch: if it's just something, If it's just a guy down the road, that's pretty easy.
• 16:42
  Patrick Weinrauch: But if it's like we're a big country, right?
• 16:45
  Patrick Weinrauch: So to fly, three or four hours to go into a reverse visitation is like a two day process, right?
• 16:54
  Patrick Weinrauch: Could we use technology to be able to help that?
• 16:57
  Patrick Weinrauch: I think, absolutely.
• 16:59
  Patrick Weinrauch: There's a space for that, right?
• 17:01
  Patrick Weinrauch: So having the remote.
• 17:06
  Patrick Weinrauch: expert with, like we've talked about, like Google Glass or, equivalent sort of devices where the remote expert can see what the, surgeon is doing.
• 17:16
  Patrick Weinrauch: is that a bridging tool?
• 17:17
  Patrick Weinrauch: The answer is yes.
• 17:19
  Patrick Weinrauch: is it?
• 17:20
  Patrick Weinrauch: I suppose if we rated things on the scale of minimum better best, is it the best?
• 17:25
  Patrick Weinrauch: The answer is no.
• 17:26
  Patrick Weinrauch: I think a fellowship with Jit would be the, that would be the gold standard.
• 17:32
  Patrick Weinrauch: but is there a person in their learning journey in whom you don't necessarily need to go expend that much?
• 17:39
  Patrick Weinrauch: do you need to have best every time?
• 17:41
  Patrick Weinrauch: The answer is there are people in their learning journey at all different stages.
• 17:45
  Patrick Weinrauch: And for some, that might be enough.
• 17:48
  Patrick Weinrauch: And we're seeing, for instance, like new surgeons coming out now who have done some anterior through their primary training.
• 17:58
  Patrick Weinrauch: So they've actually had experience in this, but they're, junior consultants and they just need that little bit of a high handholding or and then so maybe a visitation and a reverse visitation is all that, right?
• 18:10
  Patrick Weinrauch: So that's, a different person.
• 18:13
  Joseph M. Schwab: So Patrick, you, raised this question in my mind and you had mentioned this before.
• 18:20
  Joseph M. Schwab: is there a role in this type of education, especially anterior approach or other more complex procedures, For a no fly list.
• 18:29
  Joseph M. Schwab: are there people that we should just be able to say you should move on me Just do something else Or is this a situation where you enough time enough dedication enough resources?
• 18:41
  Joseph M. Schwab: And we're gonna get you to where you need to be
• 18:44
  Jit Balakumar: Oh, look, 100%.
• 18:45
  Jit Balakumar: I think I'm going to step in there and say it.
• 18:48
  Jit Balakumar: I, I have one of my mentors used to say to me, can't fly like an eagle when you're a duck, right?
• 18:54
  Jit Balakumar: And it's a horrible expression, but it's, but look, it's a very, I think we all know our abilities and, watch some of my senior surgeons who are master surgeons are beautiful.
• 19:08
  Jit Balakumar: And I just sit there thinking, Oh, am I ever going to be like that?
• 19:12
  Jit Balakumar: And I think we're all pushing ourselves to be better and better.
• 19:15
  Jit Balakumar: we know some of us have awareness, some of us don't, but I definitely think there is.
• 19:23
  Jit Balakumar: There is a higher level of manual dexterity and manual, intensity and awareness that you need to do to be able to do that, right?
• 19:32
  Jit Balakumar: It's a more technically demanding operation and makes it fun for us.
• 19:36
  Jit Balakumar: We need.
• 19:37
  Jit Balakumar: a new level of challenge.
• 19:40
  Jit Balakumar: but the flip side, it's got lots of, I guess benefits.
• 19:45
  Jit Balakumar: I am going to speak to with technology and training.
• 19:48
  Jit Balakumar: I went through a lot of things to try to enable this to be better.
• 19:52
  Jit Balakumar: So I went on augmented reality, virtual reality with, as a group called Fundamental Surgery in the UK, who've got, haptic feedback.
• 19:59
  Jit Balakumar: So you can feel the incision, feel the osteotomes, feel the broaching.
• 20:05
  Jit Balakumar: And, I'm one of those people was happy to accept that my initial belief about Covid was completely wrong.
• 20:11
  Jit Balakumar: I'm always very happy to accept and go back and say what I did was wrong.
• 20:15
  Jit Balakumar: And I can say that all of those enabling technologies, which I thought was going to be great, wasn't so good.
• 20:21
  Jit Balakumar: And I think it comes down to something very simple.
• 20:23
  Jit Balakumar: I think what Patrick said, hopefully it seeps into training enough that it may be that these visitations and reverse visitations is all that's required hopefully in the future, nothing at all.
• 20:34
  Jit Balakumar: that they've done enough training that they don't need to do it.
• 20:38
  Patrick Weinrauch: The real question though is who is the, who was the gatekeeper on that, right?
• 20:43
  Patrick Weinrauch: So if, interesting um, a trainee or so if they're a trainee, that's easy, right?
• 20:51
  Patrick Weinrauch: Because there's a, there's a standard that you need to achieve, for you to be able to pass that unit.
• 20:57
  Patrick Weinrauch: And, if you haven't achieved it, then you require, Retraining, right?
• 21:01
  Patrick Weinrauch: So that's easy.
• 21:03
  Patrick Weinrauch: What?
• 21:03
  Patrick Weinrauch: What happens when you've got the ticket?
• 21:06
  Patrick Weinrauch: got your ticket, haven't you?
• 21:08
  Patrick Weinrauch: and so the real question is, who is the arbitrator of, of the gate as you who is the gatekeeper?
• 21:18
  Patrick Weinrauch: And, is that the educator?
• 21:23
  Patrick Weinrauch: because, if someone comes to visit me, I can't tell them not to.
• 21:27
  Patrick Weinrauch: It's like I can give them some really sage like advice saying watch out and maybe you might consider a little bit of additional training.
• 21:39
  Patrick Weinrauch: but then, I think the other thing is that most.
• 21:43
  Patrick Weinrauch: Companies now are quite invested in trying to make sure that their implants are, in Australia anyway, because of our National Joint Replacement Registry, picking up the trends of revisions and failures, industry has a, a stake in ensuring that their implants are being maintained.
• 22:09
  Patrick Weinrauch: Placed in by, surgeons who have got a low revision rate and so it's in their interest to make sure that we're up to scratch.
• 22:19
  Patrick Weinrauch: and so sometimes I might have a industry come to me and say, listen, we've got the surgeon who's struggling a little bit and these are the, parts that he's finding hard.
• 22:29
  Patrick Weinrauch: He or she is finding hard.
• 22:31
  Patrick Weinrauch: do you mind if we can bring them along so you can like specifically nail there and how to deliver the femur for instance, right?
• 22:38
  Patrick Weinrauch: and so that's, where they come back to be able to learn that one particular step.
• 22:45
  Joseph M. Schwab: Join me next week for the final part of our round table discussion, examining the anterior approach from down under.
• 22:52
  Joseph M. Schwab: We finish our conversation with guests Patrick Weinrauch, Jit Balakumar, Ilan Freedman and Joe Scerri.
• 22:59
  Joseph M. Schwab: Don't forget to check our show notes for information about each of their practices.
• 23:03
  Joseph M. Schwab: Make sure to like and subscribe so we can keep this type of content coming.
• 23:07
  Joseph M. Schwab: And until next week, this is Joe Schwab reminding you to keep those hips happy and healthy.