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Managing Intraoperative and Early Complications (S+N Surgeon Roundtable) · AHF Podcast

• 0:21
  Joseph M. Schwab: Hello and welcome to the AHF Podcast.
• 0:24
  Joseph M. Schwab: I'm your host, Joe Schwab.
• 0:27
  Joseph M. Schwab: Today's episode is the fourth in our series of six surgeon roundtables recorded in partnership with Smith+Nephew, conversations that bring together surgeons who do this work every day, peer-to-peer, with one goal, practical, reproducible techniques you can actually take back to your operating room.
• 0:47
  Joseph M. Schwab: Last time, we took on revision through the anterior approach.
• 0:50
  Joseph M. Schwab: Today, we turn to the moments every surgeon prepares for but still hopes to avoid, intraoperative and early complications.
• 1:00
  Joseph M. Schwab: Where do femoral fractures and calcar cracks really start?
• 1:04
  Joseph M. Schwab: And what do you do when something breaks?
• 1:07
  Joseph M. Schwab: How do you protect the lateral femorocutaneous nerve and the soft tissues?
• 1:11
  Joseph M. Schwab: When does bleeding or poor visualization mean it's time to stop and maybe reset?
• 1:19
  Joseph M. Schwab: And in the first weeks following surgery, an early dislocation, a draining wound, a possible infection, how do you escalate without delay and without overreacting?
• 1:30
  Joseph M. Schwab: Well, three guests join me for this conversation.
• 1:34
  Joseph M. Schwab: Dr.
• 1:34
  Joseph M. Schwab: Alex Gaukhman, who trained in high-volume trauma and complex reconstruction and knows what separates a manageable complication from a true cascade.
• 1:45
  Joseph M. Schwab: Dr.
• 1:45
  Joseph M. Schwab: Molly Hartzler, who treats complications and trains residents and fellows to spot the early signals before a small problem becomes a big one.
• 1:55
  Joseph M. Schwab: And Dr.
• 1:56
  Joseph M. Schwab: Stephen Duncan, who brings a patient-centered lens to the moment things go sideways, starting with checking your own pulse first.
• 2:06
  Joseph M. Schwab: By the end, they'll share the checklists, the escalation triggers, and the hard-won lessons that shaped how they operate today.
• 2:15
  Joseph M. Schwab: So let's join the conversation.
• 2:17
  Joseph M. Schwab: Alex, I wanna start with you.
• 2:19
  Joseph M. Schwab: You trained in a sort of high-volume trauma and complex reconstruction.
• 2:25
  Joseph M. Schwab: Um, when things go sideways in the operating room, which they do sometimes, what separates, in your mind, sort of a manageable complication, um, from a true sort of disaster?
• 2:41
  Dr. Alex Gaukhman: Yeah, it's a good question.
• 2:42
  Dr. Alex Gaukhman: Um, I, I think those disasters tend to happen more often than you think.
• 2:46
  Dr. Alex Gaukhman: Um, I think recognizing the problem early and probably just maintaining the situation and really controlling your emotions and trying to, you know, figure out the problem, kind of deliberate stepwise method I think is really helpful to try to prevent a cascade instead of just pushing through
• 3:05
  Joseph M. Schwab: Molly, you, you treat a lot of complications, and at the same time, you also train residents and fellows.
• 3:11
  Joseph M. Schwab: So what's kind of one early signal that you try to teach your learners, um, to recognize before maybe a small issue in the operating room becomes a, a big one?
• 3:25
  Dr. Molly Hartzler: Sure.
• 3:26
  Dr. Molly Hartzler: Uh, so I mean, I think, you know, if things don't seem like they are going the way that you expect them to for one reason or another, maybe you're in, um, a soft tissue plane that doesn't look quite right, maybe you are reaming for a cup and it's really not matching, you know, your pre-op template, um, that's a signal to kind of s- take a step back and reassess what's going on.
• 3:51
  Dr. Molly Hartzler: Um, and, you know, take an X-ray or, uh, you know, maybe take out all your retractors and start over, uh, in terms of trying to get yourself to the right spot
• 4:03
  Joseph M. Schwab: Hmm.
• 4:04
  Joseph M. Schwab: And Steven, you're sort of known for approaching your surgery through a, a pretty patient-centered lens.
• 4:11
  Joseph M. Schwab: Uh, when complications happen, um, what mindset helps you sort of stay grounded the way Alex was talking about and focus on the patient rather than really worrying ab- specifically about the problem?
• 4:27
  Dr. Stephen Duncan: I mean, number one is, uh, check your own pulse first.
• 4:31
  Dr. Stephen Duncan: Um, make sure that, uh, you're, you're staying calm for everybody.
• 4:34
  Dr. Stephen Duncan: Can always irrigate the knee OR as well while you're trying to think about things.
• 4:38
  Dr. Stephen Duncan: Um, but just, you know, kinda own it, um, and make sure that at-- whenever you scrub out and talk to family and to the patient, that, uh, things will be okay.
• 4:46
  Dr. Stephen Duncan: And I know I really broke a guy's femur one time, and he had come from Florida.
• 4:51
  Dr. Stephen Duncan: And, uh, never forget, we put a long REDAPT in and a bunch of cables, and he came back, was happy as a clam, told all of his friends.
• 4:58
  Dr. Stephen Duncan: I'm like,"Don't tell him what we put in.
• 5:00
  Dr. Stephen Duncan: I don't think they want long REDAPT for their primary, so."
• 5:04
  Joseph M. Schwab: Well, and so let's, let's get into it, and let's talk about some complications.
• 5:08
  Joseph M. Schwab: And, and femoral complications are, uh, a great place to start, whether it's, you know, overt fractures or calcar cracks or a canal perforation.
• 5:17
  Joseph M. Schwab: Um, Steve, when, when you're thinking about a femoral fracture or calcar crack or a situation like you described with that patient, specifically an anterior approach, what are the early decision or maybe even the earliest decisions that tend to set you up for those sorts of complications?
• 5:39
  Dr. Stephen Duncan: I think it comes down to exposure.
• 5:41
  Dr. Stephen Duncan: Um, I think doing the socket is not, I, I'd say the hard part for doing DA, but getting the femur up and exposed is probably the, the critical point at which you could manage pretty much what I call most complications.
• 5:55
  Dr. Stephen Duncan: Uh, being able to put a cable on up above, but then also knowing how to then get exposure distally to flip it astis, um, and also being able to put a straight stem in, um, do- being able to feel comfortable doing a TFL release.
• 6:09
  Dr. Stephen Duncan: Now, that was probably when I first started, I didn't feel quite as comfortable with maximal exposure.
• 6:14
  Dr. Stephen Duncan: But as you do labs and when we teach at fellows courses or, um, at the different, uh, courses throughout the year, getting exposure is probably the key to being able to manage the complications,'cause you can make a DA approach almost like an exposure for a very large posterior approach if you know how to do kind of that lateral window.
• 6:33
  Joseph M. Schwab: Alex, in, in your experience, is there an intraoperative moment that's kind of the highest risk for a femoral injury?
• 6:41
  Dr. Alex Gaukhman: Yeah, I think piggybacking with, uh, on what Steve said, but you're-- it's all about exposure, exposure, exposure.
• 6:48
  Dr. Alex Gaukhman: If your exposure is poor and you don't have the correct trajectory, you know, if you're not ready to start, um, broaching and you just force it and push it through, you're gonna perforate, you're gonna fracture, you're gonna undersize, you're gonna have all kinds of i-injury.
• 7:03
  Dr. Alex Gaukhman: And that's really kind of the, the hardest part is not having the right exposure, not having the right trajectory.
• 7:09
  Dr. Alex Gaukhman: You know, sometimes the femoral neck may be a little bit too, you know, excessively there, and trying to force your broach through, that's gonna end up with a lot of injury, and that's gonna give you probably the highest rate of having a problem right then and there.
• 7:22
  Joseph M. Schwab: Molly, what mistakes do you see most often when surgeons try to push through the way Alex is describing?
• 7:31
  Dr. Molly Hartzler: Yeah, I mean, I think that there is a very real impulse to just keep moving through the surgery as quickly as you can, and when you are struggling with exposure, um, you really have to take your time and slow down and do some of the tips and tricks, you know, that we teach, like repositioning the leg, taking everything out, bringing it back up to neutral, um, you know, putting everything back in, making sure that you've done the releases that you need, uh, to get that troch out from behind the acetabulum.
• 8:01
  Dr. Molly Hartzler: Um, and so I would say that trying to rush is gonna be the biggest risk factor for causing a problem
• 8:08
  Joseph M. Schwab: Hmm.
• 8:09
  Joseph M. Schwab: Well, and let's talk a little bit about different canal morphology and maybe what our, our strategy would be for preparing different, um, different types of femurs.
• 8:18
  Joseph M. Schwab: Molly, when you're looking and comparing a Dor A to a Dor C femur, um, tell me about how you change your approach not only to broaching, but maybe to exposure and pacing, um, during femoral preparation
• 8:36
  Dr. Molly Hartzler: I don't know that I change my approach necessarily, but if I have a very tight diaphyseal canal, I will just know that I'm really gonna have to make sure that I get that femoral neck up in the wound so that I can get my trajectory, that I can push my hand, you know, towards the patient's belly, make sure that I'm getting it collinear on the lateral view and I'm not gonna have that three-point bend and get myself hung up and fracture or really undersize and leave myself open to loosening.
• 9:07
  Joseph M. Schwab: Hmm.
• 9:07
  Joseph M. Schwab: Um, Alex and, and Steve, uh, in both your opinions, I mean, w- we've run into all sorts of different, uh, types of canal morphologies.
• 9:17
  Joseph M. Schwab: How does having flexibility in, say, your stem usage help you adapt intraoperatively rather than kind of forcing a single plan?
• 9:26
  Joseph M. Schwab: And Steve, why don't we start with you?
• 9:30
  Dr. Stephen Duncan: I mean, it comes down to the planning, um, and really kind of scrutinizing your X-ray for templating.
• 9:35
  Dr. Stephen Duncan: If you're gonna, uh, be potted distally with a certain type of stem, it's gonna look all around up top, um, I know I'm gonna have to have reamers.
• 9:43
  Dr. Stephen Duncan: Um, and typically I'll, uh, fail to a diaphyseal type of reamer'cause I don't want to ream away the proximal bone.
• 9:50
  Dr. Stephen Duncan: So having, uh, I usually use like a Redapt reamer, so I'm just getting the diaphyseal bone but not touching the metaphyseal bone really helps open up that distal part, and that way we can get a, I call sufficiently sized stem that's not gonna be potted distally.
• 10:03
  Dr. Stephen Duncan: And on the flip side, same thing with the dorsi.
• 10:06
  Dr. Stephen Duncan: Um, we all, uh, are pretty, pretty comfortable cementing through the back, but just knowing that maybe some days you want to cement through the front.
• 10:15
  Dr. Stephen Duncan: Um, and having a stem that, uh, if you can adapt intraoperatively from a cementless to a cemented option, uh, specifically now that we're going to ASCs and not having to bring extra pans, um, that may be one case where you go,"Hey, I'm gonna use like a polar stem that has the ability to do both instead of having to bring two different sets."
• 10:34
  Joseph M. Schwab: Alex, what are your thoughts?
• 10:37
  Dr. Alex Gaukhman: Yeah, I, I tend to probably use the same stem for all bone morphologies nowadays, especially, you know, A and C.
• 10:44
  Dr. Alex Gaukhman: The, the As I agree, a very low threshold ream.
• 10:48
  Dr. Alex Gaukhman: Uh, recognize that early on the, you know, preoperative template plan I think is very helpful, especially if you're in an ASC, if you may not have those on the shelf.
• 10:56
  Dr. Alex Gaukhman: Um, but, you know, having the catalyst, I think it has a little bit of a better morphology distally, you know, tapers more aggressively, so you're less likely to get potted than some of the other stems, and especially the non-, uh, triple taper collar stems.
• 11:10
  Dr. Alex Gaukhman: Uh, for C, cementation is definitely probably something I'm kind of falling out of and, and using more of the triple taper collar stems, um, you know, as you get more and more comfortable with it.
• 11:23
  Dr. Alex Gaukhman: But definitely have to have, you know, cement as a good backup
• 11:27
  Joseph M. Schwab: So you mentioned, Alex, uh, both you and Steven mentioned, you know, in dense, uh, canals doing, uh, potentially some, some distal reaming if need be.
• 11:36
  Joseph M. Schwab: Are there other practical steps that you would take when using, say, a catalyst stem, um, to reduce kinda uncontrolled force during, uh, broaching an implant seating?
• 11:47
  Joseph M. Schwab: Would you alter your stem size based on canal morphology?
• 11:51
  Joseph M. Schwab: What, what are your thoughts?
• 11:54
  Dr. Alex Gaukhman: Um, I wouldn't alter the stem size, but, uh, I'd still wanna have the same kind of rotational axial stability you'd normally get with a B or a C.
• 12:01
  Dr. Alex Gaukhman: Um, but you have to recognize that sclerotic bone in some of the younger people, you're gonna be working a little bit harder.
• 12:06
  Dr. Alex Gaukhman: Um, and so, you know, sometimes the, the bigger guys, they may have like a size 60 cup, but they may have a size two or three stem.
• 12:13
  Dr. Alex Gaukhman: So that's kind of, you know, something to be on the lookout for just to make sure that you're not undersized and just pot it distally.
• 12:18
  Dr. Alex Gaukhman: But you gotta respect that sclerotic bone versus really trying to force through it.
• 12:23
  Dr. Alex Gaukhman: Um, I think having the proper, um, you know, having the proper technology is very helpful, uh, to prevent fatigue, especially if it's the end of the day and you're really working.
• 12:33
  Dr. Alex Gaukhman: And I think having some sort of automated impact, I think it's been, you know, kind of revolutionary for me
• 12:39
  Joseph M. Schwab: Uh, Molly, uh, how do tools like automated impaction help you, um, say maybe reduce variability in how you're seating your femoral stems, or how does it help you affect fracture risk, especially in those tighter, uh, femurs?
• 12:58
  Dr. Molly Hartzler: Yeah.
• 12:59
  Dr. Molly Hartzler: Um, I do use automatic, automated impaction and I, I really enjoy it.
• 13:03
  Dr. Molly Hartzler: I think it reduces my fatigue in the OR and it does make impaction more reproducible.
• 13:08
  Dr. Molly Hartzler: Um, I find that the triple taper type stems tend to seat, uh, where I broach them to.
• 13:14
  Dr. Molly Hartzler: Um, and if I don't have the impactor for one reason or another, um, I, you know, I'm very careful about the force that I'm using.
• 13:23
  Dr. Molly Hartzler: Um, if things are hanging up, you know, I, I'm careful not to hit harder.
• 13:26
  Dr. Molly Hartzler: But it, it's very nice to know that there is, uh, sort of a, a controlled amount of force that's going through that impactor
• 13:34
  Joseph M. Schwab: Steven, are you using automated impaction as well?
• 13:38
  Dr. Stephen Duncan: Yeah, and with trainees, it's, uh, nice to not have to introduce the how hard should you hit this with the mallet?
• 13:44
  Dr. Stephen Duncan: 'Cause, uh, you know, we have Division I former swimmers from Texas that, uh, they are very, very strong.
• 13:52
  Dr. Stephen Duncan: And so it's nice to have the consistency to say,"Hey, just pull the trigger.
• 13:56
  Dr. Stephen Duncan: It's gonna go where it's supposed to," as opposed to my pucker factor's going way up right now while he's helping me
• 14:02
  Joseph M. Schwab: So, so Molly, if, um, a, a calcar crack, a femoral fracture, something like that occurs, how do you decide whether you can safely continue or whether you need to change your fixation strategy, or whether you should stop completely and sort of reset the whole plan?
• 14:24
  Dr. Molly Hartzler: Yeah.
• 14:24
  Dr. Molly Hartzler: So it, it depends on what's going on.
• 14:26
  Dr. Molly Hartzler: You know, I, uh, I think like all of us, I'm extremely attentive to fracture as we're seating our final stem, and if I see anything that makes me nervous, I'm following that down to the most distal extent of where that crack goes to.
• 14:40
  Dr. Molly Hartzler: Um, it's nice using DA.
• 14:42
  Dr. Molly Hartzler: You have fluoro available.
• 14:43
  Dr. Molly Hartzler: It's easy to use, and you can kind of really see what's going on, and it depends on how far down it goes.
• 14:48
  Dr. Molly Hartzler: If it's, uh, you know, essentially confined, um, to the most superior portion of the bone, I think I can get away with cerclage.
• 14:58
  Dr. Molly Hartzler: I'll take that stem out, place the cerclage wire, put the same stem back down, um, and, uh, typically can let patients weight bear as tolerated.
• 15:06
  Dr. Molly Hartzler: If it spirals down, that's when I'm gonna say,"Hey, we need to get a diaphyseal engaging stem.
• 15:11
  Dr. Molly Hartzler: We need more distal fixation," and I'm gonna be extending my exposure
• 15:16
  Joseph M. Schwab: Steve, when that sort of situation happens in the operating room, how are you maybe keeping the team calm and, and focused in a moment like that?
• 15:26
  Joseph M. Schwab: It can be a, it can be a stressful situation, not just for you, but for everybody involved
• 15:32
  Dr. Stephen Duncan: And I, I remind everybody we are a team, and number one, if I'm not freaking out, no one else should freak out.
• 15:38
  Dr. Stephen Duncan: Um, uh, we, we had a case the other day and, uh, I said,"The only person who should freak out right now is, like, is me,'cause you guys don't see him for the next, you know, 90 days." And they're like,"Well, why aren't you freaking out?" I'm like,"'Cause freaking out doesn't help you." So, you know, biggest thing is remain calm.
• 15:55
  Dr. Stephen Duncan: Be prepared when, when this, it happens.
• 15:58
  Dr. Stephen Duncan: It's gonna happen at some point.
• 15:59
  Dr. Stephen Duncan: You're gonna break a femur.
• 16:01
  Dr. Stephen Duncan: And being comfortable being able to, as Molly said, put a cable above and below.
• 16:06
  Dr. Stephen Duncan: If you need to, uh, digress and go from your planned stem to another one, just, uh, it's not a big deal, but be comfortable being able to do it, and I think that's where you probably don't freak out.
• 16:16
  Dr. Stephen Duncan: You don't want the first time that it happens to be in a live person.
• 16:20
  Dr. Stephen Duncan: You wanna be able to do it in someone who's not gonna write a review for you online called the cadaver lab
• 16:26
  Joseph M. Schwab: It's, um, it-- The corollary to that question, Steve, is if you are freaking out, does that mean everybody should be freaking out?
• 16:35
  Dr. Stephen Duncan: Um, I, I guess so.
• 16:36
  Dr. Stephen Duncan: Um, or you better go call your attorneys at that point, uh,'cause yeah, s- something's not going right
• 16:43
  Joseph M. Schwab: So Alex, w-what sort of fixation, maybe mistakes isn't the right word, but what sort of fixation choices do you see when people maybe react a bit too quickly or a bit too aggressively to one of these intraoperative, let's say calcar fractures?
• 17:01
  Dr. Alex Gaukhman: I think the most common thing you see, um, kind of floating around the community is, uh, people bail the cement thinking it's gonna solve all their issues, and you may not have the proper, you know, uh, fracture fixation.
• 17:15
  Dr. Alex Gaukhman: You don't have a cable, um, or you don't know how to tighten it up or on the correct area and thinking that just, you know, putting cement into the canal and stuffing it in there and, and putting a stem in there is gonna fix the issue.
• 17:25
  Dr. Alex Gaukhman: And oftentimes that fails pretty, pretty fast.
• 17:28
  Dr. Alex Gaukhman: And so, um, definitely avoiding that and just doing exactly what Molly was saying.
• 17:33
  Dr. Alex Gaukhman: Find-- Exposing it, you know, using fluoroscopy, using tactile feedback, like, you know, placing the cables correctly at the right spot, ensuring they're appropriately tightened, obviously, and using the correct type stem.
• 17:47
  Dr. Alex Gaukhman: And most times you can just get it away with the same stem, uh, it's adequate.
• 17:51
  Dr. Alex Gaukhman: And then if you really need to do something else, you have to be ready to pivot to that
• 17:58
  Dr. Stephen Duncan: Alex, the one thing, I don't know if, I don't know if you've seen, Alex.
• 18:01
  Dr. Stephen Duncan: You, you said, you said the correct stem.
• 18:04
  Dr. Stephen Duncan: Uh, I'd just like to add do not cement in a cementless stem.
• 18:08
  Dr. Stephen Duncan: Um,
• 18:09
  Dr. Alex Gaukhman: Yeah, I've seen I've seen that actually.
• 18:12
  Dr. Stephen Duncan: the community.
• 18:12
  Dr. Stephen Duncan: Yeah.
• 18:13
  Dr. Stephen Duncan: And those, those, are
• 18:14
  Dr. Alex Gaukhman: That, that, that doesn't work.
• 18:16
  Dr. Alex Gaukhman: Yeah.
• 18:17
  Dr. Alex Gaukhman: Yeah.
• 18:17
  Dr. Alex Gaukhman: I mean, most times you can just pull everything out as one big glob because it's already loose, but it, it could be painful for sure
• 18:26
  Joseph M. Schwab: Um, so a lot of our listeners are-- I mean, obviously it's, it's fun and interesting for orthopedic surgeons to focus on the bony injuries.
• 18:34
  Joseph M. Schwab: Um, but a lot of our listeners have questions about soft tissue handling, nerve handling, uh, hemostasis, issues like that.
• 18:42
  Joseph M. Schwab: So Steve, I wanna stay with you and, um, talk a little bit about lateral femoral cutaneous nerve symptoms, um,'cause it's one of the most discussed areas in anterior approach, and I think a lot of surgeons are concerned about what to do about that.
• 18:56
  Joseph M. Schwab: So what specific steps, maybe during exposure, retraction, um, make the biggest difference for you in avoiding LFCN injury?
• 19:10
  Dr. Stephen Duncan: I mean, trying to stay more lateral, staying within, uh, more of the fascia, uh, of the TFL as opposed to kind of the true Smith-Pete interval where you're really on the nerve.
• 19:20
  Dr. Stephen Duncan: Um, I don't love, uh, putting tons of retractors in.
• 19:24
  Dr. Stephen Duncan: Um, usually I'll use a Charnley only, so that way, uh, I'm not going in and out a bunch of times since it's kind of a constant pressure, but not excessive, and then I try and avoid, uh, retractors, uh, on the acetabular side, specifically trainees, to avoid not just a lot of from the cutaneous nerve, but the worst one that you could probably get is the femoral nerve, uh, and trying to avoid some of that.
• 19:46
  Dr. Stephen Duncan: But I always tell all the patients that, yes, you probably will have some numbness to your thigh, um, uh, in the counseling period so that they don't call back to the nurse saying,"Why is my thigh numb?" Um, you know, I say the benefit is, is it's a muscle-sparing approach.
• 20:00
  Dr. Stephen Duncan: The downside, you may have some numbness.
• 20:03
  Dr. Stephen Duncan: It'll probably go away, but there's about a one percent chance you still might have some issues.
• 20:07
  Dr. Stephen Duncan: It's a treatable thing, and that's where always, always having a good relationship with like an interventional pain person that can do, uh, nerve blocks, uh, or even nerve ablations if they do have some persistent paresthesias or pain at a year
• 20:21
  Joseph M. Schwab: And Molly, when you're working with trainees who oftentimes are maybe a little more focused on doing the surgery faster or getting a better exposure, how do you teach sort of respect of the soft tissues?
• 20:37
  Dr. Molly Hartzler: Yeah.
• 20:38
  Dr. Molly Hartzler: I mean, it's something that I show them and we talk about throughout the case.
• 20:42
  Dr. Molly Hartzler: Um, you know, I think that we, we love to have little tiny incisions, but I think going a bit longer on our incisions really can help spare the LFC in because there's less traction on it, um, if you're not trying to wrench open this really small space with retractors.
• 20:57
  Dr. Molly Hartzler: Um, I'm pretty rabid about protecting the TFL, especially during removal of the femoral head.
• 21:02
  Dr. Molly Hartzler: You know, sometimes you'll see especially less experienced surgeons, they wanna, you know, wrench down with their T handle, um, and the TFL is very fragile.
• 21:11
  Dr. Molly Hartzler: It tears very easily.
• 21:13
  Dr. Molly Hartzler: And so I do not use an Allis retractor, and I'm looking right at it, and I'm protecting the TFL throughout.
• 21:19
  Dr. Molly Hartzler: And when I have a trainee that's doing the surgery, I'll often put my hand right on the TFL so that they can't sort of lever down onto it.
• 21:28
  Dr. Molly Hartzler: Um, but it, it's one of the things that I really emphasize.
• 21:31
  Dr. Molly Hartzler: You know, I make sure that traction is off whenever any retractors are going in because I really wanna spare my neurovascular bundles.
• 21:38
  Dr. Molly Hartzler: Um, and the-- I think that patients really do the very best when you get to the end, the muscle's not beat up, you have really good hemostasis, and you've been careful throughout the whole surgery
• 21:48
  Joseph M. Schwab: Alex, for you, what role does maybe soft tissue visualization and, and hemostasis play in the overall protection of the soft tissues?
• 22:01
  Dr. Alex Gaukhman: Yeah, I mean, one definitely leads to the other, right?
• 22:03
  Dr. Alex Gaukhman: Uh, so better hemostasis, you get better visualizations and allows you to execute, um, your, your case more easily and workflows a little bit easier.
• 22:11
  Dr. Alex Gaukhman: There's less stress.
• 22:13
  Dr. Alex Gaukhman: Um, I think, you know, early on kind of in dissection, in the superficial deep dissection, making sure that you really get those, uh, circumflex arteries.
• 22:22
  Dr. Alex Gaukhman: Um, you know, now- nowadays, I think I have less reliance on the, on the bipolar and just kind of painting everything.
• 22:29
  Dr. Alex Gaukhman: Now, I actually dissect it out and use a tonsil and cautery and really kind of get it,'cause if you don't, if you don't get those arteries right away, those veins right away, they're just gonna follow you the entire time and it just makes everything so much harder.
• 22:42
  Dr. Alex Gaukhman: Um, and, uh, just being able to execute the entire case a little bit easier.
• 22:46
  Dr. Alex Gaukhman: If you get more hemostasis or y- if you don't get hemostasis, you're constantly gonna have, you know, you know, the visualization is gonna be poor.
• 22:54
  Dr. Alex Gaukhman: You're gonna have a, um, more destruction of the soft tissues.
• 22:57
  Dr. Alex Gaukhman: You're gonna have a high risk of having a HO or a hematoma, infection, drainage, all kind of problems.
• 23:02
  Dr. Alex Gaukhman: So tackling that on early on is, is great
• 23:05
  Joseph M. Schwab: So, you know, as you've kind of worked through being able to do your dissection with maybe more targeted hemostasis, when you're seeing visualizations start to degrade because of, we'll say, bleeding or maybe even soft tissue tension, right?
• 23:21
  Joseph M. Schwab: You haven't done enough release.
• 23:22
  Joseph M. Schwab: W- what tells you it's time to pause and reset rather than push forward?
• 23:30
  Dr. Alex Gaukhman: Yeah, I mean, I, like, feel like the gut kind of is, is to just keep going, keep pushing forward.
• 23:35
  Dr. Alex Gaukhman: You're almost there, you're almost done.
• 23:36
  Dr. Alex Gaukhman: But that really kind of s- is probably a huge disadvantage.
• 23:39
  Dr. Alex Gaukhman: And not taking a step back, you really gotta pause and reassess and, and again, take the retractors out and to see where that bleeding is potentially coming from.
• 23:48
  Dr. Alex Gaukhman: 'Cause sometimes a little bit more brisk and you can-- you actually stop and pause and look at it, you probably find it pretty quickly and tackle it and, and then just really that ends that problem right then and there.
• 23:57
  Dr. Alex Gaukhman: 'Cause otherwise every step is gonna be prolonged, harder.
• 24:00
  Dr. Alex Gaukhman: You're gonna get more frustrated, more stressed, you know, uh, potential malpositioning of components, poor fixation, undersizing.
• 24:07
  Dr. Alex Gaukhman: So you really gotta have hemostasis, you gotta have visualization, and just really stop and reassess everything, and just really fight that feeling of just trying to push through and just get to the next step
• 24:19
  Joseph M. Schwab: Molly, how do you see small visualization issues contributing to more downstream complications?
• 24:30
  Dr. Molly Hartzler: I mean, it's what Alex just said.
• 24:31
  Dr. Molly Hartzler: You know, if you can't see what you're doing, you're not gonna get the fixation that you need.
• 24:35
  Dr. Molly Hartzler: You're not gonna get your components to the size that they should be.
• 24:39
  Dr. Molly Hartzler: Um, and so, you know, I, I think with anterior approach, the exposure's everything.
• 24:45
  Dr. Molly Hartzler: It's the thing that people are worried about when they're starting.
• 24:47
  Dr. Molly Hartzler: They feel uncomfortable where they are.
• 24:49
  Dr. Molly Hartzler: They don't, you know, they don't recognize what the next thing is to do in order to improve their visu- visualization.
• 24:56
  Dr. Molly Hartzler: Um, and so ri- right from the get-go, um, you know, if things are not looking right, um, utilizing fluoro, making sure your retractors are in the right places, making sure that you've done the releases that you need, they're all very important
• 25:10
  Joseph M. Schwab: And Steve, if you do need to sort of take a pause based on that, how do you communicate that pause to your team without creating stress?
• 25:21
  Dr. Stephen Duncan: Yeah.
• 25:22
  Dr. Stephen Duncan: Well, I mean, I think you just-- you're kinda straightforward with them.
• 25:24
  Dr. Stephen Duncan: If, uh, again, as Mal and Alex have said, if, if you're not seeing what you need to see, I mean, just go back and say,"Hey, I'm gonna go back and see what's going on." Sometimes I do the very polite thing and peek over the drapes and ask anesthesia,"Hey, is their blood pressure a bowling score or a golf score?" Um, and if it's sometimes high, which sometimes the bleeders that you hit before, they'll start rebleeding if the blood pressure's really spiking.
• 25:49
  Dr. Stephen Duncan: So sometimes just asking your anesthesia team, saying,"Hey, is their blood pressure one eighty?" And if it is, then, um, can you please get it down so I can see?
• 25:57
  Dr. Stephen Duncan: The other part too that I've, uh, incorporated is the femur bleeds.
• 26:02
  Dr. Stephen Duncan: So when you're doing the socket and you think you got bleeders, actually I've, I've gone to putting bone wax over the b- uh, over the cut, uh,'cause that femur just bleeds posteriorly into the socket, and, uh, you'll think that it's coming from something else, but oftentimes the femur will bleed specifically if they're pretty osteoporotic and the blood pressure's high.
• 26:20
  Dr. Stephen Duncan: So it's one thing that has actually saved me a lot of time of once you make the nut cut, just smear bone wax, and it'll stop your bleeding pretty quick.
• 26:29
  Joseph M. Schwab: This episode of the AHF Podcast is brought to you by Smith+Nephew, a portfolio medical technology business focused on the repair, regeneration, and replacement of soft and hard tissue by using technology to take the limits off living.
• 26:45
  Joseph M. Schwab: They deliver on this mission every day, making a difference to patients' lives through the excellence of their product portfolio and the invention and application of new technologies across their three global business units: orthopedics, sports medicine and ENT, and advanced wound management.
• 27:04
  Joseph M. Schwab: The Smith+Nephew CORI Surgical System offers proprietary tools and software across the full suite of procedure solutions to deliver a platform that is flexible and scalable across knee and hip joint arthroplasty indications.
• 27:20
  Joseph M. Schwab: CHOREOGRAPH pre-op planning and modeling services, combined with the RI hip solutions and the recently launched Catalyst Stem primary hip system, offers a complete solution for primary total hip arthroplasty.
• 27:36
  Joseph M. Schwab: To learn more about Smith+Nephew revision hip solutions, visit smithandnephew.com.
• 27:45
  Joseph M. Schwab: So we've talked a little bit about intraoperative, uh, complications.
• 27:49
  Joseph M. Schwab: Let's talk about some of the early postoperative complications, things like instability and wound issues, hematoma, infection.
• 27:57
  Joseph M. Schwab: Um, Steve, when you have an anterior approach patient that dislocates early, if it's happened, how do you maybe work backward to determine whether it was a planning issue, an execution issue, maybe a patient issue?
• 28:13
  Joseph M. Schwab: Tell me about your thought process
• 28:17
  Dr. Stephen Duncan: Luckily, I've only had one that's dislocated in their global period, um, and it was a function I actually did her other hip.
• 28:24
  Dr. Stephen Duncan: Uh, and so she was getting out of the bathtub, and, uh, it was a function that I didn't, uh, antevert the femur as much.
• 28:31
  Dr. Stephen Duncan: She actually had pretty neutral anteversion, and she had a fixed spine, so she popped out the back.
• 28:36
  Dr. Stephen Duncan: Now, um, luckily, the closed reduced her, and I braced her, and, uh, either, uh, she's not dislocated or she's not on Earth'cause she has not come back.
• 28:46
  Dr. Stephen Duncan: Um, but it was a counseling type of thing that I said for her.
• 28:49
  Dr. Stephen Duncan: I said,"I think you're gonna be okay, um, but if, if it happens again, then, you know, your percentage is fifty percent.
• 28:55
  Dr. Stephen Duncan: If it happens a third time, then we probably need to redo something." And so I was just gonna be frank with her as to, you know, this happened, we'll take care of you.
• 29:03
  Dr. Stephen Duncan: Um, but hopefully, at least with doing anterior approach, uh, uh, having transitioned away from posterior, we, we won't see tons of instability anymore.
• 29:12
  Dr. Stephen Duncan: I think in your learning curve, one thing to do, which is what I did, is I cheated a little bit'cause I used dual mobility, um, as a little added protection.
• 29:21
  Dr. Stephen Duncan: Um, so probably trying to use the biggest head possible, uh, in your learning curve so that you can at least hopefully avoid some of that as you're trying to get more adept with the approach and, uh, and seeing some of the outcomes.
• 29:33
  Joseph M. Schwab: Um, Molly or Alex, um, h- let's talk a little bit about navigation, whether you're using navigation and how you-- what you see its role is in maybe reducing early instability by avoiding malposition when you can, uh, identify a patient who has some, maybe some narrow functional targets.
• 29:54
  Joseph M. Schwab: Are either of you using navigation, and what's your experience?
• 30:00
  Dr. Molly Hartzler: I am not
• 30:02
  Joseph M. Schwab: Alex, how about you?
• 30:03
  Dr. Alex Gaukhman: Uh, yeah, I do use navigation on all my anterior hips.
• 30:07
  Dr. Alex Gaukhman: I do think it's another, uh, data point which is nice to incorporate into your workflow.
• 30:12
  Dr. Alex Gaukhman: You kind of have to take everything in together in addition to the, the, the, uh, the X-ray, the way, you know, the tactile feedback you get when you're checking stability.
• 30:22
  Dr. Alex Gaukhman: But I think it's an extra added step to help you, uh, give you some confidence that you're on the right path, um, whether it's cup positioning, um, or if it's, uh, you know, ensuring that your offset and leg length has been restored compared to your either your opposite side or your-- the same side, you know, depending on what your target is.
• 30:42
  Dr. Alex Gaukhman: But it is helpful.
• 30:44
  Dr. Alex Gaukhman: Um, it should not be, you know, the end-all be-all to guide you to make all clinical decisions, but I think it should be taken in conjunction and, um, to help you kind of pre-create the overall, uh, picture of what's happening
• 30:57
  Joseph M. Schwab: When you're-- Just staying with that for a second, Alex.
• 30:59
  Joseph M. Schwab: When you're doing your preoperative plan in a navigated patient, do you ever find yourself surprised as to what the recommendations are?
• 31:08
  Joseph M. Schwab: Does it ever differ substantially from what you think you might have come up with on your own?
• 31:14
  Dr. Alex Gaukhman: Uh, not typically surprised.
• 31:16
  Dr. Alex Gaukhman: Um, um, you know, probably more relieved than anything
• 31:22
  Joseph M. Schwab: It feels more definitive when you're getting the-- getting an answer from the navigation.
• 31:27
  Joseph M. Schwab: I like that.
• 31:28
  Joseph M. Schwab: Um, Molly, let's talk a little bit about early wound healing.
• 31:32
  Joseph M. Schwab: Are there, are there findings that you see in the wound early that make you most concerned?
• 31:38
  Joseph M. Schwab: And talk a little bit about how aggressive you are at intervening or maybe not
• 31:46
  Dr. Molly Hartzler: Uh, so there are a few things that I do to try to prevent wound healing issues from the get-go.
• 31:52
  Dr. Molly Hartzler: Obviously, prevention is much better than managing it afterwards.
• 31:56
  Dr. Molly Hartzler: Um, and one thing is to look at patients with a pannus and see how their pannus hangs.
• 31:59
  Dr. Molly Hartzler: You know, there's some patients that have a pannus that really sort of hangs in the center point of their body.
• 32:05
  Dr. Molly Hartzler: And so if you cheat your incision a little bit more lateral, you're actually gonna be clear of that area versus some patients where it's sort of going all the way across, um, covering the tops of both of their thighs.
• 32:15
  Dr. Molly Hartzler: Uh, I will place a wound vac on some patients if I'm worried about sort of that area and it being moist in there.
• 32:23
  Dr. Molly Hartzler: I try not to cross any creases if I can help it.
• 32:26
  Dr. Molly Hartzler: Um, instead of doing that, I will sort of go, uh, up along their, uh, iliac crest, if, if you will, like a hockey stick sort of extension instead of crossing any creases.
• 32:37
  Dr. Molly Hartzler: Um, and that really helps.
• 32:39
  Dr. Molly Hartzler: If there's patients that, uh, have a little bit of wound dehiscence superiorly, um, I usually watch it.
• 32:47
  Dr. Molly Hartzler: I will prescribe them Silvadene, which is a really nice, gentle, broad-spectrum antimicrobial cream.
• 32:53
  Dr. Molly Hartzler: Um, and I think, you know, I've been doing this for about seven years.
• 32:57
  Dr. Molly Hartzler: I've taken two patients back to the operating room for wound, for wound revisions, and, uh, I believe that they were due to failure of a running barbed suture.
• 33:07
  Dr. Molly Hartzler: Uh, and they had just sort of completely dehisced, and it was actually at the, the distal portion of their incision, not the proximal.
• 33:14
  Joseph M. Schwab: Hmm.
• 33:15
  Joseph M. Schwab: Um, Steve and Alex, so, uh, Molly mentioned, you know, negative pressure wound therapy.
• 33:21
  Joseph M. Schwab: Um, in your maybe higher risk patients or higher wound risk patients, how do you think about adjuncts like, uh, negative pressure wound therapy to reduce your downstream complications?
• 33:33
  Joseph M. Schwab: Steve, let's start with you.
• 33:36
  Dr. Stephen Duncan: Yeah, I mean, and again, the, the whole goal with the negative pressure wound vac therapy is not to suck out fluid.
• 33:42
  Dr. Stephen Duncan: It's more to be a compressive type effect.
• 33:44
  Dr. Stephen Duncan: Um, and so i-if someone's calling back saying they're having output from the wound vac, either I did a bad job in making sure that they did not have a hematoma, or there's something else going on.
• 33:56
  Dr. Stephen Duncan: Um, and I'm a little bit more aggressive to see them back in the clinic to assess their wound or, uh, figure out what's going on.
• 34:02
  Dr. Stephen Duncan: But yes, I, I do think that there's a, a good use for the negative pressure wound vac therapy.
• 34:08
  Dr. Stephen Duncan: You just have to counsel the patient if you're gonna use it, uh, on,"Hey, this thing's gonna die at, at day seven or 14." And so just knowing that, hey, um, at day six, uh, just remember it's probably gonna die on day seven or vice versa, so that they don't call back and, or show up at the ER saying, hey, that they're having a malfunction, and then all of a sudden your, your bundled payment is now starting to get hit
• 34:32
  Joseph M. Schwab: Alex, how about you?
• 34:35
  Dr. Alex Gaukhman: Yeah, I think there's a clear role for, uh, for, you know, incisional vacs, high-risk patients, uh, very low threshold to use it.
• 34:43
  Dr. Alex Gaukhman: Uh, they do generate a lot more phone calls, uh, and, and most patients ask me,"There's nothing in here.
• 34:48
  Dr. Alex Gaukhman: Why am I using this?" And so y- you know, clear, you know, communication, education, and counseling, I think, you know, getting the other members of your team to, um, help.
• 34:59
  Dr. Alex Gaukhman: I think the one thing that we've done is when we put on an incisional vac, we do-- we give them a separate insert into their discharge summary to help them go over some of the things, like Steve is saying, it's gonna die.
• 35:09
  Dr. Alex Gaukhman: It's okay that there's nothing in there, you know.
• 35:12
  Dr. Alex Gaukhman: And so those are the things that, that definitely decreases and cuts down on the amount of phone calls you generate the next day
• 35:18
  Joseph M. Schwab: So Alex, staying with you, when, when there is maybe a patient with, um, a concern, uh, early on for an infection, how do you, um, maybe approach or structure your evaluation and, um, and not just evaluation, but escalation of that patient so nothing gets, we'll say, delayed or, or dismissed?
• 35:42
  Dr. Alex Gaukhman: Yeah, I mean, you have to have, you know, clear communication with those patients and let them know that, you know, they're, they're putting into a different bucket list.
• 35:49
  Dr. Alex Gaukhman: They're kind of on the nihilist now, and they're going to the very top of it, and they're gonna be close-- they're gonna be watched very, very closely.
• 35:55
  Dr. Alex Gaukhman: And you gotta keep those patients very close to your chest and, and, you know, have a very low threshold to, um, launch a, you know, kind of an investigation with anti-- with inflammatory markers, aspirations, whatever the situation may be.
• 36:09
  Dr. Alex Gaukhman: But you can't, you can't say,"We'll see you in two weeks," or have your PA see it.
• 36:13
  Dr. Alex Gaukhman: You gotta see those patients very frequently.
• 36:16
  Dr. Alex Gaukhman: Um, you know, I utilize email very quite often, have them send me pictures, um, you know, evaluate the clinical picture.
• 36:22
  Dr. Alex Gaukhman: If they're having more pain, more dysfunction, again, obviously drainage, uh, redness or something like that, that really is a clear sign that something's gone awry
• 36:31
  Joseph M. Schwab: Molly, what sort of communication failures sort of that Alex was talking about, um, do you see that most often sort of delay a patient's diagnosis of an early infection?
• 36:45
  Dr. Molly Hartzler: Yeah, I, I mean, I think making sure that all of the messages that patients are sending are getting to you if they go to, uh, an ER at an outside hospital, that can be a problem because you may not get information from the patient or the outside providers to let you know, um, that something has been going on.
• 37:03
  Dr. Molly Hartzler: Um, fortunately, infection and primary total hip seems to be pretty rare overall.
• 37:10
  Dr. Molly Hartzler: Um, but just making sure that, uh, that the messages are actually making it to, to me and that I'm able to follow up on them
• 37:18
  Joseph M. Schwab: And Steve, how do you balance urgency of taking care of these patients with maybe not overreacting about something that's gonna run its course and be okay?
• 37:31
  Dr. Stephen Duncan: And I think that's the one nice thing with media is people, uh, can take a picture on their phone and send it to our nurse.
• 37:38
  Dr. Stephen Duncan: You know, I think a picture, uh, is able to describe a lot better than what they can describe over the phone.
• 37:44
  Dr. Stephen Duncan: And now with-- and then we're on Epic, um, patients really like when I send them the message directly back to them saying,"I think this looks fine.
• 37:52
  Dr. Stephen Duncan: Why don't you send a picture back in forty-eight, seventy-two hours?" Uh, one, they don't have to come to the office, so it does save on gas money'cause it's not cheap right now.
• 38:01
  Dr. Stephen Duncan: Uh, and two, they know that we are actually, it, like, wanna remain involved in their care and not just kinda hoping for the best.
• 38:10
  Joseph M. Schwab: So let's talk a little bit about the use of maybe checklists or escalation lists, the use of team communication in, um, trying to stay ahead of complications, at least together with your team.
• 38:25
  Joseph M. Schwab: So Molly, are there any checklists or mental frameworks that you use that help you, um, we'll say consistently catch issues early on in anterior approach cases?
• 38:40
  Dr. Molly Hartzler: Yeah.
• 38:41
  Dr. Molly Hartzler: So we have a really nice program.
• 38:42
  Dr. Molly Hartzler: Um, each surgeon in my group has a dedicated nurse navigator, and they give the patients a phone call to their home, um, within 48 hours of discharge, and they're going over a, a list of things, like you said, a checklist.
• 38:56
  Dr. Molly Hartzler: Um, and we ask about fever, drainage, strike-through on the dressing, things like that.
• 39:02
  Dr. Molly Hartzler: Um, so that's one place that we can sort of catch issues.
• 39:05
  Dr. Molly Hartzler: Um, the discharge paperwork is very clear.
• 39:11
  Dr. Molly Hartzler: These are the things that we really want you to call back about, and I always counsel my patients, I would rather have you call in or send a message and have me tell you that it's nothing than to try to manage something at home on your own and have it actually be a big issue that gets delayed
• 39:25
  Joseph M. Schwab: A- Alex, what, in your opinion, what gets missed when maybe checklists aren't used regularly?
• 39:34
  Dr. Alex Gaukhman: Uh, I think everything.
• 39:36
  Dr. Alex Gaukhman: I think checklists are so important that, you know, they're pervasive.
• 39:38
  Dr. Alex Gaukhman: They're all major industries and, you know, aviation.
• 39:41
  Dr. Alex Gaukhman: Um, I, I, I think the more complex the situation, the more things that are gonna get dropped.
• 39:47
  Dr. Alex Gaukhman: Uh, believe it or not, you know, we use a checklist at-- We have, we have two kids under two years old, and getting out of the house is absolutely chaos, and we actually do, like, a quick checklist of, like, things that we need.
• 39:57
  Dr. Alex Gaukhman: Otherwise, it takes us two hours to leave.
• 40:00
  Dr. Alex Gaukhman: So it's paramount.
• 40:01
  Dr. Alex Gaukhman: You know, I use it in all points of my life
• 40:03
  Joseph M. Schwab: Steve, how do you, uh, maybe adapt checklists so that things don't become too rigid?
• 40:12
  Dr. Stephen Duncan: Well, um, I guess I am sort of a rigid person.
• 40:15
  Dr. Stephen Duncan: I'm, uh, severely OCD, probably unmedicated, but might need it.
• 40:20
  Dr. Stephen Duncan: Um, but all of us understand what can go right and wrong, but you have to assume that the patient has zero clue on what is normal and not normal.
• 40:30
  Dr. Stephen Duncan: And so part of it's the education process.
• 40:32
  Dr. Stephen Duncan: Like we have a-- our, our nurse teaches a class that goes through the booklet that we give them.
• 40:37
  Dr. Stephen Duncan: Um, when they get discharged, uh, same thing, that there's like checklists that you should take these medications at X hours.
• 40:45
  Dr. Stephen Duncan: Um, you know, your wound should look like this.
• 40:47
  Dr. Stephen Duncan: If there's something the matter, please call this direct line.
• 40:51
  Dr. Stephen Duncan: Do not go to the ER.
• 40:53
  Dr. Stephen Duncan: Um, a-and so I should say not rigid is hoping for the best, um, following a structured plan, as Alex said.
• 41:01
  Dr. Stephen Duncan: Uh, you kinda have to assume that they're kindergartners and they need a lot of help, uh, along the way
• 41:08
  Joseph M. Schwab: Alex, um, going back to you for a minute.
• 41:11
  Joseph M. Schwab: Do you have any personal, we'll say sort of es- escalation triggers that tell you it's time to maybe get a partner involved or change strategy or delay discharge, change course with a patient?
• 41:27
  Dr. Alex Gaukhman: Yeah, I mean, I think, you know, checking your ego at the door is really important.
• 41:30
  Dr. Alex Gaukhman: I think knowing your own skill set, I think knowing your own boundaries is very important.
• 41:35
  Dr. Alex Gaukhman: You know, this kind of starts preoperatively, you know, getting other subspecialists involved, whether it's, you know, a plastic surgeon to help you with some sort of wound care or maybe you're concerned about a vascular injury on a, on a hip revision.
• 41:46
  Dr. Alex Gaukhman: I think that's really important to recognize that early on, and it just makes things so much smoother down the line when, when things do occur, so it's not last minute and so chaotic
• 41:56
  Joseph M. Schwab: Molly, how do you, how do you teach trainees to recognize moments like that?
• 42:04
  Dr. Molly Hartzler: Yeah, I mean, a lot of their learning comes in clinic, um, and trainees love to be in the operating room.
• 42:10
  Dr. Molly Hartzler: Um, but the decision-making that is the most important, I think happens outside the operating room, uh, in terms of indications and then knowing, you know, when something is feeling a little bit funny, uh, when to, when to change.
• 42:24
  Dr. Molly Hartzler: So I think one of the most beautiful things about hips is how quickly pa- patient's pain goes away.
• 42:30
  Dr. Molly Hartzler: And so for me, if I have a patient that is having pain that is worsening, um, especially with redness or drainage or malaise, things like that, you know, that really, uh, gets my antenna up.
• 42:41
  Dr. Molly Hartzler: Um, you know, one of the things about anterior hips that I've learned is that hematoma is extremely painful for these patients.
• 42:48
  Dr. Molly Hartzler: Obviously can be a risk factor for infection.
• 42:51
  Dr. Molly Hartzler: Um, and so like Alex said, I, you know, if I have a patient that I'm worried about, I'm bringing them back very frequently, probably enough that they get annoyed by me.
• 42:59
  Dr. Molly Hartzler: Um, but I really wanna make sure that I'm seeing how things evolve, because one point in time is never gonna give you all the information that you need.
• 43:06
  Dr. Molly Hartzler: It's about tracking how they're doing over time and whether that's through phone calls, um, you know, media that they're sending in, uh, to the chart or having them physically come back to the clinic every week for a while.
• 43:18
  Dr. Molly Hartzler: Uh, and then taking my trainees with me, um, walking them through my thought processes, telling them about experiences that I've learned from in the past, uh, and trying to apply those in my, in the current situation.
• 43:32
  Joseph M. Schwab: Steve, for you, how do you, um, I think I would say normalize escalation so that it doesn't feel like failure
• 43:45
  Dr. Stephen Duncan: Uh, that's a great question.
• 43:47
  Dr. Stephen Duncan: Um, I mean, again, as I think Molly said, uh, trying to stay in touch with the patients, uh, at forty-eight, seventy-two hours, and then, you know, at a week and two weeks.
• 43:58
  Dr. Stephen Duncan: Um, generally at that point, it's not gonna be what I call escalation.
• 44:02
  Dr. Stephen Duncan: It's we're kind of monitoring things, uh, but also being involved with your team, not just having your nurse kinda field all the messages.
• 44:11
  Dr. Stephen Duncan: And we all get tons of Epic messages and, you know, when you get done with the day, and you've got fifty-six messages to go through, not everything needs to come to you.
• 44:19
  Dr. Stephen Duncan: But making sure that your nurses know when to get you involved and get your input, as opposed to them kinda taking care of everything and then go,"Well, why the heck didn't you ask me?" Um, I should say be approachable with your nurses is the other part.
• 44:35
  Dr. Stephen Duncan: Um, you know, I, I, I have team events where I take out the PAs, the nurses, and everything so that, yes, at work we do work, but outside of work, we also wanna be friends.
• 44:45
  Dr. Stephen Duncan: Um, and so having that kind of cordial relationship so that they're not nervous to ask you is probably a key part to remain involved in their care.
• 44:53
  Joseph M. Schwab: Hmm.
• 44:54
  Joseph M. Schwab: Well, y- you've all been really generous with your time and expertise, and I just wanna thank you for that.
• 45:00
  Joseph M. Schwab: I, I've got one additional question for each of you, and, and Alex, I'm gonna start with you.
• 45:05
  Joseph M. Schwab: When you look back on maybe the complications early in your career that sort of shaped the way your career went, what did they change about how you operate today?
• 45:21
  Dr. Alex Gaukhman: Um, I think complications are gonna happen.
• 45:23
  Dr. Alex Gaukhman: Uh, I think it happens to all of us, whether we like it or not.
• 45:26
  Dr. Alex Gaukhman: Uh, but it's just how you handle yourself.
• 45:29
  Dr. Alex Gaukhman: It's how you handle yourself at the time of the complication.
• 45:33
  Dr. Alex Gaukhman: Um, it's how you handle yourself with the team, with the patient.
• 45:37
  Dr. Alex Gaukhman: Um, you know, specif- I have like a very specific, uh, memory from when I was probably a second year in practice.
• 45:44
  Dr. Alex Gaukhman: And, you know, I can't remember the actual complication, but I remember afterwards the rep coming up to me and saying,"Hey, great job.
• 45:49
  Dr. Alex Gaukhman: That was great.
• 45:50
  Dr. Alex Gaukhman: But listen, everyone hates you." And I was like,"Okay, that's-- it's a good time to, you know, kind of reevaluate the way you're acting in the operating room." And, uh, you know, but I think the really way you're, you're handling yourself is, is really kind of the, the most important thing because no one else really cares about anything else that you're doing
• 46:09
  Joseph M. Schwab: Molly, for you, if you could help one surgeon avoid learning things the hard way, um, what would be a principle you would want them to maybe learn or take seriously from the start?
• 46:25
  Dr. Molly Hartzler: Well, um, you know, I think kind of the theme of this, complications and the way that we handle them, i- the most important thing that I think surgeons should do is just focus on the well-being of their patient.
• 46:37
  Dr. Molly Hartzler: Um, you know, Alex said earlier, you got to check your ego, and that's really, really important when it comes to handling complications both inside and out of the operating room.
• 46:46
  Dr. Molly Hartzler: Um, one of my mentors says,"If you cut, you cry." We're all going to have complications, and it can be very tempting to try to put your head in the sand and hope that things go away, and they are not going to.
• 47:01
  Dr. Molly Hartzler: Um, and so trying to remain humble and remember that we're focusing on the well-being of our patients, and we have to embrace the discomfort of managing them because it is a humbling experience to have to take somebody back to the operating room or have a talk with them about something that did not go as you expect.
• 47:19
  Dr. Molly Hartzler: Um, but, you know, surgical skill, um, you know, that, that can be taught, and I think the internal work of staying humble and remembering that we're here to really help people, uh, and trying to act accordingly, that's something that we have to all do for ourselves.
• 47:35
  Joseph M. Schwab: Hmm.
• 47:36
  Joseph M. Schwab: Steve, for you, uh, kind of going off of this idea of humility that Molly brought up, what gives you confidence when managing complications now, and what still deserves humility, um, every time you step into the OR?
• 47:55
  Dr. Stephen Duncan: And every time I step in the OR, you always hope for the best, but you gotta be prepared for the worst.
• 48:00
  Dr. Stephen Duncan: And that preparation comes from watching videos, um, having gone to labs, and being comfortable taking care of all of it.
• 48:10
  Dr. Stephen Duncan: And I think the one thing I wish I'd had when I adopted DA was to have sort of a, a mentor that, uh, you know, as fellows, we had what I call the post-op conference review, where the attendees kind of pick apart your case and say,"What did you do right?
• 48:24
  Dr. Stephen Duncan: What did you do wrong?" Uh, I think it'd be great if there's programs where if you attend a course that that attendee could then talk to that surgeon, uh, and run through cases, um, say,"Hey, what, what could I have done differently?" And usually you can tell, you know, like, when I was going through a case with my fellow, I said,"Well, your start point on the femur was too anterior, and that's why your stem looks like it's a little too small.
• 48:49
  Dr. Stephen Duncan: This is what you should do differently." So those are the little things that would probably help, uh, for people trying to adopt and avoid some of the complications
• 48:58
  Joseph M. Schwab: Well, um, this has been a great conversation.
• 49:01
  Joseph M. Schwab: I really appreciate all of you, um, taking the time with us and sharing your expertise.
• 49:07
  Joseph M. Schwab: Thank you for joining me for this episode of the AHF Podcast, and thank you to our sponsor, Smith+Nephew.
• 49:15
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• 49:25
  Joseph M. Schwab: Please also drop any topic ideas or feedback in the comments below.
• 49:29
  Joseph M. Schwab: You can find the AHF podcasts on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube at Anterior Hip Foundation, all one word.
• 49:44
  Joseph M. Schwab: Episodes of the AHF podcast come out on Fridays.
• 49:48
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy