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Operation FUBAR: The Case No One Wanted · AHF Podcast

• 0:07
  Joseph M. Schwab: Before we start today's episode.
• 0:09
  Joseph M. Schwab: I wanted to let you know that it's a pretty visual one, so I'm gonna put a link to the YouTube video in the description so that you can see what Dr.
• 0:20
  Joseph M. Schwab: John Horberg is presenting.
• 0:22
  Joseph M. Schwab: It's a case presentation and it's a new series I'm really excited about, so it's okay for you to listen, but just know there's going to be a presentation associated with it that's pretty important for you to get an idea of what we're talking about.
• 0:35
  Joseph M. Schwab: Thank you for listening to the podcast.
• 0:38
  Joseph M. Schwab: And I look forward to seeing you over on YouTube.
• 0:41
  Joseph M. Schwab: Now, let's get on with the show.
• 1:00
  Joseph M. Schwab: Hello, and welcome to the AHF Podcast.
• 1:03
  Joseph M. Schwab: I'm your host, Joe Schwab.
• 1:06
  Joseph M. Schwab: Today we're kicking off something new, something a little raw, a little honest, and very much overdue.
• 1:13
  Joseph M. Schwab: We're launching a mini series that we call Operation FUBAR.
• 1:18
  Joseph M. Schwab: It's real cases, real complications, and real ingenuity.
• 1:24
  Joseph M. Schwab: If you've been in the OR long enough, you know already, not every case goes the way you see it on VuMedi.
• 1:31
  Joseph M. Schwab: Sometimes the plan is perfect, right up until the moment it isn't, and it's in those moments when the room goes quiet, sweat starts collecting under your mask, and the scrub tech gives you that look.
• 1:44
  Joseph M. Schwab: You know the one I'm talking about?
• 1:46
  Joseph M. Schwab: Well, that's where real surgical skill shows up.
• 1:50
  Joseph M. Schwab: The troubleshooting, the pivots, the creativity.
• 1:53
  Joseph M. Schwab: That's what this series is all about, we're starting off with someone who embodies exactly that spirit.
• 2:00
  Joseph M. Schwab: Dr.
• 2:01
  Joseph M. Schwab: John Horberg, he's been on the podcast before, and if you've heard him, you know, he brings clarity, humility, and zero hesitation, especially when he's telling you the simple truth.
• 2:15
  Joseph M. Schwab: He's here today to walk us through a complex case that, well, let's just say it didn't read like this in the pre-op plan.
• 2:23
  Joseph M. Schwab: So let's get into it.
• 2:24
  Joseph M. Schwab: John Horberg.
• 2:26
  Joseph M. Schwab: Welcome to Operation FUBAR.
• 2:30
  John Horberg: Thanks for having me back.
• 2:31
  John Horberg: Um, this is a series I'm actually pretty excited about joining.
• 2:36
  John Horberg: We spend a lot of time at all of our meetings talking about the very cool stuff, the complex stuff, the impressive stuff we do, and we show our best cases and we stand up on the podium and look like we're knight and shining armor, but.
• 2:48
  John Horberg: We all know that not every case goes the way that you want it to intraoperatively.
• 2:52
  John Horberg: We all know that sometimes even cases that we think go well intraoperatively don't go well once the patient gets to our office.
• 2:59
  John Horberg: So I think having a opportunity to share cases that don't go according to the step-by-step plan is a, a great opportunity for other surgeons to learn and see how we work through these problems.
• 3:10
  John Horberg: Um, the case I'm gonna present, uh, I thought was starting off as a, uh, fairly.
• 3:17
  John Horberg: Fairly uncomplicated primary after a somewhat unusual presentation.
• 3:20
  John Horberg: But, uh, as you'll see, as we go through the case, we get into some wrinkles along the way.
• 3:26
  Joseph M. Schwab: Yeah, let's see those Let's go ahead with.
• 3:28
  Joseph M. Schwab: To your presentation.
• 3:30
  John Horberg: That sounds great.
• 3:31
  John Horberg: And thank you for, uh, inviting me.
• 3:33
  John Horberg: This is not an uncommon, I suppose, uh, way that sometimes.
• 3:38
  John Horberg: Folks show up in my office.
• 3:39
  John Horberg: I got a, a gift from one of my sports medicine partners.
• 3:42
  John Horberg: Um.
• 3:43
  John Horberg: Uh, very pleasant 73-year-old gentleman.
• 3:46
  John Horberg: He's, uh, biggest concern is non-compliant end stage renal disease, intermittently on dialysis, on a transplant list, and then off a transplant list intermittently because he can't seem to stick with his, uh, nephrologist recommendations.
• 4:00
  John Horberg: He's got some heart disease, lung disease, uh, no falls, no injuries, just six months of gradually worsening pain that got acutely much worse over the last 30 days.
• 4:10
  John Horberg: Um, he had no history of cancer, radiation, no previous infections.
• 4:14
  John Horberg: Uh, his biggest re relevant finding is that he's on dialysis and this is the X-ray I got, uh, when he walked into the office.
• 4:21
  John Horberg: Um.
• 4:21
  John Horberg: You know, the first thing that jumps into my mind when I look at something like this is, you know, is this a metastatic lesion that's failed?
• 4:29
  John Horberg: Is this an infectious process?
• 4:32
  John Horberg: Um, you know, is it an avascular lesion to the acetabulum or the femur?
• 4:35
  John Horberg: But seeing this as the initial presentation is certainly something that, uh.
• 4:39
  John Horberg: Uh, it gets your hairs up.
• 4:41
  John Horberg: So we worked'em up top to bottom.
• 4:44
  John Horberg: CT scans showed this, uh, large central defect with what looks like probably a transverse component, uh, of an acetabular fracture and terrible secondary degenerative change.
• 4:55
  John Horberg: Um, I have similar, uh, findings on the axial cts where it looks like there's a transverse defect that may end up being a discontinuity.
• 5:04
  John Horberg: Uh, MRIs do not show anything that looks like tumor burden.
• 5:08
  John Horberg: Nothing that was concerning to myself or the radiologist.
• 5:12
  John Horberg: Um, but the other thing that I was gonna do is biopsy the bone in that sup acetabular bone, uh, uh, bone stock to rule out a metastatic lesion or.
• 5:21
  John Horberg: Fracture, uh, caused by a tumor as well as culturing joint fluid and bone from that area.
• 5:27
  John Horberg: Um, we did the, both the aspiration and the, the biopsy and culture at the same time and we got lucky.
• 5:33
  John Horberg: Um, after making this poor gentleman wait for CT scans and blood work and MRIs and scheduling a biopsy, he had no infection, uh, no tumor burden, no necrotic, just a necrotic and reactive bone.
• 5:47
  John Horberg: That was, uh, noted on the biopsy specimen.
• 5:49
  John Horberg: So.
• 5:51
  John Horberg: Just like, uh, always.
• 5:53
  John Horberg: Um, I know some of you have heard my presentations before, but I practice in a, a relatively rural area in Wyoming.
• 5:59
  John Horberg: I'm not at a level one facility, so if we're gonna do a big case, we have to plan it all out in advance.
• 6:05
  John Horberg: Um, my plan was first, uh, primary hip replacement.
• 6:09
  John Horberg: Uh, it's an anterior approach'cause I'm less surgeon doing it.
• 6:13
  John Horberg: Potentially a jumbo cup with a bunch of bone grafting for that central lesion.
• 6:16
  John Horberg: Um, potentially a cup cage in bone graft as a backup.
• 6:20
  John Horberg: Um, be prepared with interoperative pathology in case, uh, either the biopsy or the culture was uh, inaccurate.
• 6:26
  John Horberg: And we did find pus rolling out of the hip or cells on a, uh, slide.
• 6:33
  John Horberg: And we got into the, or we found kind of what we expected.
• 6:36
  John Horberg: The, the head was soft when we removed it.
• 6:39
  John Horberg: He did have a good circumferential rim of bone around the acetabulum.
• 6:43
  John Horberg: Um, the column seemed to be intact.
• 6:45
  John Horberg: There was just this large central cavitary defect, and it seemed even larger than it looked on the, on the scans.
• 6:52
  John Horberg: It was very, very deep, uh, into the pelvis, but it had a reasonable round, uh, rind of largely corticated bone around it.
• 7:01
  John Horberg: So my plan was impaction grafting.
• 7:03
  John Horberg: I wanted to take as much crush can CEUs as I could into that central defect, rely on a good rim fit, uh, around the acetone'cause it did not seem to be discontinuous.
• 7:13
  John Horberg: And, uh.
• 7:14
  John Horberg: Proceed with a hemispherical socket and a, uh, primary stem until I get ready to do it.
• 7:20
  John Horberg: And they brought me 15 ccs of crush can CEUs, uh, because that's all they could find in the refrigerator during the case and after some hemming and hawing and, and sending other people to look for bone, it turned out that that's all they had left.
• 7:33
  John Horberg: I guess I had done too many revisions in the proceeding weeks and they hadn't gotten restocked, so I had to stop and pivot and decide what I wanted to do.
• 7:44
  John Horberg: With that large central cavitary defect, I didn't wanna just go straight to a jumbo cup, um, because I still had a bunch of bare empty space and pulau behind it.
• 7:56
  John Horberg: Um, I didn't think a cup cage was the, the right choice in that situation.
• 8:00
  John Horberg: So I did have, uh, lemon wedge augments and I wound up.
• 8:05
  John Horberg: Using one of, uh, Dr.
• 8:06
  John Horberg: Krosky's techniques and placed a couple of those augments deep in the defect, uh, and then placed a large socket on top of it and used the limited bone graft I had to, uh, pack inside the windows of the augments and then unitize the construct with cement.
• 8:21
  John Horberg: Uh, and it went really well on the socket side.
• 8:24
  John Horberg: One struggle I had intraoperatively when I was working on this guy is he was very narrow, uh, on the top side of the femur at the cow car.
• 8:32
  John Horberg: Um, and I always had this mismatch that you can see on these post-op films where the distal portion of the stem looked like it was swimming in the femur.
• 8:40
  John Horberg: But I didn't have room to grow even another size.
• 8:43
  John Horberg: Um, by the time I got to my six or six and a half, uh, college stem.
• 8:48
  John Horberg: So, you know, it felt solid.
• 8:51
  John Horberg: It felt secure.
• 8:51
  John Horberg: The bone up top on the proximal aspect of the femur was surprisingly supportive.
• 8:56
  John Horberg: And I accepted these x-rays in a uh ha coded stem in hopes that it would grow in and early follow-up.
• 9:04
  John Horberg: He did fantastic.
• 9:05
  John Horberg: He came to the office, he was walking.
• 9:07
  John Horberg: He said, doc, my pain's gone.
• 9:09
  John Horberg: Uh, he was able to wean from his walker, graduate from therapy, uh, and he's the nicest guy in the world.
• 9:14
  John Horberg: Every time I saw him, he had a big smile on his face.
• 9:17
  John Horberg: Which was rewarding.
• 9:19
  Joseph M. Schwab: It looks like you put in a dual mobility cup here.
• 9:21
  Joseph M. Schwab: Is that correct?
• 9:23
  John Horberg: That is correct, yes.
• 9:25
  Joseph M. Schwab: Was that part of the original plan, or was that something you decided intraoperatively?
• 9:29
  John Horberg: It was something that was part of the original plan given the appearance of the pelvis.
• 9:33
  John Horberg: Um.
• 9:35
  John Horberg: This guy has a very outlet appearing pelvis and a, a rigid, uh, biologic fusion of his lumbar spine.
• 9:42
  John Horberg: And given that he spends hours and hours a day intermittently in a dialysis chair, and I didn't know what his functional status was gonna be like.
• 9:50
  John Horberg: I didn't know how long he had had the central acetabular defect and what the integrity of his abductors were gonna be.
• 9:55
  John Horberg: I wanted a little bit of initial stability for him.
• 9:58
  John Horberg: Might have been overkill, but that was the, the thought process.
• 10:06
  John Horberg: Of course we were very happy with our outcome.
• 10:08
  John Horberg: Uh, he was happy.
• 10:09
  John Horberg: I was happy, um, but you don't wanna get too excited too early.
• 10:15
  John Horberg: So I wind up seeing him back, uh, at nine months, which is outside of my standard follow-up schedule at six months.
• 10:22
  John Horberg: He had reported a little bit of soreness here and there, but all in all things were looking pretty good.
• 10:26
  John Horberg: Uh, I had sent him off to come back and see me at a year postoperatively, but at nine months he says he's starting to get this worsening pain in his thigh.
• 10:34
  John Horberg: Um, he's been going back and intermittently doing some pt, also intermittently participating in his dialysis.
• 10:43
  John Horberg: And these are the films I had at that time.
• 10:45
  John Horberg: Um, socket doesn't look terribly concerning to me, but that stem has wallowed out quite a bit and it looks like it's encroaching on the lateral cortex of the femur.
• 10:56
  John Horberg: And this is how I felt when I, uh, I saw him on that visit.
• 11:00
  John Horberg: So, back to the drawing board.
• 11:03
  John Horberg: We, we went back through a workup, got another CT scan.
• 11:07
  John Horberg: The, uh, throughout the scan, the acetabular component appeared to be secure.
• 11:12
  John Horberg: The bone graft appeared to be incorporating is uh.
• 11:15
  John Horberg: Much as I would expect.
• 11:16
  John Horberg: Um, inflammatory labs were normal, but I aspirated the hip anyway, and it was, uh, again, found to be normal.
• 11:23
  John Horberg: We just have this big defect, uh, in the lateral cortex of the femur in a stem that looks like it's windshield wiping back and forth.
• 11:34
  John Horberg: So again, operating in a facility that's relatively limited in terms of resources, I had to have Plan A, plan B, plan C.
• 11:45
  John Horberg: Um, obviously my first plan is to remove that stem, revise it to a modular dalal engaging stem.
• 11:52
  John Horberg: Um.
• 11:53
  John Horberg: I had a backup cup cage construct in case the, the socket was in fact loose despite what the imaging showed.
• 11:59
  John Horberg: Uh, I confirmed with the hospital that we had a couple hundred ccs or crushed cancellous bone graft.
• 12:05
  John Horberg: Um, I had a spacer available again in case I got in there.
• 12:08
  John Horberg: And this thing was an infection that was lying to me on my preoperative workup.
• 12:12
  John Horberg: Uh, and I took him back to the or, um.
• 12:18
  John Horberg: Ooh, this is just a example of a stem removal, but the things that I'm thinking about, should this stem be fiberously grown in or tighter than I thought I, I had to be ready to.
• 12:29
  John Horberg: Uh, bur any bone away from the lateral shoulder, which means I have to have a burr.
• 12:33
  John Horberg: I needed to have, um, a burr that could go down below the lesser end of the calcar, uh, to the lesser tro canner.
• 12:40
  John Horberg: Uh, I use a ball tip proximally and then a long router tip, uh, to get as deep as I can around the metaphysis.
• 12:47
  John Horberg: Uh, flexible osteotomes.
• 12:49
  John Horberg: Um, I'm currently using an extraction set.
• 12:52
  John Horberg: Uh, to work my way around the stem and then slap hammer to hit the stem backwards.
• 12:56
  John Horberg: And if all else fails, uh, as we've talked about on previous podcasts, hit that stem down as hard as I can.
• 13:03
  John Horberg: Um, this is a demonstration of a stem removal.
• 13:06
  John Horberg: I think we'll save for a different, uh, talk, but this is what.
• 13:11
  John Horberg: We wound up doing, um, we, we pulled that stem out.
• 13:15
  John Horberg: It came out with my bare hands.
• 13:17
  John Horberg: I didn't need any instruments despite having all those trays sitting there in the room and sp a little bit frustrated with me.
• 13:23
  John Horberg: Um, we put the new stem in.
• 13:26
  John Horberg: I grabbed the socket with, uh, intraoperative ice grips and gave it a good, healthy tug, and it didn't budge.
• 13:31
  John Horberg: It felt really good and solid.
• 13:33
  John Horberg: I did change the bearings.
• 13:34
  John Horberg: Um, after I pulled the stem out, there was a small breach in the cortex, uh, that I could feel with a suction tip, kind of where the tip of that stem was, but no fractures around it.
• 13:45
  John Horberg: So we revised it to a long DAF seal, engaging stem and.
• 13:48
  John Horberg: This guy's femur took a large, large stem, uh, I believe that was a 24, uh, arcos, uh, distal body.
• 13:57
  John Horberg: And then for a little bit of extra support, because the metae bone stock looked so thin and wallowed out, I packed some antibiotic alluding cement around the proximal body of the implant.
• 14:06
  John Horberg: Uh, and this is what he looked like, uh, when he came back to the office.
• 14:12
  Joseph M. Schwab: There's a real between his AP diameter and his medial lateral diameter.
• 14:17
  Joseph M. Schwab: Isn't there?
• 14:18
  John Horberg: There really is.
• 14:19
  John Horberg: And you know, I think that that contributed to what I found when I was in there on the primary, um, the, that STEM distally just looked like it was floating in space in this poor renal bone stock, uh, femur.
• 14:33
  John Horberg: Whereas on the ap, especially proximally, it was pretty darn tight.
• 14:38
  John Horberg: Um.
• 14:39
  John Horberg: Not to be terribly unexpected in the setting of, uh, renal bone wasting, but, um, made it challenging to, to reconstruct him and where we ended up.
• 14:50
  John Horberg: He's doing well.
• 14:51
  John Horberg: Um, I just saw him on Friday in clinic.
• 14:53
  John Horberg: He's, uh, back to mobilizing.
• 14:56
  John Horberg: He's weaned from his walker.
• 14:57
  John Horberg: He's still in physical therapy.
• 14:59
  John Horberg: Um, his incision is healed, his pain's improving.
• 15:03
  John Horberg: He's back to smiling every time I see him, which is.
• 15:05
  John Horberg: Uh, what's most important to me and, you know, feel like a rock star or a cowboy after finishing up the case.
• 15:12
  John Horberg: But it's not one of those cases that was the most straightforward, and it's not one of those that healed in the, uh, the manner that I hoped it would.
• 15:21
  John Horberg: But, you know, talking about cases like this, I, I think about what did I learn after the first case, after the second case.
• 15:29
  John Horberg: And, you know, where can we go from here?
• 15:32
  John Horberg: Um, the first thing I always tell everybody, whether it's at a course and somebody who's working at a level one facility with all the resources in the world.
• 15:40
  John Horberg: Uh, or in a rural place like mine, I always want to know exactly what I'm working with.
• 15:46
  John Horberg: I've never once regretted ordering too many tests or overworking up a patient.
• 15:51
  John Horberg: Um, you know, when in doubt if something doesn't smell right, order the the right test or do the right procedure to figure it out.
• 15:57
  John Horberg: Um, I like to understand complex problems like this in three dimensions.
• 16:02
  John Horberg: Um, I typically order Juda films as a, a part of my surgical planning, but I also like.
• 16:07
  John Horberg: A CT scan to understand the, the actual bony defect whenever possible, and then plan ahead.
• 16:14
  John Horberg: I wanna know what's my plan A, what's my plan B?
• 16:17
  John Horberg: What's my plan C?
• 16:19
  John Horberg: In the case of the index operation, my plan A and B got hosed and I didn't even realize that was gonna happen.
• 16:25
  John Horberg: Um, but we had a Plan D available because I've got a excellent or team and an excellent team of reps that helped me think outside the box.
• 16:33
  John Horberg: Um.
• 16:34
  John Horberg: If you don't have what you need at your facility, get it before the case.
• 16:38
  John Horberg: These places are more than willing to order loaner sets or buy instrumentation.
• 16:43
  John Horberg: Um, sometimes implants don't live on the shelf and you have to get'em shipped up, but you want to have all that stuff there.
• 16:48
  John Horberg: No matter how much the SP team is frustrated with sterilizing 40 trays before a revision and then seeing you open six.
• 16:55
  John Horberg: Um, and I think it's important to be able to think on your feet when things get squirrely.
• 17:00
  John Horberg: One of the things I love about, um, working with the Anterior Hip Foundation is I get to see such a huge bank of possibilities and opportunities, uh, and tools that I can put in my bag.
• 17:11
  John Horberg: I, I listen to other outstanding surgeons on the podcast and at meetings tell about the, the techniques and the tools they use.
• 17:18
  John Horberg: Um, it's nice having, uh, extra options in the back of your head, even if it's not something you've done before.
• 17:26
  John Horberg: I also learned that despite the fact that I'm a collared STEM zealot, um, they can only do so much.
• 17:32
  John Horberg: And in this case, uh, the collared stem didn't save me, uh, due to poor bony biology largely.
• 17:39
  John Horberg: Um, but also the, the large canal due to the, the poor bone stock, a bigger stem could have helped me in this case.
• 17:46
  John Horberg: Um.
• 17:47
  John Horberg: I think alternate fixation might've been something that also could have helped me.
• 17:51
  John Horberg: Uh, a cemented stem in this setting might've been a good idea.
• 17:54
  John Horberg: I do worry in renal bone, uh, that that bone resorbs and then you have a loose cement mantle as opposed to a loose press fit implant.
• 18:02
  John Horberg: Um, but having, uh, other options when things aren't fitting quite right on your intraoperative x-rays is not a bad idea.
• 18:09
  John Horberg: Um, and then of course, as a physician, always listen to your patients.
• 18:14
  John Horberg: Um, you know, it's, it's easy to discount someone who was doing well at six months, who's now doing poorly at nine months.
• 18:21
  John Horberg: Um, if their pain changes, uh, even after a big complex case, it could be normal, it could be nothing.
• 18:27
  John Horberg: Uh, but as I learned in this case, sometimes it is.
• 18:32
  Joseph M. Schwab: So you mentioned several times about the, the fact that the facility is somewhat of a, a rural facility and you don't necessarily have everything available to you all the time.
• 18:41
  Joseph M. Schwab: Um, and in terms of the patient, did the patient live close to the facility?
• 18:46
  Joseph M. Schwab: Did they live far away or, and would you have prepared differently based on how far it would take the patient to get to where they need to be, to be taken care of?
• 18:58
  John Horberg: Yeah, it was a, that was an interesting challenge.
• 19:00
  John Horberg: The, the patient lived about an hour, hour and a half away from our facility.
• 19:04
  John Horberg: Um, closer to another community where I have a clinic, but where I don't operate.
• 19:09
  John Horberg: Um, I think the biggest, the biggest challenge with folks coming from further away is their postoperative rehab and mobilization.
• 19:17
  John Horberg: Um, and in this case, I think that also contributed to challenges with participating in dialysis and poorly optimized renal patients are obviously a challenge.
• 19:27
  John Horberg: Um, if this was run of the mill osteoarthritis, I probably would've.
• 19:31
  John Horberg: Made him go further as far as, um, improving his renal status, figuring out a plan to get him more, uh, consistently in dialysis, even potentially see endocrinology to see if we could improve his bone stock prior to surgery.
• 19:45
  John Horberg: Uh, we have a fabulous, uh, bone endocrinologist out where I I practice that is, uh, hugely helpful in these cases.
• 19:52
  John Horberg: Um, I felt that the acetabular fracture and insufficiency injury made this a little bit.
• 19:58
  John Horberg: More of an urgent case than, uh, than maybe a run of the mill degenerative disease.
• 20:03
  Joseph M. Schwab: Could you comment a little bit, uh, too about the patient's body habitus and whether or not you felt that was contributory apart from, uh, just the renal disease?
• 20:14
  John Horberg: I was fortunate.
• 20:15
  John Horberg: He was kind of a, a classic, uh, western medium.
• 20:18
  John Horberg: I wouldn't say a.
• 20:20
  John Horberg: Uh, very slender patient, but he also wasn't one of those people that, you know, it's challenging even to get exposure.
• 20:26
  John Horberg: It was very similar to the majority of my patient population, VMI, somewhere in the mid thirties.
• 20:32
  John Horberg: Um, I think his functional status did present a bit of a challenge.
• 20:35
  John Horberg: He hadn't been mobilizing very well.
• 20:37
  John Horberg: He'd been sitting quite a bit.
• 20:38
  John Horberg: He had a bit of a hip flexion contracture, and then combining that with the spinal pelvic disease, it, it made him very stiff.
• 20:45
  John Horberg: And that was more challenging than I think the, the remainder of his habitus.
• 20:49
  John Horberg: He was a fairly muscular guy and had worked as a, a laborer, but that wasn't, uh, as challenging as it has been in some cases.
• 20:57
  Joseph M. Schwab: And because I did notice in, in the initial po uh, preoperative X-ray that you showed preoperative AP pelvis.
• 21:05
  Joseph M. Schwab: Apart from obviously the insufficiency fracture of the acetabulum, the entire bony, uh, trabecular and cortical structure appeared pretty washed out.
• 21:15
  Joseph M. Schwab: And it wasn't clear to me whether that was part of his renal disease or whether that was an issue with, um, essentially beam penetration, you know, through a, through a, a larger body habitus.
• 21:29
  John Horberg: In this case, I think that truly was poor bone stock.
• 21:31
  John Horberg: Um, he had very ghost-like bone on imaging and I think on some of those postoperative films, especially with the revision components.
• 21:39
  John Horberg: It's almost difficult to see the rim of the acetabulum to assess your version.
• 21:42
  John Horberg: It's difficult to see the entire cortical rim around the femur because his bone was so osteopenic, whereas those implants are very radio opaque.
• 21:51
  Joseph M. Schwab: Did his bone feel particularly osteopenic during the procedure itself, or did you notice a difference?
• 21:58
  John Horberg: And the acetabulum, uh, yes, there was areas that were fairly squishy.
• 22:02
  John Horberg: The, the, the rim itself felt kind of sclerotic around about a centimeter in.
• 22:07
  John Horberg: And then everything else was soft, uh, packing those implants in there.
• 22:10
  John Horberg: It had a little give packing bone graft around them.
• 22:13
  John Horberg: It had a little give.
• 22:14
  John Horberg: The proximal femur was actually fairly sclerotic around the calcar.
• 22:18
  John Horberg: I think it's because I got to the, the bone very quickly.
• 22:22
  John Horberg: Um, but it was not a difficult broaching situation.
• 22:25
  John Horberg: The, the, the distal bone was obviously very poor and it felt that way.
• 22:30
  John Horberg: I think it felt that way in the revision case too, just because the reaming was very challenging to get something that felt like a solid scratch fit on that diop engaging stem.
• 22:40
  Joseph M. Schwab: so let's talk a little bit about the moment in the initial case.
• 22:45
  Joseph M. Schwab: When you recognize that both your plan A and plan B weren't options, uh, not having operated with you, I don't know what your personality's like, but we all know surgeons have personalities and we all know that those personalities get put under stress in periods.
• 23:02
  Joseph M. Schwab: Uh, just like what you described.
• 23:04
  Joseph M. Schwab: And so can you walk me through a little bit about, you know, you were very gracious in, in how you.
• 23:10
  Joseph M. Schwab: Uh, uh, gave, uh, some credit to your surgical tech and to your, uh, reps and, and people who allowed you to help think outside the box.
• 23:19
  Joseph M. Schwab: Can you talk a little bit more about that moment and what you thought you did well during that in order to come out with a successful strategy for dealing with it, and maybe what was something that you could have done differently?
• 23:34
  John Horberg: Well, I think in the moment when, uh.
• 23:37
  John Horberg: When I asked for the more bone graft and no one could find it, obviously it's a sinking feeling in your stomach when I've got a complex case and I've got a plan of how to address it, and then suddenly that plan is falling apart.
• 23:50
  John Horberg: Um, it's probably better that you ask my PAs and my OR staff, but I like to think in the or.
• 23:55
  John Horberg: I'm fairly calm and stoic.
• 23:57
  John Horberg: Um, I listen to loud angry music and I let the loud angry music.
• 24:02
  John Horberg: Be the frustration.
• 24:03
  John Horberg: Um, I had a policy when I was training residents, uh, at my previous job back in Illinois, that I would only yell at anyone in the room if they were about to hurt one of my patients.
• 24:14
  John Horberg: Um, if a mistake was made or a problem happened and it was already over, then there's no point in getting frustrated or upset.
• 24:21
  John Horberg: Um, deal with that on your own when you go home and go to the gym.
• 24:26
  John Horberg: So I like to think I, I stay fairly calm.
• 24:28
  John Horberg: Um.
• 24:29
  John Horberg: Obviously it's easy to get frustrated when you're sending multiple people outta the room looking for things, and I think if I had to think back to that case, my biggest.
• 24:38
  John Horberg: Regret, uh, so to speak, would be not being a little bit more patient with the people who are obviously just as flustered as I was running out and digging through refrigerators in the SP area.
• 24:49
  John Horberg: Um, you know, I think the, the secondary thing is trying to figure out, well.
• 24:55
  John Horberg: Shit, what am I gonna do?
• 24:57
  John Horberg: I am frustrated at myself that I don't have a Plan D.
• 25:00
  John Horberg: Um, fortunately the, the, the way our trays are set up when we have the cup cages, that comes with augments as well.
• 25:08
  John Horberg: Um, and my reps were the one who actually said, Hey, we've got these.
• 25:11
  John Horberg: Is there any way you can do something with that?
• 25:14
  John Horberg: And at first I kind of snapped at'em and told'em, I'm the surgeon, damn it, kind of thing.
• 25:18
  John Horberg: Um, but they were right and we wound up having a, a great outcome on the socket side, but.
• 25:25
  John Horberg: I think, I think it's very important in the or that you're the captain of the ship.
• 25:28
  John Horberg: You're the one who everyone is looking to, to have all the answers and to know what's going on.
• 25:32
  John Horberg: And I like to think that I try my best to stay as stoic as I can when things are going poorly.
• 25:39
  John Horberg: Um, whether or not I'm successful, I suppose, is up to interpretation depending on, uh, who you talk to.
• 25:47
  Joseph M. Schwab: So in talking a little bit about the revision case, again, you listed A, a plan A, a plan B, or a plan C, but I suspect you had more than just those three plans in place, given what had happened during the first case.
• 25:59
  Joseph M. Schwab: Is that, am I, am I wrong about that?
• 26:02
  Joseph M. Schwab: Or, uh, was did you really just go in with those three options?
• 26:06
  John Horberg: No, we, we had, uh, the kitchen sink available to us.
• 26:10
  John Horberg: Um, I had, uh, again, additional bone graft.
• 26:13
  John Horberg: I thought that there was a chance that I might have to do some sort of impaction grafting in the proximal femur.
• 26:18
  John Horberg: I had cemented stems available.
• 26:20
  John Horberg: Um, I had modular, non modular DAF seal engaging stems, although my hope in this case was with that wallowed out.
• 26:26
  John Horberg: ESIS was to use a large modular stem.
• 26:29
  John Horberg: Um, we had the cup cage available as a backup.
• 26:32
  John Horberg: We had a, a number of other tools in the bag, so to speak, but that was at least my hope, my hope that the worst that case would get would be I had to redo the socket.
• 26:41
  John Horberg: And I was very pleased that I did not.
• 26:44
  Joseph M. Schwab: So taking this whole case kind of together, both of these two cases I should say, but this whole patient's journey, um, is there anything that within your rural health system, which, which handles quite complex cases for not being level one, not having all those, uh, you know, sort of unlimited resources available to you so to speak.
• 27:04
  Joseph M. Schwab: Is there anything that this case contributed to your thought process about how with cases like this, we need to do it differently, or maybe we shouldn't do it here, or maybe we should do it here in this way.
• 27:18
  John Horberg: I think there's two, two aspects to that case.
• 27:21
  John Horberg: I've, I've worked really hard, uh, with all the other providers in our state who are.
• 27:26
  John Horberg: Incredibly, uh, amenable to trying to help to optimize our patients.
• 27:30
  John Horberg: Um, but I still have to have a very good understanding of what's available to make these patients as medically optimized as possible.
• 27:38
  John Horberg: Um, some of the communities in Wyoming have access to nephrology, access to dialysis.
• 27:43
  John Horberg: Some of them, it's much more challenging and a burden on the patient.
• 27:46
  John Horberg: So I think figuring those things out, um.
• 27:49
  John Horberg: You know, there's some cases that I don't do in, like in, uh, Laramie as much as I would like to, or patients where I might want an onsite vascular surgeon.
• 27:57
  John Horberg: I don't have a, a vascular surgeon who's available to me, uh, where I know I'm gonna need flap coverage.
• 28:03
  John Horberg: Um, that tends to affect me more on the knee side than the hip side.
• 28:07
  John Horberg: Um, but that's another case that I have to refer away.
• 28:10
  John Horberg: Um, so.
• 28:11
  John Horberg: Doing everything I can to work with the system I have on the preoperative side.
• 28:16
  John Horberg: Um, and then it kind of reiterates the, on the intraoperative side, the importance of planning and planning for me doesn't necessarily just mean that I have to know what implants I want, order them and make sure they're there.
• 28:29
  John Horberg: It also means that I have to be aware of.
• 28:31
  John Horberg: Things like bone graft, things like the availability of cement.
• 28:34
  John Horberg: Um, things like are we out of carbide?
• 28:37
  John Horberg: Bur tips, are we out of anything else?
• 28:40
  John Horberg: So I've been working a little bit more closely with our, uh, staff at the hospital who are phenomenal and understanding and, and more than happy to order stuff just to make sure we have a inventory of things.
• 28:52
  John Horberg: But when I come into these cases, I usually shoot a text and say, Hey, how much crush can sell us?
• 28:56
  John Horberg: Do we have.
• 28:57
  John Horberg: Um, I'm gonna need a, you know, two router tip burrs.
• 29:00
  John Horberg: Can I make sure that we've got a, a handful of those available in case I break one?
• 29:04
  John Horberg: Um, things like that.
• 29:06
  John Horberg: Uh, preparation supplies, uh, are the biggest thing.
• 29:10
  John Horberg: And then the cases that I can't take on are the ones that the medical staff doesn't have the ability to take care of.
• 29:17
  Joseph M. Schwab: You know, I find it interesting that we live in a time where you could, for instance, have a smart refrigerator at home that tells you whether you're running out of milk, right?
• 29:26
  Joseph M. Schwab: But it's really, really hard sometimes to know exactly what we have on hand at our hospitals.
• 29:31
  Joseph M. Schwab: And this seems to me, and maybe you're the person to, to be thinking about this, this seems to me to be a solution that technology should be able to solve for us.
• 29:41
  Joseph M. Schwab: And, and step number one is just knowing what we have and, and, and how long, uh, it's been on the shelf.
• 29:47
  Joseph M. Schwab: And, and step two is, is coming up with some sort of, uh, predictive algorithms for knowing how long it's likely before we use that product again.
• 29:57
  Joseph M. Schwab: But that would be a really interesting, I think, sort of solution for what you're talking about, but also maybe even applicable to larger, uh, you know, level one trauma centers.
• 30:07
  Joseph M. Schwab: Um, I don't know if you, if you work with any companies who have, uh, any insight into that.
• 30:15
  John Horberg: But you know, that's a great idea.
• 30:17
  John Horberg: The facilities have inventory management software that's kind of off and hidden in a mysterious library in the backside of some, uh, EMR computer software.
• 30:27
  John Horberg: And I'm sure they know exactly what they have, but it would be a.
• 30:31
  John Horberg: Really interesting to be able to pair the surgery schedule with the types of cases we're gonna do with, like you say, an AI analytics or a predictive algorithm that says this case has potential for needing these inventory items and then being able to bring to the fore the availability of those inventory items.
• 30:50
  John Horberg: Um, I think it would also be interesting to have a way that the surgeons can look at the inventory, you know,'cause I might not.
• 30:56
  John Horberg: Be verbalizing before every single case.
• 30:58
  John Horberg: Like I need to make sure I got a bunch of extra cement, I got extra burrs, I've got, you know, extra drill bits.
• 31:04
  John Horberg: I've got a second set of cup cutter blades because I'm an big old gorilla and I might break one.
• 31:10
  John Horberg: Um, it'd be very nice if I could pop up an app or a window on Epic and say, Hey, look at that.
• 31:15
  John Horberg: I'm running low on something we might not need.
• 31:16
  John Horberg: Need to start this case.
• 31:18
  Joseph M. Schwab: Yeah.
• 31:19
  Joseph M. Schwab: Um, and so John, you've been through this.
• 31:22
  Joseph M. Schwab: I know this isn't your only case that would be eligible for Operation FUBAR because you take on a lot of complex things.
• 31:29
  Joseph M. Schwab: When if you were to give advice to either young surgeons just in their practice, or maybe even to more veteran surgeons who are just looking for another perspective on how to handle these difficult cases, when you're in the middle of them, what advice would you give?
• 31:47
  John Horberg: I think several things.
• 31:48
  John Horberg: A lot of it comes before surgery.
• 31:51
  John Horberg: Plan ahead, think about the case and everything that could go wrong, um, and have a plan a.
• 31:56
  John Horberg: E, c and D and make sure that you've got all the equipment for it.
• 31:59
  John Horberg: That's first and foremost I think, in managing complex problems.
• 32:03
  John Horberg: Um, I like to think through the case in my head if I'm laying in bed at night, the night before, it's a technique that one of my former, uh, hand surgery attendings and training taught me.
• 32:13
  John Horberg: Because a lot of times if you sit there going through the case in your head, where I'm putting retractors, what I'm cutting, you're like, oh wait, that bone's kind of thin there.
• 32:20
  John Horberg: I might need to have another option to get anterior exposure.
• 32:22
  John Horberg: Or, oh, shoot, what happens if that defect is unstable?
• 32:26
  John Horberg: And you sometimes think of things that, uh, you might not otherwise think of as you're just going through it, um, in your head.
• 32:33
  John Horberg: And then.
• 32:34
  John Horberg: This is a difficult thing'cause controlling our emotions is challenging, but I think realizing that it's your job as the captain of the ship to be calm at all times, uh, in the OR and treat your staff with respect.
• 32:46
  John Horberg: And if you do that for years and years, they'll bend over backwards to help you out when you need it.
• 32:51
  John Horberg: Um, and then you can go home and yell into your pillow when you get back home.
• 32:57
  Joseph M. Schwab: Well, I think that's some solid advice.
• 32:59
  Joseph M. Schwab: John, thank you so much for helping us kick off this new series Operation FUBAR.
• 33:05
  Joseph M. Schwab: We always appreciate having you on the podcast.
• 33:09
  John Horberg: Uh, always a pleasure.
• 33:10
  John Horberg: I think this is a fantastic idea and I think it's gonna help a lot of surgeons.
• 33:15
  Joseph M. Schwab: Thank you for joining me for this episode of the AHF Podcast.
• 33:19
  Joseph M. Schwab: As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this.
• 33:27
  Joseph M. Schwab: Also, please drop any topic ideas or feedback in the comments below.
• 33:33
  Joseph M. Schwab: You can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation.
• 33:47
  Joseph M. Schwab: All one word.
• 33:49
  Joseph M. Schwab: Episodes of the AHF Podcast come out on Fridays.
• 33:53
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and away from operation FUBAR.