Latest / AHF Podcast / Advances in Anterior Approach for Orthopedic Oncology: An Interview with Dr. Chris Johnson

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Advances in Anterior Approach for Orthopedic Oncology: An Interview with Dr. Chris Johnson · AHF Podcast

0:23
Joseph M. Schwab: Hello and welcome to the A HF Podcast.
0:26
Joseph M. Schwab: I'm your host, Joe Schwab.
0:28
Joseph M. Schwab: Today we're joined by Dr.
0:30
Joseph M. Schwab: Chris Johnson, an orthopedic oncology surgeon and leader in complex adult reconstruction.
0:36
Joseph M. Schwab: Dr.
0:36
Joseph M. Schwab: Johnson serves as president of Orthopedics Northeast, one of the largest private orthopedic practices in the Midwest, and he's based in Fort Wayne, Indiana.
0:46
Joseph M. Schwab: He's also the co-director of the Ortho Northeast Adult Reconstruction Fellowship Program and the chair of orthopedic oncology at the Parkview Pacnet Family Cancer Institute.
0:57
Joseph M. Schwab: Dr.
0:58
Joseph M. Schwab: Johnson has extensive clinical expertise in anterior total hip arthroplasty, complex revision arthroplasty and orthopedic oncology.
1:07
Joseph M. Schwab: He not only brings a unique perspective to the management of complex acetabular pathology.
1:13
Joseph M. Schwab: He's an advocate for using anterior approach for cases thought to require other types of exposures.
1:19
Joseph M. Schwab: Today he joins us to discuss a nuanced but increasingly important topic, treating metastatic acetabular disease and doing it through the anterior approach.
1:31
Joseph M. Schwab: Dr.
1:31
Joseph M. Schwab: Johnson, welcome to the A HF Podcast.
1:35
Chris Johnson: Hey Joe, thanks for having me, excited to be here, should be fun.
1:38
Joseph M. Schwab: So tell me a little bit about your background and maybe a little bit about your current practice setting.
1:42
Joseph M. Schwab: It sounds interesting.
1:45
Chris Johnson: sure.
1:45
Chris Johnson: I'm, uh, I'm originally from Michigan and did residency and Michigan State University and then did my orthopedic oncology fellowship at the University of Washington Medical Center in Seattle.
1:55
Chris Johnson: And then it came to Orthopedics Northeast, uh, to start my practice and, uh, my.
2:01
Chris Johnson: Focus was really on oncology to start and we built a sarcoma program and orthopedic oncology program there then our group has a very high volume joint replacement center and we're doing a lot of complex revisions and sort of disaster plasticity type cases.
2:16
Chris Johnson: So we started adult reconstruction fellowship as well.
2:19
Chris Johnson: So I do a lot of joint replacement and revision as well as oncology work.
2:24
Chris Johnson: And, um, on the primary side, I do a lot of anterior hips.
2:27
Chris Johnson: So kind of blending the oncology side revision side with the anterior approach.
2:31
Joseph M. Schwab: Wow.
2:32
Joseph M. Schwab: And so what, uh, what led you to explore really the use of anterior approach in sort of managing oncologic conditions?
2:42
Chris Johnson: well, I was exposed to a lot of anterior approach and residency, and, um, you know, patients do great.
2:47
Chris Johnson: And then in my own practice, you know, I have my sort of anterior primary side, which is really quite nice.
2:53
Chris Johnson: You know, quick surgeries, patients go home same day often, and, uh, outcomes are great.
2:58
Chris Johnson: And then, you know, of course, I have the oncology side, and, and, and, uh, things are more complex and challenging.
3:02
Chris Johnson: But the outcomes of anterior hips are so good, it was, it's just very natural to start blending that into, uh, more complex problems.
3:10
Joseph M. Schwab: Did you find any unique challenges that came with, um, the orthopedic oncology patient population and anterior approach?
3:18
Joseph M. Schwab: Or did it, was it a pretty seamless transition?
3:22
Chris Johnson: I.
3:22
Chris Johnson: would say it was kind of a natural progression.
3:24
Chris Johnson: We start, you know, classically acid tabular metastatic defects are taking care of with, you know, what was called a Harrington reconstruction, where you make multiple incisions, you open up the ileum and pelvis side.
3:35
Chris Johnson: You also make a second incision to do a, uh, you know, posture approach or lateral approach, and then you reconstruct the acetabulum with some Steinman pins, and it was a pretty invasive surgery.
3:45
Chris Johnson: You're taking down abductors.
3:46
Chris Johnson: Sometimes it's a big surgery and, um, required a lot of thought.
3:50
Chris Johnson: Once, um, David Geller's group in the Bronx, they, they described the tripod technique for acetabular defects.
3:58
Chris Johnson: And that really was a game changer for us, because once we started doing that, we have, you know, a nice multidisciplinary team.
4:03
Chris Johnson: In our trauma service, we started doing percutaneous screws for some more simple acetabular defects.
4:08
Chris Johnson: And then the natural progression of the world, if we're doing these percutaneous screws, it's not very invasive.
4:13
Chris Johnson: Why don't we do an answer your approach with that and start doing that for some of our asked other mastectomies.
4:17
Chris Johnson: And so we started with smaller cases and build it up to even, you know, you know, big challenging cases.
4:22
Chris Johnson: And the answer your approach works.
4:23
Chris Johnson: Well, we basically now doing metastatic disease without cutting any muscle.
4:26
Chris Johnson: Maybe we'll play it, peel off the TFL off the helium if we need a cage or something bigger.
4:31
Chris Johnson: Um, but, you know, the patients are up and walking and a six weeks.
4:35
Chris Johnson: It's almost like a primary hip for some of these patients, A big change from what we were doing with, you know, more classic Harrington type reconstructions.
4:43
Joseph M. Schwab: And let's talk a little bit about how these patients sort of present ones who are coming with, you know, metastatic disease that's around the acetabulum.
4:52
Joseph M. Schwab: How is that?
4:52
Joseph M. Schwab: I mean, how are, how are they gonna end up in your clinic?
4:54
Joseph M. Schwab: What are you gonna see?
4:55
Joseph M. Schwab: What are they gonna tell you?
4:58
Chris Johnson: Yeah, I mean, they come from all over the place, generally have a lot of pain, that's how it was discovered.
5:02
Chris Johnson: You know, so they generally have inguinal pain, similar to an arthritic patient.
5:05
Chris Johnson: You're going to have groin pain or inguinal pain because the hip joint is, is, is, um, you know, having problems.
5:11
Chris Johnson: And then they'll come in from medical oncology, they'll come in from other orthopedic doctors all over the place.
5:15
Chris Johnson: And then, um, Each case is unique, you know, the size of the defect, the primary cancer, whether it's lymphoma versus renal cell, two totally different things.
5:28
Chris Johnson: Renal cell can be much more challenging, bleeding, progression of disease, um, or other things like prostate cancer, breast cancer.
5:35
Chris Johnson: Breast cancer can be more sensitive to radiation, so really the specific diagnosis is very important to which type of metastatic disease it is.
5:43
Chris Johnson: Um, and then once they, once they present and we have them, we really, we get advanced imaging like a CT scan to sort of see the 3D defect to then plan ahead of how we're gonna, if we need to, how we're going to reconstruct it.
5:54
Joseph M. Schwab: Mm-hmm.
5:54
Joseph M. Schwab: And so how do you decide on who you're gonna operate?
5:58
Joseph M. Schwab: Uh, you know, who's a good candidate for surgery for this particular surgery?
6:03
Chris Johnson: I mean, AST is a, challenging problem and generally should require multidisciplinary approach, medical oncology, radiation oncology, orthopedic oncology, I'm a big believer in informed decision making, talking to the patients and family, giving them the risk and benefits of each scenario.
6:18
Chris Johnson: And these are big surgeries should be last resort.
6:20
Chris Johnson: If you can get away with radiation or non operative things first, certainly reasonable to try, but I would say anecdotally, in my practice, we've got a little more aggressive of surgery because we're doing an anterior approach.
6:30
Chris Johnson: We're doing percutaneous screws.
6:31
Chris Johnson: It's not as big of a deal anymore.
6:33
Chris Johnson: And so we can be a little more aggressive with getting surgery done and people are happy and you know, they, they get up and walking.
6:39
Chris Johnson: All these patients come in, they are non ambulatory, cannot walk at all severe pain.
6:43
Chris Johnson: You know, many of them are walking the day of surgery.
6:45
Chris Johnson: And so.
6:47
Chris Johnson: Um, but informant says you're making it a little more challenges than a primary hip or revision hip because you have to deal with chemotherapy.
6:53
Chris Johnson: They're probably, you know, higher host.
6:55
Chris Johnson: See, basically, they're on chemotherapy.
6:57
Chris Johnson: They're immunocompromised and then fixation, you know, we can't utilize horse metal as much because we may not have good in growth, which you can with TM in certain scenarios, but you're usually more cement and cement fixation compared to a standard revision.
7:12
Chris Johnson: So a little bit unique in that regard.
7:15
Joseph M. Schwab: So it sounds like anterior, the using anterior approach has allowed you to sort of expand your surgical indications in this population at least a little bit.
7:23
Chris Johnson: think so.
7:23
Chris Johnson: I think for me personally, I was a little more conservative with a more classic Harrington approach because it was such a big surgery.
7:29
Chris Johnson: We really, you know, it takes time to heal.
7:31
Chris Johnson: Someone has metastatic lung cancer, for example, and maybe their prognosis, their lifespan, maybe a year or less, and they're going to spend three to four months recovering.
7:39
Chris Johnson: It's like, I don't know.
7:39
Chris Johnson: You know, what is worth?
7:41
Chris Johnson: What's the appropriate boundary?
7:42
Chris Johnson: Again, family discussion with the anti approach.
7:45
Chris Johnson: You know, we're getting them healing faster.
7:48
Chris Johnson: It's a little quicker.
7:49
Chris Johnson: You know, in 6 weeks, I feel like they're usually generally pretty happy and doing pretty relatively well.
7:54
Chris Johnson: So you can get him healed quicker so that you have to worry as much about the timeline decision making.
8:01
Joseph M. Schwab: So when somebody shows up, I'm, I'm really familiar with when somebody shows up with arthritis in their hip, I know what the goals of my operation are gonna be.
8:09
Joseph M. Schwab: I mean, I, I, I know I want to get them back up and functioning, get'em playing pickleball, get'em playing golf, doing all those sorts of things.
8:16
Joseph M. Schwab: When you're treating these types of lesions in the
8:19
Chris Johnson: hmm.
8:20
Joseph M. Schwab: um, are, are your primary surgical goals different?
8:24
Joseph M. Schwab: What are you looking to achieve?
8:27
Chris Johnson: That's a great question.
8:28
Chris Johnson: The really the primary focus of treating anybody with menistic disease, whether it's in the acetabulum, the femur anywhere is immediate weight bearing.
8:37
Chris Johnson: Ambulation and function, because these patients may have a shorter lifespan.
8:40
Chris Johnson: You want to get them going.
8:42
Chris Johnson: They're often getting chemotherapy.
8:43
Chris Johnson: So if they're stuck in a bed for six weeks, it's not very good.
8:46
Chris Johnson: So they need to be up and walking to tolerate chemotherapy and subsequent treatments and also quality of life.
8:52
Chris Johnson: So the main goal is immediate weight bearing.
8:54
Chris Johnson: Unlike some revision scenarios where you may.
8:57
Chris Johnson: You know, let's say like a, uh, pelvic discontinuity and maybe you're doing a tri-flange.
9:02
Chris Johnson: You might protect their weight bearing for a little while.
9:04
Chris Johnson: Let's try to get ingrowth in the implant, etc.
9:06
Chris Johnson: In this case, we don't really have that time.
9:08
Chris Johnson: We don't have that luxury of time, so we gotta get immediate weight bearing right away.
9:11
Chris Johnson: So that's the big difference, I would say, is we want to allow for immediate ambulation.
9:15
Chris Johnson: So cement fixation in certain scenarios and, and try and get them going.
9:20
Joseph M. Schwab: And so let's talk a little bit about the technique.
9:23
Joseph M. Schwab: I mean, you mentioned the tripod technique.
9:24
Joseph M. Schwab: Tell me a little bit, can you gimme a brief description of what it, what it is, what it looks like?
9:30
Chris Johnson: so the tripod technique is much.
9:33
Chris Johnson: It's really the percutaneous screws for acetabular fractures.
9:36
Chris Johnson: It's really originally described by the trauma world um, then when David Geller's group kind of combined it brought to the ortho oncology world, which is, you know, a great concept.
9:47
Chris Johnson: I showed it to some of our trauma colleagues and say, Hey, can you guys do this?
9:51
Chris Johnson: And they're like, Yeah, we do this all the time for geriatric patients.
9:54
Chris Johnson: Falls and fractures and like, okay, well, let's let's start doing with these and I'm lucky to have a great team.
9:59
Chris Johnson: So, um, our trauma service is very good doing per screws.
10:03
Chris Johnson: So we started doing them and they do them in like 30 minutes.
10:06
Chris Johnson: I mean, it's really quick and easy.
10:07
Chris Johnson: They basically get certain specific views.
10:09
Chris Johnson: You're basically putting screws through the poster column.
10:14
Chris Johnson: anterior column and then the LC2 screw like in the trauma world.
10:18
Chris Johnson: So you're really creating a tripod to reinforce the acetabulum similar to what a Harrington reconstruction is doing by putting K wires down through the ileum trying to basically rebarb the acetabulum to put cement into it.
10:31
Chris Johnson: This is doing the same thing, but with three small incision percutaneous incisions under fluoroscopic guidance.
10:37
Chris Johnson: And you're basically putting long screws that go into good bone through the You know, the cancer and defect into good bone again because they're long screws and that allows a less invasive, quick and precise way to or rebarb the acetabulum to allow for subsequent and originally described for just the screws only.
10:59
Chris Johnson: But you could.
11:00
Chris Johnson: I think the original study had 20 patients, but they said you could augment or, you know, convert to a total hip easily.
11:06
Chris Johnson: And so we started doing screws with the tripod technique, and then in cases who had a lot of defects around the acetabulum, then, then adding, adding in a total hip.
11:13
Chris Johnson: And we started with posterior approach, because that's what I was comfortable doing in more complex things.
11:17
Chris Johnson: And as I went on, we evolved to the
11:20
Joseph M. Schwab: So when you're actually doing the reconstruction, they've got their screws in place.
11:24
Joseph M. Schwab: Um, are, are they doing any, so first of all, um, when they're getting their screws put in, are they doing any percutaneous cement application at the same time or just the screw?
11:35
Chris Johnson: you could in cases in which there are different products out there where you could put screws that have cement.
11:40
Chris Johnson: We have not been doing it.
11:41
Chris Johnson: And some places do describe that.
11:43
Chris Johnson: That's certainly an option.
11:44
Chris Johnson: What we typically do if it's if it's a screw only case, we put the screws in and see how they do.
11:49
Chris Johnson: If it's screws and total hip, we put the screws in and then I'll open it up to the anterior approach.
11:55
Chris Johnson: And it really depends again.
11:57
Chris Johnson: Each case is different where the defect is, what type of cancer it is.
12:00
Chris Johnson: We open up through an anti approach.
12:02
Chris Johnson: What's obviously nice about the anti approach is the S tablet exposures.
12:05
Chris Johnson: So nice.
12:06
Chris Johnson: There's a pine easy X ray you can see the tablet really, really well.
12:11
Chris Johnson: So it's just so convenient.
12:12
Chris Johnson: And then we'll remove the tumor, because these are more palliative cases, we're not doing a wide excision, we're doing intralesional excisions, removing the bone, often burr down to help, to, as best we can, down to normal bone, so you, then you see the remaining defect.
12:27
Chris Johnson: And then at that case, you usually have a pretty good idea going into the size, if there's discontinuity, etc.
12:32
Chris Johnson: Do you need to augment with the cage?
12:35
Chris Johnson: Are you just doing the big shell?
12:36
Chris Johnson: Are you cementing it?
12:37
Chris Johnson: We do a lot of, um, you know, cemented dual mobility liners, where we just cement them in and do that anteriorly.
12:44
Chris Johnson: Um, if we need constraint or not, you know, do they have, you know, sometimes they need a PFR, maybe the proximal femur is gone.
12:49
Chris Johnson: So really each case is unique, assessing where the defects are, what the challenges are, and how you're gonna, you know, reconstruct it most optimally.
12:57
Joseph M. Schwab: So, um, we actually got introduced through, um, a mutual acquaintance that we know at at Johnson Johnson, j and j Med Tech.
13:05
Joseph M. Schwab: DePuy Synthes, Johnson and Johnson.
13:07
Joseph M. Schwab: Um, are those the implant systems that you typically use, or what are, what kind of constructs are you typically using?
13:13
Joseph M. Schwab: It's okay to use brand names if you want to.
13:15
Joseph M. Schwab: It's, uh, you just, or are you using a variety of, uh, of items?
13:21
Chris Johnson: used a variety.
13:21
Chris Johnson: I have used a lot of J&J.
13:23
Chris Johnson: Thank you.
13:23
Chris Johnson: Um, they're, um, Bimentum Cup, I use a lot.
13:27
Chris Johnson: I think it's very, very, so I'm, you know, do a lot of J&J anterior hips.
13:32
Chris Johnson: The actus is a great stem, so it's super easy.
13:34
Chris Johnson: And we're using their valus navigation with these two.
13:38
Chris Johnson: So it's another thing compared to poster approach Harrington where you're trying to, you know, imagine putting a cup in with a huge hole.
13:43
Chris Johnson: I mean, it is, no one can be that precise at but you get to do it on the anterior perch under fluoro.
13:49
Chris Johnson: I'm putting in a cemented cup under, under VHN or under navigation assistance for printing these cuffs in a pretty, you know, relatively precise way.
13:58
Chris Johnson: So because of all that, I tended to use the J&J, Bimentum, which is a cemented single dual mobility liner, and then I just do the femur like normal, and then it's pretty simple.
14:10
Chris Johnson: we have you some like a cage has become less, less common.
14:15
Chris Johnson: A lot of companies are getting rid of cages, which would prefer they didn't because I understand that in a revision setting where you're trying to get on growth makes sense.
14:25
Chris Johnson: You know, porous metals, custom implants, augments, all that stuff makes total sense in a standard revision.
14:33
Chris Johnson: Aseptic loosening, you're trying to get osseo integration.
14:35
Chris Johnson: So the implants last in the cancer world, you don't necessarily have that.
14:38
Chris Johnson: You don't have the luxury of time.
14:40
Chris Johnson: So, cages can help, certainly, oncology cases because you can, you do the tripod to help get rid of discontinuity, reinforce the acetabulum, but then you can bridge the defect even more so if there's more massive bone loss with, um, with some cages.
14:56
Chris Johnson: And so, um, we have used Smith Nephew for certain cases because they still have a decent, nice cage system.
15:03
Chris Johnson: So, depending on what I need, I'll adjust.
15:05
Joseph M. Schwab: Yeah.
15:05
Joseph M. Schwab: Um, and I was gonna ask, I mean, because most of these, because this patient population specifically, you're talking about metastatic disease around the acetabulum, you're able to use a, a pretty standard primary stem.
15:19
Joseph M. Schwab: I mean, you mentioned the Actis stem, right?
15:20
Joseph M. Schwab: It, it's, most of the time you're gonna be putting in something fairly basic like that.
15:25
Chris Johnson: a really good question.
15:26
Chris Johnson: So I think that's something that's not been studied well, and it's a little anecdotal.
15:31
Chris Johnson: Historically, in the oncology world, you cement everything and, you know, someone has a pristine femur, but has acetabular menistic disease.
15:39
Chris Johnson: Do you need to cement the femur?
15:41
Chris Johnson: I don't know.
15:42
Chris Johnson: I mean, they might get radiation.
15:44
Chris Johnson: So, will the radiation impact the young growth on the femoral side?
15:48
Chris Johnson: Is there a higher risk of loosening?
15:49
Chris Johnson: Because they get radiation, even if they have no disease there?
15:52
Chris Johnson: Of course if they have disease in the bone, in the femur, I'm gonna cement.
15:55
Chris Johnson: But if they have a pristine, normal femur, I haven't breastfed anymore because, um, know, I haven't had a lot of problems with loosening the active.
16:05
Chris Johnson: I have a lot of experience with the active stem and a triple taper stem.
16:07
Chris Johnson: It works well and there is some risk, you know, B.
16:10
Chris Johnson: C.
16:11
Chris Johnson: I.
16:11
Chris Johnson: S.
16:11
Chris Johnson: Bone implant syndrome.
16:13
Chris Johnson: You know, people always talk about should you cement or not in the in the primary setting and all these things.
16:17
Chris Johnson: But in my mind, this is just my perspective.
16:21
Chris Johnson: You know, how many fractures would you accept?
16:24
Chris Johnson: Or how many loosenings would you accept for one catastrophic BCIS?
16:29
Chris Johnson: And so, in the oncology world, we cement more, and I have seen, you know, a handful of patients have problems with cementing.
16:35
Chris Johnson: It is a big deal.
16:36
Chris Johnson: And so, if you can get away with press fitting, I think it's, it works well.
16:40
Chris Johnson: So, I have been more and more aggressive in my practice with press fitting a standard stem in someone who has metastatic disease in the last tabulum, and haven't really had any problems
16:48
Joseph M. Schwab: So you've mentioned some of the advantages that at least you've seen in being able to do some of this through an anterior approach.
16:55
Joseph M. Schwab: Are there any technical challenges that you run into in this patient population or exposure?
17:01
Joseph M. Schwab: Uh, exposure challenges for these more complex reconstructions.
17:05
Chris Johnson: think on the acetabular side, it's honestly easier.
17:09
Chris Johnson: Um, when I compare, I think part of it is the experience thing, and just the fear.
17:14
Chris Johnson: When you do something new in a learning curve, you're worried about making mistakes and doing something wrong.
17:19
Chris Johnson: And as you get through practice, you start to gain confidence and try, you know, just try to be reasonable and do the right thing.
17:25
Chris Johnson: When I compare it to doing a, say, a Tri-Flandre custom implant on a revision setting and a post-G approach, I think it's a lot easier.
17:33
Chris Johnson: And which we've done quite a bit of those and have good experience with that.
17:36
Chris Johnson: It's still, there's still some challenges exposing the ileum without hurting the abductors, all those things.
17:40
Chris Johnson: With the anti-approach, you're supine, you can peel off the TFL, and you can expose the whole ileum extremely easily.
17:48
Chris Johnson: And then repairs really nicely, you repair it right back to the top of the ileum.
17:52
Chris Johnson: It's a really nice exposure.
17:54
Chris Johnson: I think, I remember we were doing, once we were starting to think about these things, we were doing a course for J&J actually, and we had some Fellows with us and we were doing just some cadaver labs and we were exploring like, can we really do a tri flange interiorly?
18:06
Chris Johnson: Can we put cages on interiorly?
18:09
Chris Johnson: And it was so easy and I was like, it was for me.
18:12
Chris Johnson: I was a big confidence booster because I was trying to teach people what to do, but I was really experimenting myself and I'm like, wow, I can, I can put my finger in this attic notch and feel the bottom of the issue.
18:22
Chris Johnson: It's really easy.
18:22
Chris Johnson: I mean, if you extend the incision approximately over the iliac brim and then peel off the TFL, it's one big sleeve and the whole lateral pelvis is right there.
18:32
Chris Johnson: It's pretty remarkable.
18:33
Joseph M. Schwab: Yeah, that's, uh, so how do you go about, you mentioned actually using intraoperatively, using ves for cup positioning and things like that, or, you know, using some sort of intraoperative uh, technology.
18:44
Joseph M. Schwab: How do you plan for these cases?
18:46
Joseph M. Schwab: What, I mean, what, what are you using to, to come up with your, I'm assuming there's plans A through Z right?
18:54
Chris Johnson: Yeah, we're, I mean, we're lucky that we have an institution where we have everything on the shelf.
18:58
Chris Johnson: So, I mean, I pretty much, I don't have to worry too much.
19:01
Chris Johnson: And we have we're busy and so the teams are used to what we're doing.
19:05
Chris Johnson: We're not doing it's not new every time.
19:07
Chris Johnson: But yes, no doubt.
19:08
Chris Johnson: You have to plan for everything.
19:10
Chris Johnson: Um, I'm a planner.
19:11
Chris Johnson: I like to think ahead.
19:13
Chris Johnson: And, um, but yes, sort of a stepwise approach where the defects their discontinuity.
19:21
Chris Johnson: the cancer, what's the primary diagnosis?
19:23
Chris Johnson: Renal cell versus breast versus prostate matters.
19:26
Chris Johnson: Um, do they need an embolization ahead of time?
19:29
Chris Johnson: You know, there's a lot of coordination going involved, but I think having all the implants ready, have a team, you know, your, your reps in your industry, who you're working with, make sure they know and plan ahead.
19:38
Chris Johnson: We usually like to meet ahead of time.
19:40
Chris Johnson: So we're all on the same page, but once you do enough of them and it becomes routine, everyone kind of knows where you're going, but again, I would say the planning is basically the bone defects where they're at, is there discontinuity Abductors, um, the primary diagnosis are the main, main things that come to my mind when I think about how to plan it out.
19:59
Joseph M. Schwab: And these are mostly gonna be, um, affecting what you decide to put in or it's gonna affect your surgical approach or both?
20:08
Chris Johnson: Approach not as much.
20:09
Chris Johnson: I mean, I think for me, almost always now we're going to go anterior.
20:12
Chris Johnson: Unless on the femur side, if there's something crazy in the femur side that might change how I do things.
20:17
Chris Johnson: Um, but if we're focusing just on the pelvis and the astabular side, I'll pretty much go anteriorly almost every time at this point.
20:25
Chris Johnson: Um, even body habitus and the larger patients generally is not too much of a problem, particularly more in the extensile approach.
20:33
Chris Johnson: I think if you're doing a standard, um, which we do, You know, larger patients primary hips all the time, but I think it's more challenging trying to squeeze in a, you know, primary hip and a bigger person.
20:45
Chris Johnson: They're larger obese person.
20:46
Chris Johnson: It is a little more challenging.
20:47
Chris Johnson: We're actually working on a study now, and we showed we were showing the timing how Dallas impacted our efficiency.
20:53
Chris Johnson: Which did improve our efficiency, but one of the biggest factor to the time length of surgery was the body habit is so larger, more obese patients.
21:01
Chris Johnson: So the surgery down, but with a more extensile approach, it's not as much of an issue because you're, you're, you're opening up the Ilium, so it's not, you know, it's not as easy, but it's not as much of a problem that maybe compared to that of a primary.
21:15
Chris Johnson: my
21:15
Joseph M. Schwab: So, so we had a debate at the most recent, uh, annual meeting of the A HF about, you know, what's the best surgical incision for anterior approach?
21:24
Joseph M. Schwab: Is it the traditional incision, the hooter incision, or is it the, the bikini incision?
21:29
Joseph M. Schwab: I'm guessing a lot of your patients aren't getting bikini incision.
21:32
Joseph M. Schwab: Is that right?
21:33
Chris Johnson: no, we think about that.
21:35
Chris Johnson: We talk with our fellowship, particularly, uh, we talked about bikini incision.
21:38
Chris Johnson: Not one of my partners does a bikini incision.
21:40
Chris Johnson: Um, his practice
21:41
Joseph M. Schwab: For primaries or for,
21:43
Chris Johnson: primaries.
21:44
Chris Johnson: Yeah.
21:45
Chris Johnson: Uh, but for me, no, I'm doing a standard da and I can extend approximately if I need to.
21:49
Chris Johnson: So, um, I think there's certainly some advantages of bikini.
21:53
Chris Johnson: It's something I think about a lot.
21:54
Chris Johnson: Um, for my practice.
21:57
Chris Johnson: I have, I'm choosing the standard DA approach with the, and that can extend along the ilium if I need to.
22:04
Joseph M. Schwab: So tell me a little bit about what, what's your typical, uh, post-op protocol for these patients?
22:09
Joseph M. Schwab: You've done a, you, you know, they've gotten the screws, they've gotten, let's say a, a mentum with a relatively standard stem.
22:16
Joseph M. Schwab: Um, and, um, they're gonna need chemo, maybe they need radiation.
22:20
Joseph M. Schwab: What, what?
22:21
Joseph M. Schwab: Tell me a little bit about what their post-op is gonna look
22:24
Chris Johnson: Yeah, I mean, I usually, as long as there's no abductor problems, and you know, all that's normal, I let them go.
22:30
Chris Johnson: You're up and walking right away, just like a routine, uh, routine anterior hip, really.
22:35
Chris Johnson: I just say, progress is tolerated, start with a walker.
22:38
Chris Johnson: Um, you know, usually, and this is the big difference, some of these people, You know, may have been sick for a long time.
22:44
Chris Johnson: They're really deconditioned.
22:47
Chris Johnson: So you should let them go.
22:48
Chris Johnson: They're not going to move too quick, but some patients, um, it comes on quick.
22:52
Chris Johnson: They were pretty healthy 3, 4 months ago.
22:54
Chris Johnson: And all of a sudden they're really quite sick now.
22:56
Chris Johnson: And so they may be, they may be able to recover quicker.
22:58
Chris Johnson: So there's a wide spectrum of how the patients present and who they are and how they would recover compared to that.
23:03
Chris Johnson: Maybe have a primary hip.
23:05
Chris Johnson: Um, and so, you know, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's it's.
23:06
Chris Johnson: And then the key thing is really, um, we're fortunate.
23:09
Chris Johnson: We have an oncology therapy program.
23:10
Chris Johnson: So we have some therapists who are specialized in oncology.
23:12
Chris Johnson: They do an amazing job with the patients and they kind of understand the protocol.
23:16
Chris Johnson: So that's nice.
23:17
Chris Johnson: We don't always do formal therapy though.
23:19
Chris Johnson: I would say a lot of patients just walking like a normal hip.
23:21
Chris Johnson: I don't routinely do standard therapy.
23:23
Chris Johnson: We let them progress as tolerated the oncology ruled.
23:27
Chris Johnson: I kind of field out.
23:29
Chris Johnson: Some people need more help than others.
23:31
Chris Johnson: Um, we just, we just let them progress as tolerated.
23:34
Chris Johnson: Then we do check their wounds quickly.
23:36
Chris Johnson: Um, I like to watch them one week and two weeks, particularly if they're going to be getting like...
23:41
Chris Johnson: You're trying to get back on like a VEGF inhibitor for renal cell or things like that, which are bad for wounds.
23:47
Chris Johnson: You know, I make sure the wounds heal.
23:49
Chris Johnson: Once the wound looks good, I say, okay, fine, go progress to chemo or radiation or whatever you want afterwards.
23:55
Chris Johnson: Usually at about the two week mark, the wound is looking reasonable.
23:58
Chris Johnson: There's no concerns.
23:58
Chris Johnson: I say, But it's also a discussion.
24:01
Chris Johnson: Sometimes men are like, oh, a couple more weeks doesn't really matter.
24:04
Chris Johnson: I'm like, okay, fine.
24:05
Chris Johnson: Let's, let's wait a little bit.
24:06
Chris Johnson: Or if they're like, no, we, we need to get this person on chemo as soon as possible.
24:09
Chris Johnson: I'm like, I'll be a little more aggressive with them.
24:11
Chris Johnson: And, and so really multidisciplinary discussion of
24:15
Joseph M. Schwab: Um, that it seems to me like these patients are gonna have a significant medical team around them, much more so than the average sort of primary total hip
24:25
Chris Johnson: Yeah, I mean, ideally that's the way it should be.
24:28
Chris Johnson: Um, Yeah, multidisciplinary trips, chemo, radiation, um, ortho, we have a palliative care team as well, so we have a nice multidisciplinary team to help guide them through, but every patient is different.
24:39
Chris Johnson: Many have less resources.
24:40
Chris Johnson: Some come from far away and don't have a lot of help.
24:42
Chris Johnson: And so it is, it really is case by case and trying to optimize it.
24:45
Chris Johnson: But from a standard, you know, from a hip perspective, we let them go, let them walk, no restrictions, no hip precautions, weight bear is tolerated, you know, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's Um, and I would say they're somewhat similar to a primary hip, usually by the six week mark, I get an x ray, make sure nothing's moved, make sure they're happy and if they're doing well, no problems.
25:03
Chris Johnson: I, I stopped to worry about Often
25:06
Joseph M. Schwab: And you've been doing this procedure in this patient.
25:08
Joseph M. Schwab: Population, roughly how long?
25:12
Chris Johnson: switch to interior.
25:13
Chris Johnson: So I've been in practice for eight years.
25:15
Chris Johnson: Yeah, I probably switched to doing the acetabular mets anteriorly maybe about four years ago, so halfway through.
25:24
Joseph M. Schwab: Anything that you've seen in your patients, um, in terms of long, longer term outcomes?
25:30
Joseph M. Schwab: Not, not within the first, you know, six weeks or so, that indicates to you that this is something you shouldn't be doing or you gotta be making some modifications to it?
25:39
Joseph M. Schwab: Or is this, are, are you seeing, uh, functional outcomes at least as good as if not better than what you were experiencing before?
25:48
Chris Johnson: I would say the main differences from my perspective, one is the early period.
25:52
Chris Johnson: The healing process, like you would expect, even in the anterior versus posterior in this, the early period recovery seems to be better.
26:00
Chris Johnson: I think the biggest advantage for me is really the reliability of doing the reconstruction.
26:06
Chris Johnson: do it supine under x-ray, even using hip navigation, I feel very comfortable putting in a well positioned implant, generally, and giving them a solid reconstruction that I'm, I'm really happy with.
26:19
Chris Johnson: So, for me, it's more reliable.
26:21
Chris Johnson: And I think generally, like we always say, which hip approaches you use, it's the one that you're most comfortable doing.
26:27
Chris Johnson: So I think for me, it has become that and, and it's, it is more reliable for me to do it that way.
26:33
Chris Johnson: Um.
26:34
Chris Johnson: I think the wound issues can be more challenging, though, like we've, you know, studies have documented a wound, you know, particularly for bigger patients.
26:41
Chris Johnson: You can have some wound issues at the interior approach and particularly for the sicker population is something to be aware of.
26:47
Chris Johnson: We typically will use incisional vacs post-op if they have a decent body habitus or or if they're kind of get significant chemo or anything that makes me say, Oh, gosh, this person's high risk for wound issues.
27:00
Chris Johnson: I'll put it back on them for 2
27:04
Joseph M. Schwab: Um, and one of the things we've always been concerned about in the a HF is actually just the education of anterior approach.
27:11
Joseph M. Schwab: In general, what you're doing kind of takes it to a whole nother level.
27:14
Joseph M. Schwab: And so a new surgeon coming into practice who's done an orthopedic oncology fellowship, wants to start thinking about doing these complex cases, um, integrating the anterior approach.
27:26
Joseph M. Schwab: What's your advice for how they can do that safely?
27:31
Chris Johnson: you know, I think it's really interesting.
27:32
Chris Johnson: You look at, um, you know, people's perspective on hip hip, um, approach and what they use.
27:39
Chris Johnson: It's what they're comfortable with.
27:41
Chris Johnson: It's what they're exposed to.
27:43
Chris Johnson: And so, um, I think for me personally, I was lucky that I got a lot of anterior exposure in residency.
27:48
Chris Johnson: I didn't do a lot of anterior fellowship, but then as my practice grew, I became comfortable with it.
27:52
Chris Johnson: So it was a natural blend.
27:54
Chris Johnson: And with our fellows, you know, that was one of the reasons we started the fellowship is because we felt like we were doing a lot of complex stuff.
27:59
Chris Johnson: We had a lot to offer.
28:00
Chris Johnson: It was just a genuine thing to do.
28:02
Chris Johnson: And so I think I think our fellows are getting a great experience because they're seeing a bunch of primaries, but they're also seeing some pretty unusual or more complex cases of blind and blending it together.
28:12
Chris Johnson: So I see our fellows.
28:13
Chris Johnson: They're quite used or comfortable in a standard case because it's like, wow, we just had half the pelvis exposed yesterday and now we're doing this primary hip like it seems accessible, but I think I think it takes time like anything like we know there's the learning curve with anterior approach and starting with simple things.
28:31
Chris Johnson: I mean, I, I started with just doing primary anterior hips and that made me more comfortable.
28:35
Chris Johnson: But then with my practice, there's just an easier progression to those things.
28:38
Chris Johnson: So I don't start with easy things and like anything and build up with progression start.
28:42
Chris Johnson: And I would say a big advice would be learned from your partners and colleagues.
28:46
Chris Johnson: One of my senior partners does a bunch of anterior hips.
28:49
Chris Johnson: He's really, really good at it.
28:50
Chris Johnson: And, um, I learned from him a lot, and so I, you know, implement those into the oncology side, and, and so, you know, guess one big advice is don't, you know, be careful of what you know, you know, learn from other people.
29:02
Chris Johnson: Don't be, don't be scared of, uh, don't be scared of not knowing.
29:06
Chris Johnson: I think just be really open and honest with people and, and, and try to learn from people around
29:12
Joseph M. Schwab: you.
29:12
Joseph M. Schwab: mentioned, um, earlier an area where maybe there's not so much research in long-term outcomes, for instance, in uns cemented stems in these patients.
29:21
Joseph M. Schwab: Um, let's talk a just a little bit, um, about research directions or, or innovations that are particularly exciting to you.
29:30
Joseph M. Schwab: Are there areas you're interested in?
29:32
Chris Johnson: There's so many areas.
29:34
Chris Johnson: I mean, so we're, we, um, as we're building our program, we've started a research institute, which is just getting off the ground.
29:41
Chris Johnson: So we're a lot of work.
29:43
Chris Johnson: I'm doing right now is building our, database and infrastructure and research team because there are so many areas.
29:49
Chris Johnson: It's I feel really lucky being on the oncology side and the arthroplasty side because when I go to the meetings, know, I can tell they don't really know anything about the oncology side.
29:57
Chris Johnson: And some of the topics I'm like, I'm like, they've talked about this over here.
30:00
Chris Johnson: But then you go to the oncology side.
30:02
Chris Johnson: It's just the opposite.
30:03
Chris Johnson: It's like, I'm like, you guys, we've been the hip people know this a long time ago.
30:07
Chris Johnson: So bring seeing both sides is really nice because both sides have great things to add.
30:11
Chris Johnson: So I think that's been helpful for me to seeing kind of bring the hip, the hip and knee side to the oncology side.
30:17
Chris Johnson: And I think a great example is like, is like, PGI and we PGI has very poor data.
30:26
Chris Johnson: completely non.
30:27
Chris Johnson: There's no synergy with any of the infection data.
30:30
Chris Johnson: Very little synergy.
30:31
Chris Johnson: A lot of anecdotal stuff going on timeline of antibiotics.
30:34
Chris Johnson: It's a great scenario in which we don't have great data.
30:37
Chris Johnson: But on the, and so the head PNE people are like, wow, this is really challenging, which it is, of course.
30:42
Chris Johnson: But on the oncology side, I mean, we have things like giving chemotherapy to soft tissue sarcoma patients.
30:48
Chris Johnson: I mean, we have horrible data there and giving someone chemo is a big deal.
30:53
Chris Johnson: And so like we were used to living in the world of having poor data and the key is informed decision making.
31:00
Chris Johnson: Don't be dogmatic.
31:01
Chris Johnson: Don't act like you know.
31:03
Chris Johnson: The key is to tell patients, Hey, you know, We don't really know the subject that well.
31:07
Chris Johnson: Here's the available information.
31:08
Chris Johnson: Here's the risk and benefits of these 3 approaches.
31:11
Chris Johnson: And you really evidence based medicine and informed decision making is putting the patient's preference and values 1st, not yours.
31:19
Chris Johnson: You give them the information and help them decide where they want to go with things.
31:24
Chris Johnson: So anyways, I think.
31:25
Chris Johnson: My that's a long answer to.
31:27
Chris Johnson: I think there's a ton of areas of topic.
31:29
Chris Johnson: I think, you know, fixation, the femur, like, like you said, can we press fit in these scenarios?
31:36
Chris Johnson: I think you probably can.
31:38
Chris Johnson: Um, I think the stem designs help a lot.
31:40
Chris Johnson: Like, we're, we're working on a study now for fractures.
31:43
Chris Johnson: Everyone's the swing of going to what we should be cementing more people.
31:46
Chris Johnson: I think probably was a result of, like, the Prior style generation of stems, the wedge stems are like log splitters.
31:53
Chris Johnson: Of course, there are some.
31:54
Chris Johnson: Yeah, those, of course, they had fractures, but with with our, um, triple taper stems, I don't think I don't think we're seeing.
32:01
Chris Johnson: I mean, I do all I did a 93 year old 6 weeks ago, and I just saw him in the office.
32:07
Chris Johnson: Doing great, you know, the door see, you know, very thin bone, all that.
32:12
Chris Johnson: So yeah, there's, there's lots of opportunities and getting more synergistic studies, more multidisciplinary approach.
32:18
Chris Johnson: Um, I think Michelle Garrett.
32:21
Chris Johnson: don't know if you know, she, she, she was the president of MSTS and she's done a great job of doing, you know, the, we talk about the parody trial, the safety trial.
32:29
Chris Johnson: Now the perform trials coming out, those are all oncology studies, but they're all multidisciplinary perspective, randomized control styles.
32:36
Chris Johnson: Like, so really bringing the world together to study things, I think is going to be a huge
32:43
Joseph M. Schwab: Chris, this has been, um, absolutely fantastic.
32:46
Joseph M. Schwab: I, I would love to have you come out to the a HF annual meeting and maybe show your tripod technique and, and maybe some results of that.
32:53
Joseph M. Schwab: I, I know we've got surgeons out there who are hungry to see, maybe not to do oncology cases, but to see the limits of really what can be done with anterior approach, which is, which is one of the things that I'm hearing you describe.
33:05
Joseph M. Schwab: So we'd love to have you come out to Nashville next year.
33:08
Chris Johnson: Oh yeah.
33:09
Chris Johnson: I'd be happy to be there.
33:10
Chris Johnson: Sounds like a lot of fun.
33:11
Joseph M. Schwab: Um, and I really appreciate you joining me on the A HF podcast.
33:16
Joseph M. Schwab: We'll see you soon.
33:16
Joseph M. Schwab: Okay.
33:18
Chris Johnson: Okay.
33:18
Chris Johnson: Thanks for having me.
33:19
Chris Johnson: Appreciate it.
33:21
Joseph M. Schwab: Thank you for joining me for this episode of the A HF Podcast.
33:25
Joseph M. Schwab: We think of the a HF as a family.
33:27
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33:35
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33:43
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33:58
Joseph M. Schwab: New episodes of the ahf Podcast come out on Fridays.
34:01
Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and cancer free.