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Operation FUBAR: I Bet You Can't Do That! · AHF Podcast

• 0:00
  Joseph M. Schwab: Hi, today's episode is another visual one, so I'm gonna put a link to the YouTube video in the description so you can see what Dr.
• 0:09
  Joseph M. Schwab: Ben Feibel is presenting.
• 0:11
  Joseph M. Schwab: He does a really good job of explaining what he's showing, so it's not absolutely necessary to see it, but trust me, you'll probably want to see it anyway.
• 0:22
  Joseph M. Schwab: Before we get started, I wanna share something that happened after we stopped recording this episode.
• 0:28
  Joseph M. Schwab: Once the microphones were off, Ben and I kept talking for a few minutes and the conversation shifted to something quieter and honestly harder.
• 0:38
  Joseph M. Schwab: He talked about how difficult it was to put this case on display to walk through a story where things didn't go as planned, and where complications piled up.
• 0:49
  Joseph M. Schwab: Where the outcome wasn't the one he wanted for the patient or for himself.
• 0:56
  Joseph M. Schwab: Ben's a very skilled surgeon, and he's still early in his career, and I could hear how much this case weighed on him, not just technically, but emotionally.
• 1:07
  Joseph M. Schwab: One thing that's important to know about Operation FUBAR is that I don't see these cases ahead of time.
• 1:14
  Joseph M. Schwab: I come into these conversations without slides, without a roadmap, so that my reactions and the discussion itself can be as spontaneous and genuine as possible.
• 1:26
  Joseph M. Schwab: What you hear unfolding is real.
• 1:28
  Joseph M. Schwab: It's not scripted.
• 1:30
  Joseph M. Schwab: And when we stopped recording.
• 1:33
  Joseph M. Schwab: What stayed with me was how important it was for him to talk about this case anyway, how acknowledging failure and complication and limitation isn't weakness.
• 1:46
  Joseph M. Schwab: It's part of the work, and for many of us it's also cathartic.
• 1:51
  Joseph M. Schwab: I shared with him that when I was a young surgeon, I had a case that haunted me for years, a case I replayed over and over in my head wondering what I missed, what I should have done differently.
• 2:04
  Joseph M. Schwab: And I remember thinking at the time how isolating that felt like everyone else had it figured out, and I was the only one carrying that weight.
• 2:14
  Joseph M. Schwab: Hearing someone else say, I'm struggling with this too.
• 2:19
  Joseph M. Schwab: Would've mattered more than I realized back then, and that's what this series is really about.
• 2:26
  Joseph M. Schwab: Not perfect cases, not victory laps, but honesty and reflection and the shared experience of doing hard things in imperfect conditions.
• 2:39
  Joseph M. Schwab: With that in mind, let's get into today's episode of Operation FUBAR.
• 3:08
  Joseph M. Schwab: Hello, and welcome to the AHF Podcast.
• 3:10
  Joseph M. Schwab: I'm your host, Joe Schwab.
• 3:13
  Joseph M. Schwab: Welcome to episode two of Operation FUBAR, our series where experienced surgeons walk us through the cases that didn't follow the script, maybe didn't resolve cleanly, and didn't reward confidence with certainty.
• 3:29
  Joseph M. Schwab: In this episode, we're joined by Ben Feibel.
• 3:32
  Joseph M. Schwab: An adult hip and knee reconstruction specialist in Louisiana who's thoughtful, technically skilled, and most importantly for this series, honest about the emotional and professional weight of difficult cases.
• 3:46
  Joseph M. Schwab: And before we get into it, what makes this type of conversation especially valuable isn't the anatomy or the implants.
• 3:54
  Joseph M. Schwab: It's the mindset, the moment when a case stops being about what can be done and starts being about what needs to be done.
• 4:03
  Joseph M. Schwab: It's that tension between persistence and restraint, between technical possibility and judgment.
• 4:11
  Joseph M. Schwab: And at some point in every surgeon's career, someone says the words, I bet you can't do that.
• 4:17
  Joseph M. Schwab: What follows can define years of decision making.
• 4:22
  Joseph M. Schwab: I won't give away any details here, but this is a story about judgment under pressure, the limits of reconstruction and the courage it takes to acknowledge when the best outcome isn't only the one you initially set out to achieve.
• 4:38
  Joseph M. Schwab: Ben, welcome to Operation FUBAR.
• 4:43
  Ben Feibel: Glad to be here.
• 4:43
  Ben Feibel: Thank you.
• 4:45
  Joseph M. Schwab: Let's talk a little bit about your, uh, background and, um, where you're at in your practice.
• 4:52
  Ben Feibel: Yeah, so I, uh, did my medical training, uh, in Louisiana at LSU in Shreveport.
• 4:58
  Ben Feibel: Um, did my residency and my, uh, uh, medical medical training there.
• 5:03
  Ben Feibel: I went to Southern Illinois University and did my adult reconstruction fellowship there with Gordon Allen, John Horberg, who I think you've had on before.
• 5:11
  Ben Feibel: And, um, I've been practice three and a half years now.
• 5:14
  Ben Feibel: I'm the, uh, total joint surgeon, reconstruction guy, revision guy in our group, uh, multi-specialty group.
• 5:21
  Ben Feibel: But, uh, shreveport's pretty small, so get a lot of complex cases.
• 5:25
  Joseph M. Schwab: And it sounds like you're gonna be talking about one of those complex cases today.
• 5:29
  Joseph M. Schwab: Is that right?
• 5:31
  Ben Feibel: Very much, sir.
• 5:32
  Ben Feibel: When you guys reached out to me, I knew the exact case I was gonna present to you guys.
• 5:36
  Ben Feibel: So
• 5:37
  Joseph M. Schwab: Excellent.
• 5:38
  Joseph M. Schwab: Well, without further ado, why don't we bring up your case?
• 5:41
  Ben Feibel: there we go.
• 5:42
  Ben Feibel: So the title of the talk came from one of my, uh, sports partners who showed me an x-ray and.
• 5:51
  Ben Feibel: claims that I kind of said, oh yeah, that, that we need to leave that alone.
• 5:55
  Ben Feibel: And then he came back to me and he said, man, I bet you can't fix that.
• 5:58
  Ben Feibel: You bet you can't do that.
• 5:59
  Ben Feibel: And so, uh, that's where this case kind of starts, um, with this particular patient.
• 6:06
  Ben Feibel: Um, so this is a dp.
• 6:08
  Ben Feibel: He's a 66-year-old male, history of hypertension, COPD and smoking.
• 6:13
  Ben Feibel: Um.
• 6:15
  Ben Feibel: No, as you can see in the X-rays, he was a history of a Girdlestone procedure three years prior.
• 6:20
  Ben Feibel: Uh, the patient really was a poor historian, could not really give me a reason.
• 6:24
  Ben Feibel: The assumption was infection.
• 6:26
  Ben Feibel: He had had no prior arthroplasty prior to this.
• 6:29
  Joseph M. Schwab: Hmm.
• 6:30
  Ben Feibel: Um, and the prior procedure was done via the, uh, posterolateral approach, uh, at the time.
• 6:38
  Ben Feibel: Um, so there's just a AP hip there on that side, and you can see she, he's significantly shortened here.
• 6:44
  Ben Feibel: Um, and so pre-op workup, obviously I did a CBC, CRP, and ESR, all of which were normal.
• 6:50
  Ben Feibel: Um, I didn't subsequently, uh, did, uh, undergo intra articular joint aspiration, which yielded, uh, no sign of infection.
• 7:00
  Ben Feibel: So my plan for this patient was a direct anterior approach.
• 7:03
  Ben Feibel: My plan was to do a frozen section and if positive plan for antibiotic spacer, and if negative, I was gonna plan'em for an augmented cup with a diaphyseal-engaging modular stem.
• 7:12
  Ben Feibel: With his significant shortening, I did counsel the patient on possible needing for a femoral shortening osteotomy.
• 7:18
  Ben Feibel: Although with it being a Girdlestone within three years, I did feel that I would be able to proceed and, uh, get him as much to length as possible.
• 7:27
  Ben Feibel: So he obtained clearances from everybody.
• 7:30
  Ben Feibel: And so the original procedure, uh, again, was on the first of, uh, December, uh, two years ago.
• 7:38
  Ben Feibel: As you can see, he's still significantly shortened as far as hip center goes.
• 7:42
  Ben Feibel: But on the HANA table, soft tissues were very, very tight.
• 7:46
  Ben Feibel: Um, uh, when I say, uh, I had to use every trick I had, my reps were pulling significant traction to get this hip reduced.
• 7:54
  Ben Feibel: And so at the time, um, this is a 36 millimeter head that is a, uh, a, um, a cup with the, uh, augment already built in a RAAS Cup, and then that was a 19 millimeter body plus zero, and that was.
• 8:08
  Ben Feibel: As tight as we could get him at the time.
• 8:12
  Ben Feibel: Uh, surgery went well.
• 8:13
  Ben Feibel: Um, minimal blood loss.
• 8:15
  Ben Feibel: He did great.
• 8:16
  Ben Feibel: Um, and so, uh, I don't wanna jump too quick.
• 8:20
  Ben Feibel: And so he was waiting on rehab, placement was up with therapy.
• 8:23
  Ben Feibel: The guy had been in a wheelchair, uh, for, since the last procedure, so three years.
• 8:28
  Ben Feibel: So the guy was up walking a hundred feet.
• 8:31
  Ben Feibel: Did well, went to stand up, uh, again, uh, I'm not sure how it is all over the country.
• 8:35
  Ben Feibel: With his given insurance.
• 8:36
  Ben Feibel: It took him a while to get approved for rehab.
• 8:39
  Ben Feibel: And then on day seven he popped out.
• 8:42
  Joseph M. Schwab: And this was while still in the hospital
• 8:44
  Ben Feibel: He was waiting on rehab placement.
• 8:45
  Ben Feibel: Yes, sir.
• 8:46
  Ben Feibel: So obviously what I concluded was that he, you know, was stretching the soft tissues out his abductors.
• 8:53
  Ben Feibel: Everything was beginning to stretch out and so I said, okay, uh, not ideal, but we took him back for revision surgery with plan to lengthen him, increase his offset, and try to get him restored to natural hip center and everything.
• 9:06
  Ben Feibel: So it took him to surgery again, lengthened him out.
• 9:09
  Ben Feibel: At this point I went to a 21 millimeter plus.
• 9:14
  Ben Feibel: 21, 21 millimeter body and a plus eight head.
• 9:17
  Ben Feibel: So we were able to lengthen amount some more, and again, still very, very tight and, uh, was pleased with where we were.
• 9:24
  Ben Feibel: I mean, we're not perfect by any means, but we're getting there.
• 9:27
  Ben Feibel: And my hope was, you know, this would be where he settled.
• 9:30
  Ben Feibel: Um, and so he was discharged and came back on the 16th.
• 9:36
  Ben Feibel: So he is lasting about a week at this point.
• 9:39
  Ben Feibel: Um, and he dislocated again, again, I went to dual mobility, uh, on that last case as well when I, um, revised him, due to his poor soft tissue envelope and he dislocated again.
• 9:51
  Ben Feibel: Um, again, uh, it's always happened when I was not on call and typically happened on a weekend, um, as usual as these go.
• 9:59
  Ben Feibel: Um, and so I came in on a weekend and revised him yet again.
• 10:05
  Ben Feibel: This was him on 1217.
• 10:07
  Ben Feibel: Again, you can see we're.
• 10:08
  Ben Feibel: Still continuing to increase his length.
• 10:10
  Ben Feibel: He has a, uh, 21 proximal body with a plus 20 body in there with a plus three head.
• 10:16
  Ben Feibel: So we're gaining length with our, our proximal body without maxing out our head.
• 10:21
  Ben Feibel: So I was pleased there, knowing in the back of my mind, we are slowly approaching, you know, our maximum with this type of stem.
• 10:29
  Joseph M. Schwab: And you're keeping the same, the same distal diaphyseal fitting portion of the stem in.
• 10:34
  Joseph M. Schwab: Right.
• 10:35
  Ben Feibel: yeah.
• 10:36
  Ben Feibel: From case one, when I tell you that part of the case, that bit the, the diaphyseal stem bit and did not wanna come out, I tried to take it out on this, the second case and the third case.
• 10:47
  Joseph M. Schwab: Oh, wow.
• 10:47
  Ben Feibel: And it was, uh, not wanting to come out and I tried every trick ex next to an ETO, the guy, um, you know, it was a lot of education for this guy.
• 10:55
  Ben Feibel: Um.
• 10:57
  Ben Feibel: Uh, you know, being an anterior surgeon, we pride ourselves on dislocations, and this was my first dislocation I've had, of course.
• 11:05
  Ben Feibel: And,
• 11:06
  Joseph M. Schwab: Sounds like it was your first, second, and third.
• 11:10
  Ben Feibel: it was exactly, and, um, you know, I, at this point I was about a year and a half into practice and so, um, you know, trying to explain to him the reasons why and those kind of things were difficult.
• 11:21
  Ben Feibel: And so again, this was on 1217.
• 11:25
  Ben Feibel: He discharged, went to rehab, came back and saw me on the 4th of January, and clinic still looked just like this was stable as you removed all was doing well, he was then transferred to home with home health and comes back on the 13th.
• 11:42
  Ben Feibel: This is what he looks like.
• 11:45
  Ben Feibel: And so, um, again, starting to get very concerned at this point, he is not draining.
• 11:49
  Ben Feibel: The incision has healed well, uh, despite, you know, multiple surgeries in a very short time.
• 11:55
  Ben Feibel: And took him back.
• 11:57
  Ben Feibel: And this was on the 15th and this was the most pleased I was with the entire of the process.
• 12:03
  Ben Feibel: I was like, okay, we've got him anatomic, we've restored his hip center.
• 12:08
  Ben Feibel: And I felt at this point we've got him to the point where I feel this is where he wants to be.
• 12:13
  Ben Feibel: And I felt very confident at this point.
• 12:16
  Ben Feibel: Um.
• 12:17
  Ben Feibel: It then followed me back up, uh, two more times.
• 12:20
  Ben Feibel: I saw him, uh, 10 days later, then subsequently two weeks later was doing great.
• 12:25
  Ben Feibel: Uh, no troubles was walking, not much, but walking some.
• 12:30
  Ben Feibel: This was still interop here.
• 12:33
  Ben Feibel: Um, and this was, excuse me, this was immediate post-op right here, uh, from that last case there.
• 12:39
  Ben Feibel: Pretty tight.
• 12:40
  Ben Feibel: I, I was pleased with where we were, um, thought finally we were able to get him restored.
• 12:45
  Ben Feibel: And again, of note this last feature, he was at a 23 proximal body that was plus 30 and a plus eight head.
• 12:52
  Ben Feibel: So I'm now maxed out everything that I had this or as proximal body goes.
• 12:58
  Joseph M. Schwab: the same cup that you put in in the first procedure?
• 13:02
  Ben Feibel: Yes.
• 13:03
  Ben Feibel: Cup has been great.
• 13:04
  Ben Feibel: Cup Cup was the easiest part of the whole case.
• 13:06
  Ben Feibel: And so that, and it went nothing issue there.
• 13:09
  Ben Feibel: And so because of, if I went back, you could see, because he had some, you know, some changes proximally and superiorly in that, his native hip socket.
• 13:18
  Ben Feibel: I, I, that's why I went with this augment and I'll talk about it in a minute.
• 13:21
  Ben Feibel: You know, I think it partly was the difficulty and the reduction, uh, going forwards.
• 13:28
  Ben Feibel: Um.
• 13:29
  Ben Feibel: Then he comes back on the 21st, uh, of February.
• 13:34
  Ben Feibel: And the wound's now draining.
• 13:36
  Ben Feibel: Uh, serous drainage labs are elevated, but he did have recent surgery at this point.
• 13:41
  Ben Feibel: We had to have a tough conversation.
• 13:43
  Ben Feibel: Um, the patient states he was tired of having surgery, um, didn't want anything else done, but wanted this, whatever we did.
• 13:50
  Ben Feibel: Going further to be the last thing, and I, I discussed with him in great length.
• 13:54
  Ben Feibel: I said, I can't guarantee that you know.
• 13:57
  Ben Feibel: I'll be able to guarantee him no dislocations.
• 14:00
  Ben Feibel: I can't guarantee anything.
• 14:01
  Ben Feibel: You know, at this point, the soft tissue envelope around the hip was becoming more tenuous with every time I went in there.
• 14:08
  Ben Feibel: And so after lengthy discussion, um, we made the decision to basically restore him back to what he had.
• 14:17
  Ben Feibel: So I basically took everything out.
• 14:19
  Ben Feibel: Um, and he still currently sits with a Girdlestone procedure.
• 14:23
  Ben Feibel: Um, I was able to.
• 14:24
  Ben Feibel: Subsequently get him back, you know, get all the, the implants out and, uh, we cleared the infection, antibiotic beads, those kind of things.
• 14:33
  Ben Feibel: And so currently the patient's back to where we started, um, it was a big learning case for me.
• 14:39
  Ben Feibel: Um, uh, of course, me being the young gung-ho surgeon, I wanted to keep going and see if I could, you know, restore him and get him back.
• 14:47
  Ben Feibel: You know, whether it's ego, whether it's, you know, me wanting the best for my patients or a combination of both.
• 14:53
  Ben Feibel: Uh, that was.
• 14:54
  Ben Feibel: That was the issue.
• 14:55
  Ben Feibel: Um, followed him up several times.
• 14:57
  Ben Feibel: We discussed, you know, where we were and he was fine going back, back to how he was just with another incision.
• 15:04
  Ben Feibel: Um, again, difficult for me to do, um, in my particular practice and how I was trained.
• 15:11
  Ben Feibel: Um, but it was a big learning curve, you know, basically, you know, I was unable to appropriately, I guess, um.
• 15:24
  Ben Feibel: Make the assumption of how much his soft tissues were gonna stretch out, and with that slow stretching out of his abductors and all the tissues, of course there was quite a bit of scar excision on the index case.
• 15:34
  Ben Feibel: Um, and then subsequently thereafter.
• 15:36
  Ben Feibel: Um, the second thing was because he did walk, but he spent a lot of time in his wheelchair.
• 15:40
  Ben Feibel: He stayed in a kind of an ally rotated position.
• 15:42
  Ben Feibel: I even had him in a hip orthosis after the final procedure, which I've not had to do before or after since that time with an anterior approach.
• 15:51
  Ben Feibel: Um, trying to keep him from doing that.
• 15:54
  Ben Feibel: And the only thing I can think of, you know, the way he was sitting was constantly levering on that proximal body because on the last procedure when I did explanting that the stem, the proximal body was still had some micro motion in there.
• 16:10
  Ben Feibel: And I, I could never ascertain and, you know.
• 16:14
  Ben Feibel: The, the, uh, I, I'll call it the warrior in me or whatever, wanted to keep going and try to get it better, but the patient just said, man, I just, I can't keep doing this.
• 16:23
  Ben Feibel: And I said, I understand.
• 16:24
  Ben Feibel: And so, uh, we cleared his infection and he is back where we started.
• 16:28
  Ben Feibel: So we basically did, you know, four surgeries and did not necessarily make him better.
• 16:33
  Joseph M. Schwab: well let's talk about this a little bit'cause I, I have a few questions and I, I want to start off with some of the technical aspects of this from your perspective.
• 16:41
  Joseph M. Schwab: So you, you showed us a nice, um, uh, set of, of plain radiographs, kind of documenting everything that happened to him.
• 16:49
  Joseph M. Schwab: Did he get any additional advanced imaging when some of the complications started occurring?
• 16:55
  Joseph M. Schwab: Or was it something that you felt comfortable evaluating intraoperatively.
• 17:01
  Ben Feibel: I did get a preoperative CT just to evaluate his.
• 17:05
  Ben Feibel: I wanted to really get a better look at his cup.
• 17:07
  Ben Feibel: Um,'cause I was actually as much worried about the socket as I was the femoral stem, because just with him sitting out with a Girdlestone, you know, rubbing, you know, on that superolateral aspect, I wanted to make sure I had enough bone stock, which I did.
• 17:20
  Ben Feibel: I mean, I had, you know, I had cup cages there, I had, you know, everything at our disposal if needed.
• 17:25
  Ben Feibel: It didn't need it, I wanted to bring his hip center back to native in the socket because I knew with that cup I could do that.
• 17:32
  Ben Feibel: And so that's where I started.
• 17:33
  Ben Feibel: And then, yeah, I believe that case between two and three, I did CT scanning just to make sure nothing was being missed.
• 17:40
  Ben Feibel: Was there a breach, was there a fracture?
• 17:42
  Ben Feibel: None of those things either there.
• 17:43
  Ben Feibel: Um, and so yeah, I did get c uh, CT before the index procedure and then between case two and three
• 17:51
  Joseph M. Schwab: And, and no concern about, um, about cup anteversion, cup inclination, anything like that based on the CT between two and three.
• 18:01
  Ben Feibel: No, I did use the ma, I did use the Mako c Mako, uh, robot for the cup and, and, um, you know, I did make a few changes here and there, and I was very pleased with my cup placement.
• 18:12
  Ben Feibel: You know, I, I tend to, on these, you know, I don't abide by the 40 20 year rule.
• 18:17
  Ben Feibel: Uh, with that a hundred percent, I may under antevert a little bit with that known problem.
• 18:23
  Ben Feibel: Um, with that, and I like, I think he was probably 40 15, if I mean correctly, is what I'm putting in that,
• 18:29
  Joseph M. Schwab: So, so you were using Mako for this or you were using robotic navigation?
• 18:32
  Joseph M. Schwab: Some sort of, uh, it sounds like,
• 18:34
  Ben Feibel: for the, yeah, for, for the index case?
• 18:36
  Ben Feibel: Yes, sir.
• 18:36
  Ben Feibel: I
• 18:37
  Joseph M. Schwab: for the index case, and that's what you're doing for most of your primary total hips.
• 18:41
  Joseph M. Schwab: Is that correct?
• 18:42
  Ben Feibel: Most, yeah.
• 18:43
  Ben Feibel: Probably 70, 80%.
• 18:44
  Ben Feibel: Yes, sir.
• 18:45
  Joseph M. Schwab: And in this particular case, was there a reason that it didn't fall in the 20 to 30% that you don't use it?
• 18:52
  Joseph M. Schwab: Is this, is this a case that you would specifically indicate using robotics for, or what was the thought process there?
• 18:59
  Ben Feibel: Um, uh, because I use it a lot at this, the given hospital I was using yet, and that my workflow with my team, um, I felt that it was appropriate, you know, I was dealing with so much scar.
• 19:10
  Ben Feibel: I was concerned too about using, you know, doing a manual cup about, you know, being able to, I don't wanna say able to see, but taking down so much soft tissue for a manual cup with the robot with me, able to dial anything in.
• 19:22
  Ben Feibel: I felt the, it was, it was advantageous to do that.
• 19:26
  Joseph M. Schwab: Yeah, and so a couple.
• 19:28
  Joseph M. Schwab: Of questions as a sort of, as a young surgeon who's taking on a complicated case, wants to feel, uh, you know, you, you kind of talked about the warrior attitude and things like that.
• 19:39
  Joseph M. Schwab: And you want, you want to be out there proving yourself and taking on the hard cases.
• 19:43
  Joseph M. Schwab: Um, when you get to.
• 19:46
  Joseph M. Schwab: Not the first revision, which one could maybe even anticipate, right?
• 19:50
  Joseph M. Schwab: That this is gonna be a complicated, uh, uh, follow up story, but when you get to the second revision, do you start thinking any differently or, you know, walk me through your sort of mental process as the, the, uh, we'll, we'll say complications continue piling up.
• 20:09
  Ben Feibel: Yeah.
• 20:10
  Ben Feibel: Um, so I have, I'm the only, uh, in my group, I'm the only anterior based surgeon.
• 20:15
  Ben Feibel: Um, As far as workflow and plan, you know, I, I, my older partner agreed.
• 20:21
  Ben Feibel: He said, I think that, you know, you're doing the right thing.
• 20:23
  Ben Feibel: I think you're just continuing, he's continuing to stretch out.
• 20:25
  Ben Feibel: And again, the frustrating part for me was, although it took, you know, four procedures to get there, I, I finally thought that I'd gotten him right where I wanted it.
• 20:36
  Ben Feibel: And that was the part that was the most humbling and frustrating at the same time, uh, was that, and um, and so, um, yeah.
• 20:46
  Ben Feibel: And so at that point, you know, I think I would've, number one, probably asked for more help versus, you know, I, I'm, I don't transfer stuff out.
• 20:55
  Ben Feibel: I don't, I would've trained that way.
• 20:56
  Ben Feibel: Um, you know.
• 20:58
  Ben Feibel: But, um, I just, I was to the point and the patient kind of made that decision that he was done and tired of doing it.
• 21:04
  Ben Feibel: And so that was, that was the frustrating part.
• 21:07
  Ben Feibel: You know, I understand his wishes and I respected it, but that was the, the difficult part.
• 21:12
  Ben Feibel: So.
• 21:13
  Joseph M. Schwab: Well, and let's talk a little bit too about, um, you know, when you get to that point with the patient where you've got a plan for, you know, now we're on, we're on step four, we're on step five, we're on step six.
• 21:26
  Joseph M. Schwab: And, and you, you continue to have things in your arsenal.
• 21:29
  Joseph M. Schwab: Um, how do you, uh, how do you sort of structure a conversation with a patient where, um, maybe you feel like there's still life left in what you want to do and the patient is, um, expressing concern about going forward for whatever reason?
• 21:47
  Ben Feibel: Yeah, I mean the, the, the delineating factor I think for him and somewhat for me was when he began to drain, um, with the concern for infection.
• 21:57
  Ben Feibel: Because when I explained to him the process in which with, for him, I would probably would've gone with the two stage, you know, revision on him because of his, you know, soft tissue envelope and the amount of procedures we had done.
• 22:11
  Ben Feibel: I, I, I, when I explained those things, he finally said, doc, I'm, I'm just, I'm done.
• 22:18
  Ben Feibel: And, and I said, I respect that.
• 22:20
  Ben Feibel: And I kind of told him, I said, we're basically gonna put you back just like you were, as long as you understand that.
• 22:25
  Ben Feibel: And I think that was the only, I guess, positive thing is it wasn't like you were taking someone that was somewhat ambulatory and who was functional.
• 22:37
  Ben Feibel: Um.
• 22:38
  Ben Feibel: You're putting him right back where he was opposed to him.
• 22:40
  Ben Feibel: If he, he had had a native hip in, he had gong down this road.
• 22:43
  Ben Feibel: I guess that was somewhat helpful and that was what he said himself is like, doc, I'll just go back like I was at MK, um, although very tough.
• 22:52
  Ben Feibel: That was a hard feel for me to swallow, uh, to be quite frank, you know.
• 22:57
  Joseph M. Schwab: And so when that next Girdlestone comes into your office, uh, how, how are you gonna approach it?
• 23:02
  Joseph M. Schwab: What are you gonna do differently?
• 23:04
  Joseph M. Schwab: What are you, how are you gonna counsel the patient?
• 23:06
  Joseph M. Schwab: And, and, uh, how does this look the next time around?
• 23:10
  Ben Feibel: Yeah, and I've had several others since then.
• 23:12
  Ben Feibel: Um, and they've done okay.
• 23:13
  Ben Feibel: They've done great and, um, you know, one procedure and we, you know, and they're over a year out and I haven't had trouble and so far, um.
• 23:23
  Ben Feibel: So I think it's just, you just learn what's just about one of the worst things that could happen with these multiple surgeries in such a short time.
• 23:31
  Ben Feibel: It'd be different if it was, you know, three or four months at a time.
• 23:35
  Ben Feibel: I could almost stomach that a little bit better.
• 23:37
  Ben Feibel: But as far as it being such a close timeframe, the index case was 12 one, but the final case, uh, on, you know, 12, 22 21.
• 23:47
  Ben Feibel: So over a three month period.
• 23:49
  Ben Feibel: He had all these surgeries and that was the part that was difficult.
• 23:52
  Ben Feibel: I think it's just counseling patients knowing what could happen.
• 23:55
  Ben Feibel: Um, I think in the south, at least, you know, referencing not people by name, but referencing, Hey, I've had this case before.
• 24:01
  Ben Feibel: This is what happened.
• 24:02
  Ben Feibel: And I'm a very candid, open person.
• 24:04
  Ben Feibel: I don't paint a, uh, I paint a real picture for people.
• 24:08
  Ben Feibel: Not so much a, I don't wanna, you know, give them too much hope, but I want them to understand the reality, you know,
• 24:13
  Joseph M. Schwab: How much do you think the original reason for his Girdlestone came into play in this case?
• 24:20
  Joseph M. Schwab: It's, that's such a unknown area.
• 24:23
  Joseph M. Schwab: Um, were there aspects of that that you think were contributing or not so much?
• 24:29
  Ben Feibel: I think it's a little bit of both.
• 24:31
  Ben Feibel: I think, um, you know, I, I was trying to find out, you know, Louisiana's not a very large, you know, it's a pretty good, tight-knit community of orthopedists.
• 24:40
  Ben Feibel: I knew it was done two hours south of us.
• 24:42
  Ben Feibel: Um, and he thought he knew who had done it.
• 24:46
  Ben Feibel: And I actually reached out to that guy and kind of discussed, I looked through all the EMRs trying to find some reason, and uh, the guy that I spoke to didn't even remember the case to be quite frank with you.
• 24:57
  Ben Feibel: Um, and so I said, okay.
• 24:59
  Ben Feibel: Um, and so I think that was one, two, I think having to do with his, um.
• 25:08
  Ben Feibel: How he, his positioning and how he set, I think the man set with his leg rotated at all times.
• 25:14
  Ben Feibel: Shortened, uh, definitely didn't help.
• 25:16
  Ben Feibel: He wasn't as much of a, um, he wasn't, I've seen Girdlestones to be a lot more functional than he was pre-op, but I do think that planning wall as well, so.
• 25:26
  Joseph M. Schwab: In your preop, that actually raises another question.
• 25:28
  Joseph M. Schwab: So, in your preoperative imaging when you ctd, were you able to assess some of the, uh, quality of, um, you know, the surrounding musculature, the, the abductors, the short external rotators?
• 25:42
  Ben Feibel: A little bit.
• 25:42
  Ben Feibel: Yes.
• 25:43
  Ben Feibel: I mean, um, you see somewhat, I mean, he still had abductors, um, but when I, you know, when I delivered the femur during the procedure, I mean he, um, you know.
• 25:55
  Ben Feibel: There was plenty of abductor there at the time of surgery going into it, you know, um, I'm obviously not anti dual mobility as you can see, but at the time, I mean,'cause that I stress all these interop, you know, I, I had my own little, you know, algorithm of, of stressing, you know, for stability and, and he passed all the, that was another frustrating part.
• 26:15
  Ben Feibel: You know, I brought him to ninety degrees and bone hooked him straight, you know, vertical and could not, you know, without any tracks, he could not dislocate the hip.
• 26:23
  Ben Feibel: So, um, there was a lot of soft tissue in the prior Girdlestone bed and along the shoulder of the, uh, of the femur that, you know, I had to take down.
• 26:33
  Ben Feibel: But it didn't seem to be, it, it was all, uh, you know, scar more than anything else you.
• 26:38
  Joseph M. Schwab: Hmm.
• 26:40
  Joseph M. Schwab: So you've touched on this a little bit, but the, the other question I have for you is, um, is really about the patient's perspective at the end, and you said the patient obviously didn't want any further surgery, seemed to be okay with going back to his, you know, sort of essentially his initial state.
• 26:58
  Joseph M. Schwab: And the question I would have for you is, did you get the impression that he was happy that you.
• 27:06
  Joseph M. Schwab: Tried or was he upset at the result?
• 27:10
  Joseph M. Schwab: And maybe, maybe you have some insight into that or maybe you don't.
• 27:14
  Ben Feibel: Oh I do.
• 27:15
  Ben Feibel: Um, you know, I will say I felt like I did a good job.
• 27:20
  Ben Feibel: Before the index case of painting the picture of what could happen.
• 27:24
  Ben Feibel: And he told me, he said, doc, I want you to try it.
• 27:27
  Ben Feibel: And I, and knowing that in the back of my head that he said that was helpful, um, and, you know, and that I actually referenced that conversation when you had the, the explant conversation.
• 27:40
  Ben Feibel: Um, and he said, doc, we tried and he was not upset.
• 27:43
  Ben Feibel: I mean, he.
• 27:44
  Ben Feibel: I think I would've been, uh, and at the same I per, as a patient, knowing what I know, I would've been upset.
• 27:51
  Ben Feibel: But at the same time, he said, doc, I've been this way for three years.
• 27:54
  Ben Feibel: And so, oddly enough, and I've seen him subsequently since then, you know, intermittently for different things.
• 27:59
  Ben Feibel: And, um, he's got, he's, he's doing, he's okay.
• 28:04
  Ben Feibel: And, um, so I do have insight there, you know, but I think having that conversation, documenting that conversation well on the onset, I think was.
• 28:14
  Ben Feibel: Was a, was a, was a big thing.
• 28:16
  Joseph M. Schwab: Does his response or maybe his, we'll, we'll say for lack of a better term, his satisfaction with what you tried to do for him.
• 28:25
  Joseph M. Schwab: Um, was it, is that surprising to you or is it something you would expect, or how do you think about that?
• 28:33
  Ben Feibel: Uh, I mean that's twofold.
• 28:35
  Ben Feibel: I mean, with him being okay with it, despite all the procedures, number one, number two, uh, you know, the state of Louisiana, no.
• 28:42
  Ben Feibel: He didn't sue me.
• 28:43
  Ben Feibel: That's nice too.
• 28:45
  Ben Feibel: Um, you know, which was good.
• 28:47
  Ben Feibel: Uh, but at the same time it just, it was surprising.
• 28:52
  Ben Feibel: I, I was not prepared for, he came to me when I saw him that last time before the last procedure, and he just, he said, I, I just can't keep doing this.
• 29:04
  Ben Feibel: And I said, I understand.
• 29:06
  Ben Feibel: I told him about, I said, I just wanted him to make sure he understood that I'm not gonna ever get you in, get you back to walking.
• 29:12
  Ben Feibel: Which the other frustrating factor was the guy got up and walked.
• 29:15
  Ben Feibel: I mean, he walked, uh, I wanna say I looked at the PT notes, uh, yesterday when I was reviewing for this.
• 29:20
  Ben Feibel: And I mean, he walked 150, 200 feet, like day two or three after his first surgery.
• 29:26
  Ben Feibel: And so that was the other part that was hard for me as a physician and a surgeon was we, we did it.
• 29:33
  Ben Feibel: You know, we got him, we got him.
• 29:35
  Ben Feibel: My joke was we got him vertical and got him walking and uh, and for to lose that was harder for me, I think, than it was for, you know, you know.
• 29:42
  Joseph M. Schwab: interesting.
• 29:43
  Joseph M. Schwab: Interesting.
• 29:44
  Joseph M. Schwab: Um, so you do still get to see him occasionally it sounds like, for other, other issues.
• 29:49
  Joseph M. Schwab: Is that
• 29:49
  Ben Feibel: yeah.
• 29:50
  Ben Feibel: I, I mean, I think I've injected his shoulder a time or two and, uh, you know, that same partner that told me that he, he did a reverse total shoulder on him and it's actually dislocated several times and he's a very good surgeon and he hasn't had any issues so.
• 30:02
  Ben Feibel: It's one of those things, it's kind of a, you know, he's just one of those guys and, and, uh, we take care of him when he needs us, but he, um, was doing okay.
• 30:11
  Joseph M. Schwab: My goodness.
• 30:12
  Joseph M. Schwab: Well, I, I'm sure he's, uh, I'm sure he is thankful to have a group of surgeons who are looking after him, but it sounds like, uh, he, he's one of those albatrosses that can hang around a surgeon's neck for a long period of time.
• 30:24
  Joseph M. Schwab: I.
• 30:25
  Ben Feibel: Yeah.
• 30:25
  Ben Feibel: Uh, I'm not upset.
• 30:26
  Ben Feibel: It wasn't in my board collection period.
• 30:31
  Joseph M. Schwab: Um, well Ben, I really appreciate you sharing this case.
• 30:35
  Joseph M. Schwab: And, um, and the next time somebody tells you, uh, I bet you can't do that, are you gonna be thinking about this case?
• 30:43
  Ben Feibel: Oh, a hundred percent.
• 30:44
  Ben Feibel: And, uh, and, and I, uh, I, I will, and not just with, with this kind of particular case, but any case that's, uh, that, that, that has been said to me, uh, going forward since that time, I, I'll never forget it, so.
• 30:58
  Joseph M. Schwab: Well, thank you for sharing this case.
• 31:00
  Joseph M. Schwab: Thank you for sharing it, um, with our listeners and thank you for, for being on, uh, Operation FUBAR on the AHF podcast.
• 31:09
  Ben Feibel: No, thank you guys so much for having me.
• 31:11
  Joseph M. Schwab: Thank you for joining me for this episode of the AHF podcast.
• 31:16
  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.
• 31:30
  Joseph M. Schwab: All one word, episodes of the AHF podcast come out on Fridays.
• 31:35
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy.
• 31:40
  Joseph M. Schwab: Healthy and maybe free of Girdlestones.