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

• 0:07
  Joseph M. Schwab: I had the opportunity a few weeks ago to sit down with a group of Australian hip surgeons.
• 0:12
  Joseph M. Schwab: Through our conversation they helped me understand the landscape of anterior approach hip surgery in Australia.
• 0:18
  Joseph M. Schwab: In fact, they weren't shy in sharing their opinions about the good, the bad and the ugly of training on anterior approach from down under.
• 0:27
  Joseph M. Schwab: Over the course of almost an hour we discussed how the Australian market compares to other national markets like the United States and Great Britain.
• 0:35
  Joseph M. Schwab: According to the Australian National Joint Registry, anterior approach makes up just over 30% of all primary total hip arthroplasties.
• 0:44
  Joseph M. Schwab: For me, this enlightening discussion helped me understand what's driving the increase in popularity for anterior approach in Australia.
• 0:52
  Joseph M. Schwab: The surgeons I talked to were Patrick Weinrauch, Jit Balakumar, and Ilan Freedman.
• 0:59
  Joseph M. Schwab: All practicing hip surgeons in Australia.
• 1:02
  Joseph M. Schwab: Also in on the conversation was Joe Scerri, a sales rep for Applied Medical, who has a particular passion for anterior approach.
• 1:10
  Joseph M. Schwab: Over the course of the next few episodes, we'll cover the whole conversation.
• 1:15
  Joseph M. Schwab: But let's begin by learning about.
• 1:17
  Joseph M. Schwab: each surgeon.
• 1:18
  Joseph M. Schwab: starting with.
• 1:18
  Joseph M. Schwab: Mr.
• 1:19
  Joseph M. Schwab: Patrick.
• 1:19
  Joseph M. Schwab: Weinrauch.
• 1:21
  Patrick Weinrauch: Yes I'm a a, hip surgeon.
• 1:24
  Patrick Weinrauch: I, do only hips.
• 1:26
  Patrick Weinrauch: I've been in private practice, for about 16 years now and I've been doing anterior approach for about 13 years or so, 12, 13 years, something like that.
• 1:39
  Patrick Weinrauch: probably 75 to 80 percent of my practice is arthroplasty, about 20 percent is arthroscopy.
• 1:49
  Patrick Weinrauch: I do a fair number of, resurfacing procedures, so out of my primary arthroplasty, about 50 percent of my work is resurfacing and 50 percent is conventional total hip replacement.
• 2:02
  Joseph M. Schwab: Are you using anterior approach for both, resurfacings and, standard conventional total hips?
• 2:09
  Patrick Weinrauch: No, so I use, posterior approaches for my resurfacing, anterior approach from a conventional total hip replacements, and revisions are a bit of a mix.
• 2:19
  Patrick Weinrauch: Predominantly posterior approaches for my revisions, depends on the clinical situation.
• 2:26
  Joseph M. Schwab: And, Elan, tell us about yourself.
• 2:28
  Ilan Freedman: Yes, I, finished training in 2012.
• 2:31
  Ilan Freedman: I actually followed Patrick the same, uk hip arthroscopy fellowship.
• 2:36
  Ilan Freedman: but when I was in the UK I got the, opportunity to spend a weekend in France with, Frederick Laude anterior hip surgeon.
• 2:43
  Ilan Freedman: hip arthroscopy didn't really gel that much with me, but from that opportunity ended up doing, anterior approach through Frederick.
• 2:51
  Ilan Freedman: And, I just do, adult arthroplasty, probably 60% hip, 40% knee.
• 2:58
  Ilan Freedman: Purely anterior approach for most, except for a difficult revisions
• 3:02
  Joseph M. Schwab: You're quite active on LinkedIn, I see, as well.
• 3:06
  Joseph M. Schwab: You've got, almost 15, 000 followers on LinkedIn.
• 3:09
  Ilan Freedman: Yeah, I try to be.
• 3:10
  Ilan Freedman: I'm purely private practice, so I don't have the luxury of a public appointment, so it's purely private.
• 3:15
  Ilan Freedman: So initially it was a bit of awareness and I guess a bit of marketing, I enjoy posting what I do, enjoy posting papers, enjoy being a little bit, challenging or, mildly controversial, but it's been good to just get a bit of awareness for my practice, but I've kept it up and you actually learn a lot.
• 3:31
  Ilan Freedman: I've learned more from some of the case studies on LinkedIn.
• 3:34
  Ilan Freedman: Then I do from, journal papers, people posting interesting stuff and commenting and sharing.
• 3:40
  Ilan Freedman: And it's been quite a good forum.
• 3:42
  Joseph M. Schwab: We certainly don't shy from controversy here.
• 3:44
  Joseph M. Schwab: Jit, why don't you tell us a little bit about yourself?
• 3:47
  Jit Balakumar: So I finished medical school in 1998, finished my orthopedic training in 2006.
• 3:53
  Jit Balakumar: So similar to Patrick.
• 3:56
  Jit Balakumar: and, even though I'm a pediatric, type surgeon, look, my practice is probably 70 percent arthroplasty, and 20 to 30 percent arthroscopy and 20, 10 percent osteotomies.
• 4:10
  Jit Balakumar: I do a lot of osteotomies, PAOs, but, like overall picture, it's probably a small proportion of my practice.
• 4:18
  Jit Balakumar: And, I started the DAA journey actually, similar to Ilan, I was doing a fellowship in France, and even before that I saw it in Australia, but I saw, I was doing a knee fellowship and saw frederick Laude next door, and the controversies he was creating at the time, and then, I spent some time with Keith Berend just doing some visitations, came back to Australia, just made perfect sense with the arthroscopy and osteotomy practice to do something supine with fluoroscopic guidance, for me, it was all about trying to incorporate that into my preservation practice and then I spent two weeks with Dr.
• 4:57
  Jit Balakumar: Joel Matta, who started your AHF, I can see, I was very lucky DePuy had funded that and I've gone through a journey on table, off table with DePuy and then, now with Medacta.
• 5:10
  Jit Balakumar: I am a zealot when it comes to anterior hips, but look, to be honest, as I tell patients, I don't, they're all the same anterior posterior at 3 to 6 months.
• 5:20
  Jit Balakumar: It's probably something that, I used to use my enabling technology to, hopefully improve patient outcomes.
• 5:29
  Joseph M. Schwab: In your journey through trying out different technologies, identifying different implant companies, what is it that you feel?
• 5:39
  Joseph M. Schwab: pushes you in one direction helps you gravitate towards a specific technology.
• 5:45
  Joseph M. Schwab: The people that you work with?
• 5:47
  Joseph M. Schwab: Is it the results that you get?
• 5:49
  Joseph M. Schwab: Is it the, shine and the glitter of the technology, so to speak?
• 5:52
  Joseph M. Schwab: what's your biggest factor?
• 5:55
  Jit Balakumar: I think the people I work with really, that's probably Patrick and I've actually worked on a few things together, but the people I work with is probably the most important thing.
• 6:03
  Jit Balakumar: I feel like there's a lot of young who are spheres of influence they're very smart, really, disruptors in the traditional sense.
• 6:13
  Jit Balakumar: I don't want to work with people who are disrupting for the sake of disrupting, but, it has to come out into metrics such as improved patient outcomes, satisfaction.
• 6:23
  Jit Balakumar: And I think, that's where you see really good diversity when you work with great people, who've got very different thought processes.
• 6:31
  Jit Balakumar: So that to me is the most important.
• 6:33
  Jit Balakumar: One of my colleagues, Andrew Shuman, Aaron Buckland, they're the pioneers of this.
• 6:39
  Jit Balakumar: Hip spinal pelvic.
• 6:41
  Jit Balakumar: they're very much.
• 6:42
  Jit Balakumar: he's very much a posterior approach surgeon so it is interesting to be part of that and you almost have to be very careful how you do the anterior approach in that space where I was the junior surgeon So but it's been embraced very well in that space
• 6:59
  Joseph M. Schwab: And, Joe, last but not least, you and, quite honestly, I'm not sure this group would have come together if it had not been for you reaching out Tell me a little bit about, your work with Applied Medical and how you, how you came to put this group together to have this conversation.
• 7:17
  Joe Scerri: Yeah, I think I would probably characterize it as serendipitous because, with the, the business that I'm working with at the moment, which is, the Alexis, protector for, for tissue protection.
• 7:34
  Joe Scerri: when I had a look at the users, around the country, what I found was the majority of them were doing the anterior approach.
• 7:42
  Joe Scerri: And so what I tried to do was to try and find out which surgeons were actually performing that case, even though we have products for the as well, and lateral and so on, depending on the incision size, I could not find a group of people that came together as anterior hip surgeons.
• 8:02
  Joe Scerri: And so as part of that, investigation, I discovered, the Anterior Hip Foundation, which you're heading up, Joe uh Joe.
• 8:13
  Joe Scerri: And it just struck me that why don't we have something like that?
• 8:17
  Joe Scerri: And a couple of us have talked about that.
• 8:20
  Joe Scerri: And so that's when I reached out to you and I mentioned that, in your introduction, that 30 percent of cases in Australia are done anterior.
• 8:30
  Joe Scerri: And it just struck me that we've got lots of meetings around the country for sports medicine, the hips, the shoulders, the knees.
• 8:37
  Joe Scerri: And then subspecialty groups within that, but there's nothing, about direct anterior and given that it's 30 percent of something like 54, 000 cases last year.
• 8:48
  Joe Scerri: It just struck me that when I look at some of the things that your, your foundation put out and just seen recently with the masterclass and things like that.
• 8:58
  Joe Scerri: That you're quite advanced in terms of how you bring, the things that apply those people together.
• 9:07
  Joe Scerri: And even as most recently with some of those, starting from the basics really, right through to revision cases and so on.
• 9:16
  Joe Scerri: I guess I've got a vested interest in terms of where our product lies.
• 9:20
  Joe Scerri: But at the same time, I see the benefits and I take Jit's point.
• 9:24
  Joe Scerri: But when you look at it as a younger person.
• 9:27
  Joe Scerri: Even though maybe six months out, three months out, you might be the same.
• 9:31
  Joe Scerri: Most people want to get back to work really quickly.
• 9:33
  Joe Scerri: And if they've got a choice between the two, then that's probably what they'll select in the hands of the right person.
• 9:39
  Joseph M. Schwab: let's talk a little bit about that 30 percent that you're seeing in Australia, because by comparison, if you look at the National Joint Registry in the UK, it's about 1 percent of primary total hips are done through an anterior approach.
• 9:57
  Joseph M. Schwab: the American Joint Replacement Registry, the AJRR, It doesn't, actually, interestingly enough, capture approach, but the American Association of Hip and Knee Surgeons at their annual meeting usually does a survey and the most recent survey that they've published from 2022 indicated around 56, 57 percent of total hips are being done through an anterior approach.
• 10:23
  Joseph M. Schwab: I bring these two up because given that Australia and the United Kingdom have historically, nationally, economically had greater alignment.
• 10:34
  Joseph M. Schwab: why do you think Australia is closer in number to the U.
• 10:38
  Joseph M. Schwab: S.
• 10:38
  Joseph M. Schwab: than the U.
• 10:39
  Joseph M. Schwab: K.
• 10:40
  Joseph M. Schwab: in anterior approach?
• 10:42
  Patrick Weinrauch: I, think that it's probably worthwhile looking back at the, history of the introduction of, DAA to Australia.
• 10:49
  Patrick Weinrauch: if you go 15, 16 years ago, the DAA was not really commonly performed in Australia.
• 10:56
  Patrick Weinrauch: The two main surgical approaches would've been posterior and then anterolateral actually being pretty common.
• 11:04
  Patrick Weinrauch: and, that's I think probably a vestige of our training through, public hospital systems and probably a legacy of, as you say, from our, heritage with a lot of us going and doing fellowships in the UK.
• 11:19
  Patrick Weinrauch: when you look at the uptake, Over the last eight or nine years on it in our registry, we've seen that the, poster approaches stayed actually pretty steady.
• 11:31
  Patrick Weinrauch: It's been, it's stayed at about 55 percent the whole way along the last, eight years.
• 11:38
  Patrick Weinrauch: And what we've seen is a melting away of the anterolateral approach and, and those numbers.
• 11:45
  Patrick Weinrauch: down to 10, 15 percent now, whereas the anterior approaches has taken up that slack.
• 11:53
  Patrick Weinrauch: yes, I think it's worthwhile sort of reflecting on that.
• 11:55
  Patrick Weinrauch: And we've seen that over the last few years, it's been a fairly static sort of, split of 55%, 30%, 50%.
• 12:03
  Patrick Weinrauch: 10, 15%.
• 12:06
  Ilan Freedman: I was last week in Europe and they had a, at a European anterior hip meeting and they went through basically country by country.
• 12:12
  Ilan Freedman: And I think America was about 55%.
• 12:14
  Ilan Freedman: Most European countries are about 40%.
• 12:17
  Ilan Freedman: Sweden, for whatever reason, was 1 percent and the UK was 1%.
• 12:20
  Ilan Freedman: So I think the UK, first of all, has a very proud tradition in Exeter and elsewhere in terms of why they do things the way that they do.
• 12:28
  Ilan Freedman: I think there's a little bit of, Anglo Franco, dislike.
• 12:32
  Ilan Freedman: I think that I think it was initially seen maybe as a French operation.
• 12:35
  Ilan Freedman: but also I think in Australia has a public and private health care system and the majority of joints now done in the private system.
• 12:43
  Ilan Freedman: And I think frankly, initially there is some, there's some competition, who can get patients better quicker, who can recover faster.
• 12:50
  Ilan Freedman: There's a little bit of looking for a point of difference in Australia and in the States, whereas the UK and elsewhere, which is purely public, they may not have that.
• 13:01
  Ilan Freedman: that rivalry or competition between surgeons, which drives some of these, quicker, faster out of hospital quicker.
• 13:07
  Ilan Freedman: It's not maybe not as competitive.
• 13:09
  Ilan Freedman: I think the anterior approach has been driven at least initially by some competitive advantage.
• 13:16
  Ilan Freedman: but yeah, just maybe the UK and Sweden are the ones that are holding out and the rest of the world is, I think, coming on board.
• 13:24
  Jit Balakumar: I might, add to that and I'm going to say something controversial and say, look, I think problem with anterior approach is surgeons have ruined it, right?
• 13:33
  Jit Balakumar: They've, used it as a marketing tool.
• 13:36
  Jit Balakumar: And, and I would say again, I'm in a big private practice where I'm cognizant of the fact that, my point of difference was I'm a hip preservation surgeon, I'll do, a lot of arthroplasty probably more than my arthroplasty colleagues.
• 13:51
  Jit Balakumar: I'm not going to make that a point.
• 13:52
  Jit Balakumar: And that also includes not talking about anterior.
• 13:56
  Jit Balakumar: it's like the Mako revolution that's happened with the knee.
• 14:00
  Jit Balakumar: and I would argue that it's, very, the natural, the organic revolution is actually patient driven.
• 14:07
  Jit Balakumar: The market wants it, right?
• 14:09
  Jit Balakumar: And, I'll have patients coming in.
• 14:11
  Jit Balakumar: I don't even talk about anterior.
• 14:13
  Jit Balakumar: And they will say, just to be clear, do you do the anterior approach?
• 14:16
  Jit Balakumar: And I'm like, look, why I showed you the cut is in the front of the hip, right?
• 14:20
  Jit Balakumar: But I don't really like to talk about this.
• 14:22
  Jit Balakumar: And I think this is where have to be careful.
• 14:25
  Jit Balakumar: I think Pat made an excellent point, really what it comes down to is approach, the Hardinge, which is very safe.
• 14:33
  Jit Balakumar: I'm going to offend someone and say, look, I call it lovingly the burglars approach because you're robbing someone of their abductors potentially for their life, but, it's potentially taken that group and said, okay, let's incorporate that the anterior approach clearly has some advantages, but it has some disadvantages in learning curve.
• 14:54
  Jit Balakumar: And, and scenarios, perhaps it's not the right thing.
• 14:59
  Jit Balakumar: I don't think, I think what we will see is over time.
• 15:04
  Jit Balakumar: people will use the anterior approach and one of public hospitals I work at, which is the last bastion of, training.
• 15:11
  Jit Balakumar: So we've got to train, similar to your academic institutions in the US.
• 15:17
  Jit Balakumar: the trainees have to be able to do the approach and the surgery, the majority of it, if not all of it, and certainly when I was training, I was doing all of it without the, the, boss in theater, but it'd be pretty hard to show an anterior approach through a fairly small incision to a trainee and then be confident they're doing it well without you looking over their shoulder.
• 15:37
  Jit Balakumar: But now we've got six surgeons in one of the public hospitals I work at who do anterior.
• 15:42
  Jit Balakumar: So it's slowly changing, I would say, and I think the best thing is it's happening organically.
• 15:48
  Joseph M. Schwab: I know you, you had mentioned spending time with Dr.
• 15:51
  Joseph M. Schwab: Matta and I've had extensive conversations with Dr.
• 15:54
  Joseph M. Schwab: Matta about this concept of, is it the marketing or is it the market?
• 15:58
  Joseph M. Schwab: And he has always, held the belief or he's expressed the belief to me anyway, that approaches, or, surgical advancements that rely simply on marketing have a tendency to fall apart if they're not, worthwhile surgical approaches, whereas something like the anterior approach has really benefited from the market deciding it's what it wants and, and people being able to deliver a good quality product based on that, or in this case, a good quality surgery based on that.
• 16:33
  Joseph M. Schwab: Join me next week for part two of examining the anterior approach from down under.
• 16:38
  Joseph M. Schwab: I'll return with my guests, Patrick Weinrauch, Jit Balakumar, Ilan Fredman, and Joe Scerri.
• 16:45
  Joseph M. Schwab: You can check our show notes for information about each of their practices, and don't forget to like, and subscribe so we can keep this type of content coming.
• 16:53
  Joseph M. Schwab: Until next week, this is Joe Schwab reminding you to keep those hips happy and healthy.