Latest / AHF Podcast / Part III: Examining Anterior Approach from Down Under

Transcript

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

• 0:07
  Joseph M. Schwab: Welcome to part three of examining the anterior approach from down under.
• 0:11
  Joseph M. Schwab: Let's get back to the last portion of 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: Speaking of things that have changed how you look at or how you think or how you learn in your surgical approaches, what would you, if we can go around to each of you, but what would you say have been the single sort of biggest disruptors in your practice, whether it's an actual practical technique that you've learned around the anterior approach, an implant, or a new piece of technology that's really changed or improved the way that you've done anterior total hips.
• 0:54
  Ilan Freedman: Yeah, no single, Technology, I think, just, I think using fluoro, and then I think there's a whole lot of fluoro based systems, whether it's verifier or Velys or whatever.
• 1:07
  Ilan Freedman: I think, I've changed incision from longitudinal to bikini, this little, but these things are chasing the 2 percent improvements.
• 1:14
  Ilan Freedman: I don't think there's been a single element of anterior that's, that's changed.
• 1:22
  Ilan Freedman: I looked briefly at off table, went back to what I knew, but little things that make marginal differences.
• 1:29
  Ilan Freedman: I use special, I use a special skin sealant.
• 1:32
  Ilan Freedman: So just, we're chasing, the one percenters now.
• 1:36
  Ilan Freedman: There's no single thing that's really revolutionized, my anterior approach specifically.
• 1:43
  Patrick Weinrauch: Mine's, mine's not surgical.
• 1:47
  Patrick Weinrauch: so I'd say, the, incorporation of low dose spinal, right?
• 1:54
  Patrick Weinrauch: So low dose spinal has made, has really made a big difference to my patient's first 24 hours and, their experience of the surgery.
• 2:04
  Patrick Weinrauch: a spinal where they're able to still walk straight away and, to be able to, they haven't lost motor function.
• 2:12
  Patrick Weinrauch: Yet they don't need big doses of opiates and yeah, they're really comfy and they've got no nausea and they don't get, they get less constipation and all that sort of stuff.
• 2:20
  Patrick Weinrauch: So I think for me, if I look at the one thing that's really made my patients most happy, because listen, I do lots of posterior approaches to you see, And, and they both go really well, right?
• 2:34
  Patrick Weinrauch: And I suppose that leads into the second thing.
• 2:35
  Patrick Weinrauch: If I'm allowed a second disruptive technology,
• 2:38
  Joseph M. Schwab: of
• 2:38
  Patrick Weinrauch: the second disruptive technology is just the change in mindset of, of our teams, right?
• 2:47
  Patrick Weinrauch: Where we've got teams of therapists and nurses who are, willing to be able to get people mobilized, early and they've got, they're quite used to dealing with all of that.
• 3:01
  Patrick Weinrauch: any of the problems that people might see in the peri surgical period, yet still push on with good rehabilitation.
• 3:08
  Patrick Weinrauch: And, so that mindset that you don't have to lie a patient in 24 hours and that's so if I've got two, it'd be the spinal and it'd be the team, right?
• 3:19
  Patrick Weinrauch: It's actually for me, it's probably not the approach.
• 3:23
  Ilan Freedman: Yeah, no, I'd say having a, having a regular team.
• 3:26
  Ilan Freedman: I was working in a hospital where.
• 3:28
  Ilan Freedman: Every theater list would be a different team.
• 3:29
  Ilan Freedman: And I think, anterior approach is, it's, intense for the surgeon, but, also pretty hard for the scrub nurse if they're a newbie.
• 3:36
  Ilan Freedman: So I think hospitals which have recognized, Just giving you a, consistent scrub team, who know your instruments, having a company rep, which, doesn't change every week, just giving, I agree with Pat that the team is beyond just, the surgeon.
• 3:53
  Ilan Freedman: There's so many sub teams within that, within the anterior approach, which are very important.
• 3:58
  Jit Balakumar: Look, I think the table I've been using the HANA table, since Dr Matta convinced me to his probably to his benefit.
• 4:05
  Jit Balakumar: We've got about three of those tables in our hospital.
• 4:10
  Jit Balakumar: and I love it.
• 4:10
  Jit Balakumar: I've tried to, for J and J.
• 4:12
  Jit Balakumar: I was like the K.
• 4:13
  Jit Balakumar: O.
• 4:13
  Jit Balakumar: L.
• 4:13
  Jit Balakumar: For off table for the whole of Asia Pacific, and it was just the most unpleasant experience with, 140 kilo, 160 kilo patients.
• 4:22
  Jit Balakumar: It's not fun, but look, it's, each of them have its own benefits and disadvantages.
• 4:28
  Jit Balakumar: But I think the table for me is big disruptor.
• 4:31
  Jit Balakumar: And, I think, planning to me is a big change only to, I would say, we all know, total hip in the century, 95 percent improved patient outcomes, 60 percent forgotten hip, but I'm confident that either through experience, through impeccable planning, 3D planning, my bandwidth of forgotten hip is increasing.
• 4:57
  Jit Balakumar: And particularly in the anterior approach, I'm learning, actually, you know what, I'll probably put people, change their anterior offset, reamed a bit more anteriorly.
• 5:04
  Jit Balakumar: Now I'm focusing on reaming into the right pillar.
• 5:09
  Jit Balakumar: obsessed about getting rid of the psoas impingement by tucking the cup in deep, but you can get extra articular impingement, which I wasn't appreciating as much with just Dynamic examination.
• 5:19
  Jit Balakumar: So I think that 3D planning really gives you that, bit of information.
• 5:25
  Jit Balakumar: and to me, that's a big disruptor.
• 5:29
  Joseph M. Schwab: How were you guys incorporating your team in the learning portion of the, approach?
• 5:36
  Joseph M. Schwab: How were you bringing a team up to speed?
• 5:39
  Ilan Freedman: I think, first of all, the company which I've had referenced, which was sending surgeons education was also sending the reps.
• 5:46
  Ilan Freedman: So they put a lot of investment into trying to educate not just their team, but their sales team.
• 5:51
  Ilan Freedman: And then it's up to the surgeon to, we run what we call in services where you'd be running a little mini workshop for your team and the company would bring the gear and the stuff and you have to just give the time to go through the trays and to workshop those cases and to, Also, you'd be a bit pushy initially that you wanted a consistent team.
• 6:11
  Ilan Freedman: The hospitals didn't necessarily give it to you the first time you asked for it.
• 6:14
  Ilan Freedman: Ironically, the more senior the surgeon, the better the team.
• 6:17
  Ilan Freedman: So you had this situation where when you were a very junior surgeon without much experience, you'd get the least experienced nursing team, which makes no sense.
• 6:24
  Ilan Freedman: it should be flipped the other way.
• 6:26
  Ilan Freedman: But, having enough, having enough, say in the hospital to, to get the team that you want and to spend the time educating them.
• 6:36
  Joseph M. Schwab: Elon, as you become the more experienced surgeon, are you willing to give up the experienced team for the less experienced one?
• 6:43
  Ilan Freedman: I should be, but no, you hang on to what you hang on to what you've earned.
• 6:47
  Ilan Freedman: But, but it is a bit ironic that the, new surgeon in the hospital gets the least experienced nurse,
• 6:53
  Patrick Weinrauch: That does bring up an important point, though, is that, say, for instance, when I do have someone come and visit and they want to learn anterior approach and they, see it and they've maybe they've done a couple of visitations, they're at that point of getting ready to pull the trigger and they ask me, how do I incorporate this seamlessly into my, into my practice, or, with the minimum amount of turbulence and I think that the, you've got to think of the surgery as a team sport, right?
• 7:24
  Patrick Weinrauch: And so you've got a mental model of what you.
• 7:28
  Patrick Weinrauch: Wanted to look like because you've seen it and you've trained it and you've, thought about it.
• 7:32
  Patrick Weinrauch: You read about it and you've been on visitations and you've done, certain about training, but the rest of the team, none of them have seen it.
• 7:40
  Patrick Weinrauch: All right, so they got no, they got, you haven't got a shared mental model there.
• 7:44
  Patrick Weinrauch: And so to be able to achieve that, you've got to.
• 7:48
  Patrick Weinrauch: achieve.
• 7:48
  Patrick Weinrauch: You've got to deliver some form of education to them.
• 7:51
  Patrick Weinrauch: And I think the best way in which you, you can achieve that is to bring that your key people with you when you're learning, right?
• 8:03
  Patrick Weinrauch: So if you go into a cadaver lab, if whoever's running the cadaver lab will allow them to be able to bring, for instance, your first assistant or your scrub sister, right?
• 8:14
  Patrick Weinrauch: you scrub stuff, then they can see that, right?
• 8:17
  Patrick Weinrauch: and we've had visitations where they've brought in the lead scrub nurse, right?
• 8:23
  Patrick Weinrauch: And they, and because when they come and see the procedure, the surgeon is focused on do this, release that, do this, do that.
• 8:32
  Patrick Weinrauch: But the scrub sister's looking at the flow and they're seeing how they drape and, which, bits of equipment they need and the sort of, and so when it comes to time of actually needing to do the surgery in their new place.
• 8:46
  Patrick Weinrauch: The thing that's going to be the hardest is the surgeon works and walks in and he goes, Oh, let's whack some drapes on.
• 8:51
  Patrick Weinrauch: But I wasn't really thinking, I wasn't really taking much attention to all of those little things that, that the other members of the team, that's their world, right?
• 9:02
  Patrick Weinrauch: And they see that stuff, right?
• 9:04
  Patrick Weinrauch: And they grab it and then they transplant it in.
• 9:07
  Patrick Weinrauch: And yeah, because we're so focused on what we do, right?
• 9:11
  Patrick Weinrauch: So I think, I think, the key point out of that is that if you can, get some form of education for your staff around you, and that's, how I introduced it into my practice.
• 9:24
  Patrick Weinrauch: I had my lead, surgical assistant who happens also to be a nurse, Come with me.
• 9:32
  Patrick Weinrauch: And then she was able to not only, assist me.
• 9:36
  Patrick Weinrauch: so there was a buddy system there, but also she was able to very easily translate that over to the other staff to be able to say, this is what you need to do right in a way in which I wouldn't have been able to articulate myself.
• 9:48
  Jit Balakumar: The issue is for me, this is a, Ideal situation, teamwork is dream work.
• 9:55
  Jit Balakumar: You've heard, I'm sure you've all heard Christophe Corden talking about the efficient anterior reproach.
• 10:00
  Jit Balakumar: And he did this great talk about how many minutes is saved in a day translated to how many years it's saved in his life, right?
• 10:07
  Jit Balakumar: And, it made me very depressed,
• 10:10
  Patrick Weinrauch: least you're not waiting for, At least you're not waiting for cement to set.
• 10:17
  Jit Balakumar: I realized is that every three years my table technician moves on to, becomes a rep there.
• 10:22
  Jit Balakumar: They joined some company, right?
• 10:23
  Jit Balakumar: Oh, my nurses get pregnant or if they can't get pregnant, they move on.
• 10:29
  Jit Balakumar: And, I always say, look, in our hospital, we, I refer to the surgeons as the big five, like in the game parks.
• 10:36
  Jit Balakumar: And, I'm just a hyena, jokingly knowing that secretly I'm in the big five, but you want to, I think you have to be open to the idea that it's not like it used to be.
• 10:48
  Jit Balakumar: Everyone's moving.
• 10:50
  Jit Balakumar: People have ambitions, the really good stuff that we have actually some time want to move on, To something else.
• 10:58
  Jit Balakumar: it's a very hard, hard thing to be able to do that.
• 11:03
  Jit Balakumar: And I think what I've actually got a lot more of is patience.
• 11:06
  Jit Balakumar: I've just realized I'm no longer getting frustrated.
• 11:09
  Jit Balakumar: And, I want to be more like Roger Federer, when all those unforced errors happen and not like Nick Kyrgios, because when I see that new member of nursing staff in my theater, I don't want to be smashing that racket on the floor.
• 11:22
  Jit Balakumar: And so I would say, look, I agree with everything that Pat and Alana are saying.
• 11:27
  Jit Balakumar: I have a different experience.
• 11:29
  Jit Balakumar: I'm getting to the stage where I'm like, Oh my God, how did this happen all of a sudden?
• 11:34
  Jit Balakumar: And there's some completely new member of staff in my theater or on the wall.
• 11:38
  Jit Balakumar: There's a physio who says, let's start using the walking frame and don't sit and bend over more than 90 degrees.
• 11:44
  Jit Balakumar: That's what's happened.
• 11:48
  Jit Balakumar: how did that happen?
• 11:49
  Jit Balakumar: And, I don't, are you, guys seeing that at all or not really?
• 11:54
  Jit Balakumar: Maybe I'm the only one who's just getting all this change and stuff.
• 11:57
  Patrick Weinrauch: No, I think, I think that having, I think the benefit of having a, a high volume practice though is that, people can learn things pretty quickly because they, just get repetition really fast, right?
• 12:14
  Patrick Weinrauch: and if they're, if you're doing enough volume, there's a critical mass where, or, Yeah, even if they're not your regular staff, even your irregular staff have now had the opportunity to be able to do lots of them.
• 12:28
  Patrick Weinrauch: So there's like depth in the team.
• 12:32
  Patrick Weinrauch: so if you have a complete stranger come in, you know that you've you're surrounded by lots of people who aren't complete strangers.
• 12:40
  Patrick Weinrauch: So there's enough you can accommodate there.
• 12:42
  Patrick Weinrauch: So we can have two new staff come in.
• 12:44
  Patrick Weinrauch: And that's not that's fine.
• 12:46
  Patrick Weinrauch: We, we do that all the time.
• 12:49
  Patrick Weinrauch: and pretty quickly, they learn the ropes because there's enough resilience in the system to be able to compensate for that.
• 12:55
  Patrick Weinrauch: Yeah.
• 12:56
  Patrick Weinrauch: I think that's probably one of the, one of the, one of the, tagline, benefits of having a reasonable volume practice too.
• 13:07
  Patrick Weinrauch: Yeah.
• 13:08
  Joe Scerri: I was gonna say, the big thing that I've noticed is if you go back maybe 15 years, a surgeon would change an implant and nothing else would change around him or her.
• 13:21
  Joe Scerri: whereas, whereas now, if you go to, your question, Joe, direct anterior, suddenly you've got to change the draping, to Ilan's point.
• 13:29
  Joe Scerri: You might need to use plural or you may not.
• 13:32
  Joe Scerri: you might want to use the table.
• 13:33
  Joe Scerri: You may not.
• 13:35
  Joe Scerri: you're going to need a bunch of different retractors.
• 13:36
  Joe Scerri: You may or may not.
• 13:39
  Joe Scerri: you might do the figure four.
• 13:40
  Joe Scerri: and so all of those things have now changed.
• 13:44
  Joe Scerri: As distinct from just changing from a, I don't know, porous coated stem with HA or one without, or a polished stem and maybe using cement.
• 13:54
  Joe Scerri: Whereas now, suddenly, all these people that are involved in you having a successful outcome, there's a lot of moving parts and what I've noticed, in the last few years is just the amount of laptops that are in theatre now looking at screens and, what, what degree is that and what, angle is that?
• 14:13
  Joe Scerri: Whereas back in the old days, you were lucky sometimes if someone did a pre op plan with a template.
• 14:21
  Joe Scerri: so it's, what are you planning?
• 14:24
  Joe Scerri: What's the strategy today, doc?
• 14:25
  Joe Scerri: And it's I don't know.
• 14:26
  Joe Scerri: I haven't seen the x ray yet.
• 14:28
  Joe Scerri: and we've come a long way and that's a credit to the industry and people are getting that great attention.
• 14:35
  Joe Scerri: And also it was like back in the day it was, what clinical history do you have?
• 14:39
  Joe Scerri: And now it's more about how you put it in rather than what you're putting in.
• 14:43
  Joseph M. Schwab: Gentlemen, I want to thank you for taking time to talk with me today and, and thank you for helping educate our listeners.
• 14:51
  Joseph M. Schwab: And of course, thank you for everything you do for your patients.
• 14:56
  Joseph M. Schwab: If you're interested in learning more about today's guests, you can check out our show notes for their practice links.
• 15:02
  Joseph M. Schwab: Join us every Friday for a new episode of the AHF podcast.
• 15:06
  Joseph M. Schwab: You can find us an audio form in your favorite podcast app, or watch our video podcast on YouTube.
• 15:13
  Joseph M. Schwab: Don't forget to like and subscribe and leave us a five star review to help us reach a wider audience, and to keep this content coming.
• 15:21
  Joseph M. Schwab: Until next week, this is Joe Schwab reminding you to keep those hips happy and healthy.