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2025 Great Debates: Obesity does not need to be optimized prior to Anterior Approach · AHF Podcast

• 0:00
  Joseph M. Schwab: Hi, this is Joe Schwab and if you recognize my voice, it's probably because you've heard another episode of the AHF podcast, which means you're listening again, and I can't tell you how much I appreciate that.
• 0:15
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• 0:41
  Joseph M. Schwab: Anyway, thank you so much for being a listener and a subscriber to the AHF podcast.
• 0:47
  Joseph M. Schwab: Now let's get on with the show.
• 1:05
  Welcome to the AHF podcast.
• 1:07
  I'm your host, Joe Schwab.
• 1:10
  I've said it before and I'll say it again.
• 1:13
  One of the reasons we host these great debates is because surgeons are at their best when they disagree passionately.
• 1:20
  I.
• 1:21
  At their funniest when props start coming out during the opening statement.
• 1:26
  Today's topic is one of those questions every hip surgeon wrestles with, do we really need to optimize obesity?
• 1:34
  Before an anterior hip replacement, the pro position is Dr.
• 1:38
  Nicholas Webber, a tumor surgeon, an anterior approach convert, and a self-described quote.
• 1:45
  "immensivist" and apparently proud owner of an alpaca named after me.
• 1:51
  I didn't know this before the debate, and I'm still kind of processing that.
• 1:56
  Opposing him is Dr.
• 1:57
  Todd Kelley, who heard no slides and decided that meant yes, props, including but not limited to pants, coins, a fake pannus, and a demonstration that I think will live in AHF history.
• 2:14
  If you've ever wondered what happens when serious surgical philosophy meets a kindergarten pep talk about doing hard things.
• 2:23
  This debate is your answer.
• 2:26
  Let's get into it.
• 2:29
  Joseph M. Schwab: I'd like to call to the stage Dr.
• 2:31
  Joseph M. Schwab: Nicholas Webber and Dr.
• 2:35
  Joseph M. Schwab: Todd Kelley, who has come with some props.
• 2:38
  Todd Kelley: You said No slides.
• 2:39
  Todd Kelley: No
• 2:39
  Joseph M. Schwab: slides, but I didn't say anything about no props.
• 2:42
  Joseph M. Schwab: Alright, position statement:"Obesity..." this is like a double negative kind of thing.
• 2:48
  Joseph M. Schwab: "Obesity does not need to be optimized prior to anterior approach." The pro position, Dr.
• 2:54
  Joseph M. Schwab: Nicholas Webber likes some big right, likes some big, that's that's what you're saying.
• 2:59
  Joseph M. Schwab: And Charlie.
• 3:00
  Joseph M. Schwab: Okay.
• 3:00
  Joseph M. Schwab: And the con position, uh, Dr.
• 3:03
  Joseph M. Schwab: Todd Kelley, Dr.
• 3:05
  Joseph M. Schwab: Webber,
• 3:06
  Nicholas Webber: you guys don't know me, so I'm gonna tell you about my journey a bit while I'm telling you about that, because you may not care.
• 3:13
  Nicholas Webber: I want you to think of.
• 3:15
  Nicholas Webber: Your three most appreciative patients, the one that brought you the most tamales, the one that brought you the most chocolate chip cookies, the one that gave you the biggest fluffiest hug you've ever had in your life.
• 3:29
  Nicholas Webber: Think of those, and I'm gonna introduce myself.
• 3:33
  Nicholas Webber: I'm a tumor surgeon.
• 3:34
  Nicholas Webber: Uh.
• 3:35
  Nicholas Webber: I started doing joint replacement when I started a tumor program at a, a big hospital.
• 3:40
  Nicholas Webber: And of course, he imported me from Wisconsin to give this talk just to kind of poke more at Wisconsin.
• 3:45
  Nicholas Webber: Um, when you start a sarcoma program, everything's a tumor.
• 3:51
  Nicholas Webber: 160 pound pannus tumor, a butt that's dragging behind in a wheelchair tumor, absolutely perfectly fine.
• 3:59
  Nicholas Webber: Every older partner I had called me the immensivist.
• 4:03
  Nicholas Webber: Perfectly fine being the immensivist.
• 4:05
  Nicholas Webber: So when I got to starting my practice, I said, okay, I'm gonna do everything.
• 4:11
  Nicholas Webber: That's what everybody says.
• 4:13
  Nicholas Webber: And I did everything.
• 4:14
  Nicholas Webber: So part of everything is doing everything that people don't want to do.
• 4:20
  Nicholas Webber: For 15 years, I became this end of the road type of surgeon, all posterior for 10 years.
• 4:26
  Nicholas Webber: So I've been there.
• 4:28
  Nicholas Webber: Uh, Ben Domb came and gave a talk, uh, at Aurora and said.
• 4:32
  Nicholas Webber: There are all these outliers in the posterior approach.
• 4:34
  Nicholas Webber: I stood up and said, you don't do anyone with A BMI under 25, or excuse me, over 25.
• 4:41
  Nicholas Webber: He said, absolutely, yes I do.
• 4:43
  Nicholas Webber: I made all these excuses for doing the anterior approach three times.
• 4:46
  Nicholas Webber: I tried to do the anterior approach in my patient population, which is A BMI of who knows, and I'll tell you a little bit about that the first time.
• 4:55
  Nicholas Webber: Blood bath.
• 4:56
  Nicholas Webber: I don't know what I'm doing.
• 4:57
  Nicholas Webber: Why am I a tumor surgeon doing something that's so difficult?
• 5:00
  Nicholas Webber: Second time, okay, I'll do this.
• 5:02
  Nicholas Webber: I stayed up all night thinking my of my anterior approach the next day and I said, why did I think about that?
• 5:07
  Nicholas Webber: And my osteosarcoma resection, I didn't think about, forget it.
• 5:13
  Nicholas Webber: My one kind of take home to those of you who are posterior surgeons, have someone come and visit you, teach you how to do an anterior approach.
• 5:19
  Nicholas Webber: Someone did that to me, changed my life and I'm gonna really get into things.
• 5:23
  Nicholas Webber: I have an alpaca at home named Joe Schwab, not necessarily'cause Joe Schwab helped me do that, but he may have.
• 5:30
  Nicholas Webber: So to the question, I don't know if you have a kindergartner in kindergarten, they say, can you do hard things?
• 5:38
  Nicholas Webber: I changed from being a pure orthopedic surgeon to a dad, and I want my kids to know you can do hard things.
• 5:46
  Nicholas Webber: We have more and more literature saying yes, there are still complications with.
• 5:51
  Nicholas Webber: Obese patients, however, is their patient satisfaction the same?
• 5:56
  Nicholas Webber: Yes.
• 5:56
  Nicholas Webber: Is it better?
• 5:57
  Nicholas Webber: Maybe not.
• 5:58
  Nicholas Webber: Do we have problems with incisions?
• 6:00
  Nicholas Webber: Absolutely.
• 6:02
  Nicholas Webber: Do we have problems with incisions in little old ladies who have really thin skin?
• 6:05
  Nicholas Webber: Do we have problems in women who have had C-sections?
• 6:09
  Nicholas Webber: A hundred percent there are problems.
• 6:11
  Nicholas Webber: Is that a reason to say obesity needs to be optimized?
• 6:14
  Nicholas Webber: What does that even mean?
• 6:15
  Nicholas Webber: Think of A BMI of 37, big strong construction worker.
• 6:19
  Nicholas Webber: Think of a BMI of 47, someone whose belly you can tape to the side do a perfect approach.
• 6:26
  Nicholas Webber: I don't have a problem doing any of that.
• 6:30
  Nicholas Webber: We can change their BMI, we can change all the controllable factors, but in real life, does it need to be optimized?
• 6:37
  Nicholas Webber: The answer is no.
• 6:39
  Nicholas Webber: And Dr.
• 6:40
  Nicholas Webber: Kelley, you and your kids, they can do hard things.
• 6:44
  Joseph M. Schwab: Four minutes.
• 6:46
  Todd Kelley: Alright, sir, we're going South side Chicago on you here.
• 6:50
  Todd Kelley: Right here.
• 6:50
  Todd Kelley: Right here.
• 6:51
  Todd Kelley: Alright.
• 6:52
  Todd Kelley: Tell a little story first.
• 6:54
  Todd Kelley: Medical College of Wisconsin.
• 6:55
  Todd Kelley: I'm on an interview for residency.
• 6:58
  Todd Kelley: Interviewer asks me, hands me a sack of coins, says, reach in there, count up, tally up those coins.
• 7:04
  Todd Kelley: I say All, all right, start doing it.
• 7:07
  Todd Kelley: And uh, the idea is, okay, you gotta figure out what you're doing with your hands.
• 7:10
  Todd Kelley: You've gotta communicate, you gotta think all at the same time.
• 7:13
  Todd Kelley: So I'm gonna challenge you to, let's do this anterior style.
• 7:18
  Todd Kelley: Come on over here.
• 7:20
  Todd Kelley: These are my pants.
• 7:21
  Todd Kelley: They're, they're relatively clean.
• 7:22
  Todd Kelley: I want you to reach in my front pocket there and count up those coins and tally'em up.
• 7:27
  Todd Kelley: And let's see what you get.
• 7:28
  Todd Kelley: Now all you guys are thinking, where's he going with this?
• 7:30
  Todd Kelley: Right?
• 7:30
  Todd Kelley: No, no, no.
• 7:31
  Todd Kelley: You can't look at it.
• 7:32
  Todd Kelley: We're doing hard things here.
• 7:33
  Todd Kelley: We're doing hard things.
• 7:34
  Todd Kelley: You gotta feel it.
• 7:35
  Todd Kelley: You gotta feel it.
• 7:37
  Todd Kelley: You gotta feel it.
• 7:39
  Todd Kelley: What do you got there?
• 7:40
  Todd Kelley: Come on.
• 7:40
  Todd Kelley: I only got four minutes here.
• 7:42
  Nicholas Webber: We got, we got a quarter here.
• 7:44
  Nicholas Webber: 50 cents.
• 7:45
  Todd Kelley: You're too slow.
• 7:46
  Nicholas Webber: 60.
• 7:48
  Nicholas Webber: 65 cents.
• 7:49
  Todd Kelley: 60.
• 7:50
  Todd Kelley: Brilliant.
• 7:51
  Todd Kelley: You can, you can count, you can do math.
• 7:53
  Todd Kelley: Alright.
• 7:54
  Todd Kelley: Wow.
• 7:56
  Todd Kelley: Here we go.
• 7:57
  Todd Kelley: Um, now this, this pair of pants here, there's a little extra tissue in here.
• 8:01
  Todd Kelley: You can just throw these on the floor.
• 8:04
  Todd Kelley: I'll, I'll clean it up.
• 8:05
  Todd Kelley: I'm gonna ask you to reach in and do that same task, anterior style.
• 8:10
  Todd Kelley: Now, while you're doing that, I'm gonna tell another story here.
• 8:13
  Todd Kelley: Um, early in my career, I go to a Matta course and I ask Matta, Hey, I, I need some advice on obese patients.
• 8:20
  Todd Kelley: How, how do I, how do I navigate this?
• 8:22
  Todd Kelley: And, and Dr.
• 8:23
  Todd Kelley: Matta, you know, he's pretty, he's pretty blunt.
• 8:25
  Todd Kelley: He says.
• 8:26
  Todd Kelley: He says, yeah, just tell'em they're too fat.
• 8:28
  Todd Kelley: They'll go away.
• 8:30
  Todd Kelley: Right?
• 8:31
  Todd Kelley: So that didn't work for me.
• 8:33
  Todd Kelley: So here's my discussion with, with, with obese patients.
• 8:36
  Todd Kelley: You doing okay?
• 8:37
  Todd Kelley: Yeah.
• 8:38
  Todd Kelley: Here's my discussion with obese patients.
• 8:40
  Todd Kelley: I say, listen, I, I, we're gonna do a good job for you, but I, I, I need you.
• 8:45
  Todd Kelley: Help me help you.
• 8:47
  Todd Kelley: Right?
• 8:47
  Todd Kelley: We, we ask smokers to quit smoking.
• 8:50
  Todd Kelley: We ask diabetics to, to work on their blood sugar.
• 8:54
  Todd Kelley: I, I tell them, Hey, we're gonna do a good surgery for you, but I ask you, I ask you to lose a little bit of weight.
• 8:59
  Todd Kelley: Let's come back in a couple of weeks and and we'll see where we're at.
• 9:04
  Todd Kelley: Plenty of research out there that, that looks at.
• 9:06
  Todd Kelley: Oh, you know what I, I forgot.
• 9:08
  Todd Kelley: I forgot.
• 9:08
  Todd Kelley: The pan is here.
• 9:09
  Todd Kelley: We're gonna hang this pannus up here too.
• 9:12
  Todd Kelley: Alright, now, now you mentioned you can get through this pannus here, right?
• 9:16
  Todd Kelley: So CORR, CORR study 2023 looked at how low that pannus hangs on an x-ray.
• 9:23
  Todd Kelley: Higher, uh, higher risk of wound complications, higher risk of, uh, infections, higher risk of fractures when there's a pannus in your way there and you here, just tape that here, just tape that up and out of your way.
• 9:36
  Todd Kelley: You can just tape that pannus up.
• 9:38
  Todd Kelley: You just keep working there.
• 9:39
  Todd Kelley: And, um.
• 9:41
  Todd Kelley: So plenty of research that looks at higher risk of infection, higher risk of DVT, higher risk of fracture in obese patients.
• 9:48
  Todd Kelley: If we don't, and we're just talking about modifying, we're just talking about optimizing'em.
• 9:53
  Todd Kelley: And I think it's really important to say here, we optimizing their care is not delaying their care.
• 10:01
  Todd Kelley: It's not denying them care.
• 10:04
  Todd Kelley: It is just ensuring that they have a good outcome.
• 10:07
  Todd Kelley: Alright.
• 10:08
  Todd Kelley: My, my second point, the reason I'm doing this is, is to show you that yes, this is hard and yes, we can do hard things, but I don't think we can do our best at it.
• 10:17
  Todd Kelley: Right.
• 10:17
  Todd Kelley: I mean, he, I don't know that you even found a coin in there.
• 10:20
  Todd Kelley: I certainly do.
• 10:21
  Todd Kelley: Right, right.
• 10:22
  Todd Kelley: So, so, you know, this is hard and I think we can make errors if we're not optimizing our patient.
• 10:29
  Todd Kelley: The other thing is, is you know, there's a lot of research out there that looks at you.
• 10:32
  Todd Kelley: We know joint replacement surgeons, there's a high physiologic load doing obese anterior approach, um, higher, uh, or, uh, orthopedic load on on us.
• 10:42
  Todd Kelley: So I think you have to think about yourself here a little bit too.
• 10:45
  Todd Kelley: These are
• 10:46
  Joseph M. Schwab: get through one minute rebuttal.
• 10:49
  Nicholas Webber: So here's what happens when you tell patients to optimize their body mass index.
• 10:53
  Nicholas Webber: What happens is they diet, they go on wegovy.
• 10:56
  Nicholas Webber: And what happens is that.
• 10:59
  Nicholas Webber: Your pannus goes away, right?
• 11:02
  Nicholas Webber: Everything that you need to get out of your way to do an anterior approach goes away a hundred percent.
• 11:08
  Nicholas Webber: It does not if their pannus hangs to their knees.
• 11:13
  Nicholas Webber: My wife is here and I, and I love her, and we drive by this farm every day, and this guy's pannus.
• 11:17
  Nicholas Webber: He hangs down to his knees.
• 11:19
  Nicholas Webber: I made him lose weight.
• 11:20
  Nicholas Webber: I did the 10% thing.
• 11:22
  Nicholas Webber: And he did, and I think he lost it from his shoulders.
• 11:24
  Nicholas Webber: So I'm almost positive, almost positive.
• 11:29
  Nicholas Webber: I wanna optimize body mass index, but it's not necessarily optimizable.
• 11:34
  Nicholas Webber: You have to treat these patients.
• 11:35
  Nicholas Webber: I have to treat patients with osteosarcomas.
• 11:37
  Nicholas Webber: If they're BMI is 70, we're in a similar situation.
• 11:41
  Nicholas Webber: There are people that are just as debilitated by their arthritis as they are by their osteosarcoma.
• 11:46
  Nicholas Webber: In one way or another, we gotta do what we gotta do.
• 11:49
  Joseph M. Schwab: One minute rebuttal.
• 11:50
  Todd Kelley: I'm gonna take you through another scenario.
• 11:52
  Todd Kelley: You got two patients.
• 11:53
  Todd Kelley: One patient comes into your office, their BMI is 40 and they say, doc, you gotta help me.
• 11:59
  Todd Kelley: Give me some pain meds, do my surgery.
• 12:01
  Todd Kelley: I I, I need to get this done.
• 12:02
  Todd Kelley: And I give them that same conversation, come back in two months, lose weight.
• 12:06
  Todd Kelley: Their BMI starts at 40.
• 12:07
  Todd Kelley: I got another patient whose BMI comes in at 42 and I give them that same instruction.
• 12:13
  Todd Kelley: Now this one comes back with a BMI now of 40, so now they're both at 40.
• 12:18
  Todd Kelley: Right.
• 12:19
  Todd Kelley: Which one do you think is gonna do better with that surgery?
• 12:24
  Todd Kelley: Same.
• 12:25
  Todd Kelley: Otherwise, I think if you plug that into Christoph's algorithm, you're gonna see that this patient who did lose some weight and optimize their care does a little bit better.
• 12:34
  Todd Kelley: And, and the reason is the psychological term for that is called locus of control.
• 12:38
  Todd Kelley: One has an external locus of control.
• 12:40
  Todd Kelley: They want someone else to do something for them.
• 12:42
  Todd Kelley: The other has an internal locus of control.
• 12:45
  Todd Kelley: They are able to kind of take control and do some things for themselves to get them in a better position to go that surgery.
• 12:52
  Todd Kelley: Thank you.
• 12:52
  Joseph M. Schwab: Thank you, gentlemen.
• 12:53
  Joseph M. Schwab: Excellent debate.
• 12:54
  Joseph M. Schwab: Excellent.
• 12:57
  For all the humor in this debate, and there was a generous amount, including a live demonstration of anterior approach coin retrieval through two layers of pants.
• 13:08
  Both Dr.
• 13:09
  Webber and Dr.
• 13:10
  Kelly were wrestling with the same fundamental question.
• 13:12
  How do we give high risk patients the safest path forward without judging, delaying or abandoning them?
• 13:21
  Dr.
• 13:22
  Webber reminded us that some patients just need someone willing to take on a hard case.
• 13:28
  Dr.
• 13:28
  Kelly reminded us that asking patients to participate in their own optimization is part of compassionate care.
• 13:36
  Both of them reminded us that pannus height apparently matters more than any of us learned in residency.
• 13:44
  No matter which side you lean toward.
• 13:47
  It all comes back to the patient, their pain, their goals, their effort, and yes, maybe even their sense of humor.
• 13:56
  Thank you for listening to this episode of the AHF podcast.
• 14:02
  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.
• 14:10
  Please also drop any topic ideas or feedback in the comments below.
• 14:16
  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.
• 14:31
  One word, episodes of the AHF Podcast come out on Fridays.
• 14:37
  I'm your host, Joe Schwab, asking you to keep those hips and pannuses happy and healthy.