Latest / AHF Podcast / Cut For Time: Anterior Total Hip Replacement in the (Super) Morbidly Obese with Dr. Bob Sershon

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Cut For Time: Anterior Total Hip Replacement in the (Super) Morbidly Obese with Dr. Bob Sershon · AHF Podcast

• 0:24
  Joseph M. Schwab: Hello, and welcome to another episode of the A HF podcast.
• 0:29
  Joseph M. Schwab: I'm your host, Joe Schwab.
• 0:31
  Joseph M. Schwab: My guest today is Dr.
• 0:33
  Joseph M. Schwab: Robert Shan at the Anderson Orthopedic Clinic, and he's here to give us another cut for time episode.
• 0:40
  Joseph M. Schwab: Dr.
• 0:41
  Joseph M. Schwab: Shan, welcome to the A HF podcast.
• 0:44
  Joseph M. Schwab: Why don't you tell our listeners a little bit about your practice, your training, and what you're gonna talk about today?
• 0:51
  Bob Sershon: Yeah, I appreciate it.
• 0:52
  Bob Sershon: Thanks for having me on.
• 0:53
  Bob Sershon: Um, yeah, so Bob Shan Anderson Clinic, uh, Anderson Clinic trained actually, um, fellowship back in 20 18, 20 19, joined the practice right after that.
• 1:05
  Bob Sershon: COVID hit, which was, uh, interesting being first year in practice having that stuff happen.
• 1:12
  Bob Sershon: But, uh, it actually was ended up being great for me because a lot of the other places shut down and a bunch of revision volume and all the complex stuff that couldn't wait started to come in right away.
• 1:21
  Bob Sershon: So, um.
• 1:23
  Bob Sershon: Things, they couldn't wait.
• 1:24
  Bob Sershon: They had to go.
• 1:25
  Bob Sershon: That was still medically necessary.
• 1:26
  Bob Sershon: So it built a pretty quick practice through that.
• 1:29
  Bob Sershon: And, uh, over time, you know, when you do enough complex stuff, you kind of get known as the guy in the area that's doing that.
• 1:35
  Bob Sershon: So, um, a lot of the, uh, more difficult cases, more complex revisions, seeing things like that started to stroll through.
• 1:43
  Bob Sershon: So, um, now, you know, we're, we're.
• 1:46
  Bob Sershon: Out in Alexandria, Virginia, uh, really over the, uh, entire Northern Virginia area right outside of DC And, uh, my practice is only hip and knee replacements.
• 1:55
  Bob Sershon: Uh, we're very subspecialized at the Anderson Clinic.
• 1:59
  Bob Sershon: Basically, all of our partners are fellowship trained one way or the other, and just stick to their subspecialty.
• 2:03
  Bob Sershon: So you won't see me doing any ankles or wrists or anything like that.
• 2:08
  Bob Sershon: Uh, never did, never will.
• 2:09
  Bob Sershon: So, uh, probably terrible of those now.
• 2:11
  Bob Sershon: Um, but, uh, yeah.
• 2:14
  Bob Sershon: Yeah, that's it.
• 2:14
  Bob Sershon: We got great fellowship, do some research, um, you know, real proud of everything the institution's done so far and, you know, good talking about some, uh, big people on big cases.
• 2:26
  Joseph M. Schwab: Well, and we had you invited, you came and, and were part of the a HF uh, uh, annual meeting this past year in Nashville, and you are part of the revision session.
• 2:35
  Joseph M. Schwab: And we're intending to give this talk, uh, as a part of that session that, uh, session was so, uh, popular and had so much, uh, involvement from, uh, our audience and so much discussion back and forth that we literally lost time for your talk.
• 2:51
  Joseph M. Schwab: And so, uh, for better or for worse, you get to be the second in our, uh, cut for time series, uh, here on the a HF podcast, and you're gonna be talking to us about.
• 3:02
  Joseph M. Schwab: Uh, doing anterior approach in the super morbidly obese patient.
• 3:06
  Joseph M. Schwab: Is that correct?
• 3:07
  Bob Sershon: Uh, that's, that's right.
• 3:08
  Bob Sershon: And then we got, uh, one more case that just to add on, um, if we have time revision, uh, morbidly obese patient.
• 3:16
  Joseph M. Schwab: Let's, uh, let's get to it.
• 3:18
  Joseph M. Schwab: The floor is yours.
• 3:20
  Bob Sershon: Great.
• 3:21
  Bob Sershon: Great.
• 3:21
  Bob Sershon: So, um, here we go.
• 3:23
  Bob Sershon: These are my disclosures, you know, um, involved with Zimmer Biome and day care, so.
• 3:29
  Bob Sershon: High BMI, total hips, we know higher wound complications.
• 3:33
  Bob Sershon: It's not just from the front, from the back as well.
• 3:35
  Bob Sershon: Higher rates of PJI, higher revision rates.
• 3:38
  Bob Sershon: Really just any complication essentially.
• 3:40
  Bob Sershon: You name it.
• 3:41
  Bob Sershon: We found that it's, it's higher with higher BMI.
• 3:44
  Bob Sershon: Um, and then, you know, unfortunately on the flip side, a lot of these patients are doing it to, to lose weight and, you know, they, they really don't afterwards.
• 3:52
  Bob Sershon: And, uh, you know.
• 3:55
  Bob Sershon: Reasons why, who knows?
• 3:56
  Bob Sershon: Lifestyle life choices.
• 3:57
  Bob Sershon: It's just been too long for them.
• 3:59
  Bob Sershon: Uh, that's something I used to talk to people in clinic about, and Joe, I don't know if, if, if you talk to people in clinic about that afterwards, but, uh, I, I've stopped discouraging, um, them saying, Hey, you're probably not gonna lose weight after this.
• 4:11
  Bob Sershon: I give'em a chance.
• 4:13
  Bob Sershon: Uh, in my opinion, I Do.
• 4:14
  Bob Sershon: You do the same or.
• 4:16
  Joseph M. Schwab: Yeah, I, you know, it's, I, the weight discussion's always interesting, but it's, it's not likely that unless they gained a whole bunch of weight in the, you know, two years or so before they, uh, got their hip replacement because their hip was bothering them.
• 4:29
  Joseph M. Schwab: It's unlikely they're gonna lose it afterwards, but I, I don't usually mention it.
• 4:33
  Joseph M. Schwab: I encourage'em to be as active as they want to be.
• 4:36
  Bob Sershon: Yeah.
• 4:37
  Bob Sershon: Yeah.
• 4:37
  Bob Sershon: And I, and that's the route to go of it.
• 4:39
  Bob Sershon: You know, in the back of my mind I just say, all right, we're doing this for pain relief and hopefully better function if the weight comes.
• 4:44
  Bob Sershon: That's a huge plus.
• 4:45
  Bob Sershon: So.
• 4:46
  Bob Sershon: Uh, you know, where that goes, you know, in, in our world unfortunately is, you know, harder surgery, arguably worse outcomes and not necessarily patient reported outcomes, right?
• 4:55
  Bob Sershon: 'cause they get, they get substantial relief from that aspect, but we're talking complications.
• 5:00
  Bob Sershon: Um, and then is it worth the risk?
• 5:02
  Bob Sershon: I mean, you have a lot of institutions on bundled programs.
• 5:05
  Bob Sershon: Um.
• 5:06
  Bob Sershon: Yeah, some people get dinged for having complications at their institutions, readmissions, reoperations.
• 5:12
  Bob Sershon: And so some people just won't even take these patients on and they've drawn these hard cutoffs that makes access for them pretty hard.
• 5:18
  Bob Sershon: So, uh, we don't have that, uh, at our institution and we, we take all comers and we try to individualize it because the risk is really gonna be shared right between the patient and the surgeon.
• 5:27
  Bob Sershon: So, um, it's not our hip that's getting infected, it's, it's their hip and they have to live with that.
• 5:32
  Bob Sershon: And that's, that's a tough thing to live with.
• 5:34
  Bob Sershon: So.
• 5:35
  Bob Sershon: Um, we, we just do shared decision making and, and if we feel like their pain and function are significantly, uh, impacting their life, then we go ahead with the replacement knowing that hey, they, they might have a complication that somewhat of normal weight didn't have.
• 5:49
  Bob Sershon: Um, we're just very straightforward about that.
• 5:52
  Bob Sershon: So, you know, dealing with this population and preoperative planning is so important.
• 5:58
  Bob Sershon: So, um, you have, you know, the exam mobility, I'm not just talking about their mobility walking in the room, I'm talking about the mobility of their panis, right?
• 6:07
  Bob Sershon: So you have some people that have a very mobile panis.
• 6:10
  Bob Sershon: Um, it, it moves, it gets out of the way easy.
• 6:13
  Bob Sershon: Uh, you know, some people you looked underneath.
• 6:16
  Bob Sershon: I got a little bit of what we'll call some funky stuff, and that's something that you, you really wanna, you know, uh, pay attention to because you don't want fungal infections and things like that.
• 6:27
  Bob Sershon: Those are notoriously hard to treat.
• 6:29
  Bob Sershon: So that's someone where you may say, oh man, I actually have to go through the back on this one.
• 6:33
  Bob Sershon: Uh, just to avoid any type of local, um, contamination, uh, booty check, right?
• 6:40
  Bob Sershon: I, I teller fellows do booty check where, where do they store their fat?
• 6:43
  Bob Sershon: 'cause some people actually from the front.
• 6:47
  Bob Sershon: All their fat is stored posteriorly and, and actually, you know, they may be morbidly obese and have large bellies, but maybe it's mobile.
• 6:54
  Bob Sershon: You tape it outta the way.
• 6:55
  Bob Sershon: Um, they don't really have much in the way of soft tissue in the front, and it's really not that much more difficult of a case to do so where they store their fat.
• 7:04
  Bob Sershon: Really, um, uh, important for, for DA and then leg lengths.
• 7:10
  Bob Sershon: You know, I, I tell the, you know, the fellows, Hey, we wanna be close.
• 7:14
  Bob Sershon: Like we, we wanna, leg lengths are one of the biggest things for litigation and patient satisfaction.
• 7:20
  Bob Sershon: Um, but you know, if you have to give them a few more millimeters of offset or length in order to give yourself a, a stable hip in this population, feel free to plan to do that.
• 7:31
  Bob Sershon: Um, in terms of implants.
• 7:33
  Bob Sershon: You know, you could use whatever you want.
• 7:34
  Bob Sershon: It's dealer's choice.
• 7:35
  Bob Sershon: I think all the data at this point though, um, from both anterior posterior is pointing towards these triple tapered stems with a collar, uh, the cup.
• 7:44
  Bob Sershon: I like to use a cup that you can get a large head and a smaller cup.
• 7:47
  Bob Sershon: So, um, almost every company at this point now, you can get a 36 head or larger to size 50, uh, which is, which is great.
• 7:55
  Bob Sershon: Um, some companies are already at a 52, you're starting to get a 40 head in there.
• 7:59
  Bob Sershon: Um, that's, that's definitely positive.
• 8:02
  Bob Sershon: If you can't, uh, consider dual mobility, maybe this is a population at increased risk or dislocation.
• 8:07
  Bob Sershon: Um, whether or not that's also true from the front, that's probably debatable, but, uh, it is something that you want to keep in mind.
• 8:14
  Bob Sershon: Uh, constrained line.
• 8:15
  Bob Sershon: I mean, I think that's just overkill on a first timer.
• 8:18
  Bob Sershon: Um, automated impact or, I, I love using these things, you know, whether you're using.
• 8:24
  Bob Sershon: You know, we could do branded by, by company, you know, concise or hammer one of these things.
• 8:29
  Bob Sershon: Uh, I think it saves a ton of time.
• 8:31
  Bob Sershon: It gives you consistent impacting all the way through for me, it really helps me control the version, uh, of the STEM as it's getting sent on the way down.
• 8:39
  Bob Sershon: Um, which is, which is great.
• 8:42
  Bob Sershon: Then also your other technology.
• 8:43
  Bob Sershon: These are larger people.
• 8:44
  Bob Sershon: So you know, if you're doing this off table with no fluoro, I would say that that's a hard task.
• 8:50
  Bob Sershon: Um, it's hard to feel their malleoli, everything's draped out.
• 8:55
  Bob Sershon: Uh, I, I prefer in, in my practice to use some sort of navigation, um, ai, robotic platform, mixed reality, whatever people want to use.
• 9:04
  Bob Sershon: Then have offset ready.
• 9:05
  Bob Sershon: And by offset I'm talking offset reamers, offset insertion handles, offset broaches, offset insertion.
• 9:12
  Bob Sershon: Anything that you can do to have offset, even the hand table, if you're using a table, uh, you know, they have the standard hook and the high offset hooks.
• 9:21
  Bob Sershon: So these are all things that you're gonna wanna have ready, maybe not necessarily used, but at least have ready, um, when you're, when you're planning for the surgery.
• 9:30
  Joseph M. Schwab: Do.
• 9:30
  Joseph M. Schwab: Any challenges with the, do you see any challenges with the automated impactor in, in these large individuals?
• 9:38
  Joseph M. Schwab: I know, uh, or is it, is that just taken care of by the offset, um, you know, broach handles and things like that?
• 9:45
  Bob Sershon: I, I only use the, the straight impact, or I, I haven't used the offset.
• 9:50
  Bob Sershon: I, I've had it ready in preparation of, Hey, they're just too big.
• 9:53
  Bob Sershon: I can't get this out of the way.
• 9:55
  Bob Sershon: But I, I've personally not run into the issue.
• 9:57
  Bob Sershon: Um, I, I don't know, have, have you.
• 10:00
  Joseph M. Schwab: No, I, I mean, I, it's, it's interesting that you mention that, right?
• 10:02
  Joseph M. Schwab: Because, um, you know, originally when I first started, uh, well over a decade ago.
• 10:09
  Joseph M. Schwab: I, I think I was using offset on everybody just'cause I thought that was, would be easier.
• 10:14
  Joseph M. Schwab: And I've gotten to the point where I just, I rarely use offset even in the more obese, uh, patients.
• 10:20
  Joseph M. Schwab: And, uh, with something as big as a, as some of these automated impactors are, it seems to be far enough away from the patient, even in obese situations that it hasn't, I haven't noticed it being problematic.
• 10:34
  Bob Sershon: Yeah, I'm, I'm right with you on that.
• 10:36
  Bob Sershon: I think they do have offset.
• 10:38
  Bob Sershon: Articulations or handles that you could pop in there if you need.
• 10:41
  Bob Sershon: Um, but I do wonder how much power is, is lost through that.
• 10:46
  Bob Sershon: Um, but, uh, may, maybe I'll give it a whirl one day, but, but for now, I just haven't needed it.
• 10:51
  Bob Sershon: So, um, so here we go.
• 10:54
  Bob Sershon: You know, 55-year-old female coming in, BMI 55.
• 10:57
  Bob Sershon: Uh, she traveled two hours for surgery because nobody locally was able to take care of her, whether or not it was from cutoffs or they just couldn't handle the case.
• 11:05
  Bob Sershon: It, you know, that's debatable problem's been going on for years.
• 11:09
  Bob Sershon: Um, you know, really these, this pa this population usually comes to you trying extensive non-operative treatment.
• 11:16
  Bob Sershon: Um, most of these patients, at least that I've seen it.
• 11:19
  Bob Sershon: Has some type of intraarticular steroid injection, which, which for me is really just diagnostic is, is it really coming from their hip?
• 11:26
  Bob Sershon: Um, especially when they don't have, you know, severe erosive bone, bone arthritis, like I'll show you on the next case.
• 11:31
  Bob Sershon: Um, so, and we do all that planning and here we go.
• 11:34
  Bob Sershon: So here's, here's the, uh.
• 11:36
  Bob Sershon: Intraoperative views.
• 11:37
  Bob Sershon: I'm trying to give you all of the same patient here so that we can see.
• 11:40
  Bob Sershon: But you know, even with her on the table, she has such a large panis that it is completely over the operative site, even with Lang supine.
• 11:49
  Bob Sershon: Um, the uh.
• 11:51
  Bob Sershon: The center, you know, leg holder there if you will, um, between the legs you could barely see.
• 11:56
  Bob Sershon: It's kind of poking its way out.
• 11:58
  Bob Sershon: But she's one of these people that has a large mobile panis.
• 12:03
  Bob Sershon: Um, and so you would say, Hey, this actually isn't that terribly difficult of a case once you take the outta the way and you let the fat fall posteriorly as well as you could see.
• 12:15
  Bob Sershon: I mean, it's hanging down there pretty low.
• 12:18
  Bob Sershon: Um.
• 12:20
  Bob Sershon: Pre-op fluoro views are, you know, you just wanna match exactly what you got.
• 12:25
  Bob Sershon: Pre-op uh, there's, there's been debate back and forth about standing versus supine views and, you know, functional range of motion and all of these, all, all of these other factors.
• 12:37
  Bob Sershon: What, what we found at our institution.
• 12:38
  Bob Sershon: We tried doing standing views for a while.
• 12:42
  Bob Sershon: Um.
• 12:43
  Bob Sershon: With patients like, like this, they're morbidly obese.
• 12:47
  Bob Sershon: You, the pan is hanging so low that you have a really hard time, at least we did getting quality x-rays and then reproducing their standing film supine.
• 12:57
  Bob Sershon: You were doing all these crazy things with fluoro.
• 13:00
  Bob Sershon: Um, so we actually.
• 13:03
  Bob Sershon: After trying standing, went back to supine films on everyone.
• 13:07
  Bob Sershon: All of our surgeons, uh, at the clinic, for the most part, they're, uh, are doing da and that's how we positioned during surgery.
• 13:14
  Bob Sershon: Um, so, so we've continued getting, getting supine and just matching supine.
• 13:19
  Bob Sershon: And, uh, you know, fortunately on our dislocation side, I mean our rate at the institution for anterior is, you know, like 0.3 some something below a half percent.
• 13:28
  Bob Sershon: Are you doing anything different?
• 13:29
  Bob Sershon: Are you getting standing films or?
• 13:32
  Joseph M. Schwab: No, in my practice it's supine.
• 13:34
  Joseph M. Schwab: Um, I, you know, I'm, uh, a bit of a, a Joel Matta disciple on this.
• 13:39
  Joseph M. Schwab: You know, he always teaches the frontal plane of the body is what's most important.
• 13:43
  Joseph M. Schwab: You know, the, the position.
• 13:45
  Joseph M. Schwab: Uh, supine versus standing is less important than the position of the frontal plane of the body with the pelvis in the position that you're operating in, so usually supine.
• 13:56
  Joseph M. Schwab: Um,
• 13:57
  Bob Sershon: so we're on the
• 13:57
  Joseph M. Schwab: yeah, I mean it's, we're, we're, we're talking probably like you described, you know, less than hundredths of tenths of a percent difference probably in our dislocation rates based on that.
• 14:10
  Joseph M. Schwab: So, who knows?
• 14:12
  Bob Sershon: Yeah.
• 14:13
  Bob Sershon: So, um, but it's important to get, you know, to, to really match these shots and, and, um, if you're not using, uh, navigation or something like that, it's hard to get the C-arm unless you have one of those large, you know, 12 inch or or larger square, uh, c-arm that I've seen.
• 14:30
  Bob Sershon: Um, it's hard to get the entire pelvis in there, and then there's a lot of parallax.
• 14:34
  Bob Sershon: So, uh, that's, that's a challenge if you're not using something where you can do an overlay.
• 14:39
  Bob Sershon: Um.
• 14:41
  Bob Sershon: So now you got everything draped out.
• 14:43
  Bob Sershon: We do that normally.
• 14:44
  Bob Sershon: And then, you know, from the bikini standpoint, the way that I like to do it, and, and there's not too many variations of this'cause it, it's not a very forgiving incision if you're not in the right spot.
• 14:55
  Bob Sershon: Um, so I'll, I'll put my, my pinky finger right on the a SIS and then go three finger breaths distal.
• 15:02
  Bob Sershon: Uh, and that's been the most reproducible way for me.
• 15:05
  Bob Sershon: I mean, some people just, you know, put their ring finger, um, right below a SIS, but, uh, that that's how I do it.
• 15:12
  Bob Sershon: And.
• 15:13
  Bob Sershon: Most patients, I mean, the incisions a little bit smaller probably than 10 centimeters.
• 15:18
  Bob Sershon: But on these larger patients, I give a larger incision.
• 15:22
  Bob Sershon: Uh, it's you, you just have to, for visualization purposes, in my opinion.
• 15:28
  Bob Sershon: Um, I tend to not travel medially to the A SIS, although I would tell you in a large patient where you have a really thick subcutaneous fat layer, you're probably safe to do that.
• 15:39
  Bob Sershon: Without, you know, being at risk of getting into any of the vessels or anything like that.
• 15:42
  Bob Sershon: So let me get to the next one.
• 15:49
  Bob Sershon: So the approach is pretty standard.
• 15:51
  Bob Sershon: Once you get through the skin, right, you get down to the fascia, you find your A SIS, that's gonna be your lighthouse.
• 15:55
  Bob Sershon: It's gonna tell you, Hey, this is where I know I'm at.
• 15:59
  Bob Sershon: It's a reproducible landmark.
• 16:00
  Bob Sershon: And so for anyone taking these cases on for the first time, I would say, Hey, make your incision.
• 16:07
  Bob Sershon: Feel a SIS know where you are in terms of space and then get into your capsule, or sorry, into your fashion work your way down to capsule from there, uh, once you get down into the hip, I, I like to use an inferior tag stitch on the inferior LA image.
• 16:22
  Bob Sershon: It just helps get the capsule out of the way.
• 16:24
  Bob Sershon: Uh, some people don't do that.
• 16:25
  Bob Sershon: Some people do a complete capsulotomy or a capsulectomy, I should say.
• 16:29
  Bob Sershon: That's probably dealer's choice.
• 16:31
  Bob Sershon: Are, are you doing anything different on that in terms of the, the, uh, capsule.
• 16:36
  Joseph M. Schwab: No caps.
• 16:37
  Joseph M. Schwab: Capsular management for me is, is a, a stitch on, on both flaps and I, I do a capsulotomy and I, I use those as retractors basically.
• 16:45
  Bob Sershon: Exactly.
• 16:46
  Bob Sershon: Yep.
• 16:47
  Bob Sershon: I mean, it's, it's really nice to use his retractors and it, it really helps stay outta the way, especially with a bikini, you're not mastering the middle of the incision.
• 16:55
  Bob Sershon: Um.
• 16:55
  Joseph M. Schwab: Right.
• 16:55
  Joseph M. Schwab: I.
• 16:56
  Bob Sershon: Uh, on these large patients, I, I almost never use fluoro to identify the saddle or what I wanna make my neck cut.
• 17:04
  Bob Sershon: Uh, but on these, if I'm not sure, bring in fluoro, um, it, it is such a useful tool for anterior, especially in, in a learning curve or your, your fresh out of fellowship or something like that.
• 17:17
  Bob Sershon: Um, and if it's a big stiff hip, like this lady was very mobile, um, but if it's a big stiff hip, uh, make a napkin ring.
• 17:25
  Bob Sershon: Like make it easy on yourself to get that head out.
• 17:28
  Bob Sershon: Uh, and early on, I, I did that on every case.
• 17:31
  Bob Sershon: And then as I got more comfortable and just more confident with doing things, I, I, I moved away from it.
• 17:36
  Bob Sershon: But I don't think you're ever really wrong to do that.
• 17:40
  Joseph M. Schwab: Are you normally just doing a single cut on your, on your standard primaries?
• 17:44
  Bob Sershon: Normally, yes.
• 17:45
  Bob Sershon: Um, and that's stem.
• 17:47
  Bob Sershon: Yeah.
• 17:48
  Bob Sershon: We can go back to that.
• 17:49
  Bob Sershon: I mean, that's, uh, STEM dependent as well, right?
• 17:52
  Bob Sershon: So.
• 17:53
  Bob Sershon: Some of, some of these implants have a little bit of a longer neck built in, uh, naturally.
• 17:57
  Bob Sershon: Uh, like if we're gonna compare vendors, like I, I would say that, you know, I feel that, you know, the Z one has a little bit of a longer neck than Actis.
• 18:05
  Bob Sershon: If you're looking at triple taper stems, those are the two that I used here.
• 18:08
  Bob Sershon: So, you know, I might cheat a little lower if I use Zimmer or if I, you know, I have to use the pew, I might go a little bit higher with a net cut.
• 18:15
  Bob Sershon: Um, but it, that's, that's again, deal dealer's choice.
• 18:18
  Bob Sershon: No right or wrong there.
• 18:22
  Bob Sershon: So with reaming, I, I still, even in these large patients, ream with a straight reamer, um, I haven't used, uh, at least that I can remember.
• 18:31
  Bob Sershon: Maybe I have, but I, I don't recall using the offset reamer, even though I have it available all the time.
• 18:37
  Bob Sershon: 'cause you just don't wanna get in a situation where they have such large anterior subcutaneous fat on their thigh that it's.
• 18:44
  Bob Sershon: Pushing you completely inverted and vertical, um, which is the tendency, uh, on these patients when you're reaming.
• 18:52
  Bob Sershon: So, uh, do, do you switch over in the larger patients to offset, or do you use offset all the time, or you said you
• 18:57
  Joseph M. Schwab: No, generally.
• 18:59
  Joseph M. Schwab: Generally straight reamer.
• 19:00
  Joseph M. Schwab: Yeah, generally straight reamer.
• 19:02
  Joseph M. Schwab: Mm-hmm.
• 19:02
  Bob Sershon: Yeah, it's, it's amazing.
• 19:03
  Bob Sershon: I mean, just'cause it's hemispherical, I mean, you, you get a great ream.
• 19:07
  Bob Sershon: Um, I think you just on these patients especially need to be careful about not reaming out the anterior wall because that fat is gonna wanna push you anterior.
• 19:18
  Bob Sershon: Um, it'll also want to have, you have a tendency to raise the, uh, the center of the cup as well.
• 19:25
  Bob Sershon: So, um, I'm, when I'm reaming I'm kind of pushing down in posterior to, uh, to keep the hip center lower as or as low as we reasonably can and to not ream out the anterior wall.
• 19:37
  Bob Sershon: 'cause I do it under direct visualization.
• 19:39
  Bob Sershon: So this picture here is with the lights off the wound, no headlight on, and you could still see in the wounds.
• 19:46
  Bob Sershon: Then you could imagine, turn your headlight on, put the, or the operative field lights pointing back in the wound.
• 19:51
  Bob Sershon: Um, and you get actually a, a very reasonable view here.
• 19:56
  Bob Sershon: Uh, I like to, when I'm reaming, uh, under visualization take out, uh, so if we're gonna say that towards the head is 12 o'clock, I'll usually have, uh, like a pointed cobra.
• 20:09
  Bob Sershon: I call it the medium, um, right down near the TAL.
• 20:13
  Bob Sershon: And I'll take that out because that tends to get in the way of the reamer for me.
• 20:18
  Bob Sershon: And I'll just have that shorty that pointed shorty retractor that you could see, um, right over the anterior brim there.
• 20:24
  Bob Sershon: And then something posteriorly to help me from catching all the fat and tissue as I'm getting in and out of the wound.
• 20:30
  Bob Sershon: Um, so you know, then when you send your, you know, your reamer down, you could use fluoros.
• 20:36
  Bob Sershon: I'm bringing Fluor up here to show you.
• 20:39
  Bob Sershon: Just the AP pelvis that I always get to make sure that I have symmetric obterator and that I'm not in a inlet or outlet view.
• 20:46
  Bob Sershon: I'm matching their, their ap, that we got supine beforehand in these larger patients.
• 20:51
  Bob Sershon: But if you're not sure how medial you've reamed or you want to get more medial, you're not sure of your cup size.
• 20:58
  Bob Sershon: Bring in fluoro ream under fluoro if you don't usually do that, I mean, a lot of guys, you know, especially, you know, really high volume guys can ream under fluoro really well, um, without reaming out the walls.
• 21:09
  Bob Sershon: Um, do you ream under fluoro or are you a direct visualization guy?
• 21:13
  Joseph M. Schwab: No, I'm a, I'm a ream under fluoro guy, uh, with a, with a direct visualization double check.
• 21:18
  Joseph M. Schwab: I would say less than half the time, but, but yeah.
• 21:22
  Joseph M. Schwab: Uh, um, it's, uh, the, it's one of the benefits that you mentioned, and I, I think this is true even in, in straightforward patients.
• 21:30
  Joseph M. Schwab: But in difficult patients, if you're ever not sure what's going on.
• 21:33
  Joseph M. Schwab: Uh, or you want to double check, bring fluoro in.
• 21:35
  Joseph M. Schwab: It's just super easy.
• 21:36
  Joseph M. Schwab: Right?
• 21:37
  Joseph M. Schwab: And, and it's, whether it's with your cup or with your stem, or with your approach, uh, with your, your cuts.
• 21:42
  Joseph M. Schwab: Yeah.
• 21:43
  Joseph M. Schwab: Just bring fluoro in.
• 21:45
  Bob Sershon: Yeah.
• 21:45
  Bob Sershon: And the, and the feel on these patients is admittedly not as good in terms of how you feel the reamer catching and engaging.
• 21:52
  Bob Sershon: Uh, so what, what I'll do is I'll, you know, on all the cases we just measure the head we go up.
• 21:58
  Bob Sershon: It's just like, let's say we measured a 51 millimeter head.
• 22:01
  Bob Sershon: I'd start at a 51, uh, reamer and, and probably get up to a 53.
• 22:06
  Bob Sershon: Um.
• 22:07
  Bob Sershon: On these patients.
• 22:08
  Bob Sershon: Some people they like to ream very small to medial eyes and then get bigger and bigger and bigger.
• 22:13
  Bob Sershon: I think that's probably a little bit more dangerous under direct visualization'cause you can't really see that you're, you're centered and not ec eccentrically reaming.
• 22:23
  Bob Sershon: Um, so I, I would say if you normally start small and go up, my preference for this case specifically would be, Hey, change it up a little bit.
• 22:31
  Bob Sershon: Start with a reamer that really fills the acetabulum early on.
• 22:36
  Bob Sershon: And media lies from there.
• 22:39
  Bob Sershon: Um, and then you have your offset, and again, navigation or, you know, mixed reality.
• 22:45
  Bob Sershon: What whatever you want to use is great for there.
• 22:47
  Bob Sershon: So you get your cup in.
• 22:49
  Bob Sershon: I always have my templates up.
• 22:51
  Bob Sershon: I am crippled if I don't have templates.
• 22:55
  Bob Sershon: I, I mean, I.
• 22:56
  Bob Sershon: I rely on it for everything.
• 22:58
  Bob Sershon: Um, just as a double check and, you know, how medial should I go, how many yield do I wanna go?
• 23:03
  Bob Sershon: And these larger patients, um, I will personally have, you know, less of a, uh, hesitation to leave their cup of hair more lateral just to help with a little bit of offset.
• 23:16
  Bob Sershon: Um, if I don't wanna lengthen them and maybe I want to add a couple millimeters of offset for.
• 23:21
  Bob Sershon: Attention purposes.
• 23:23
  Bob Sershon: Um, but, but here, you know, we, we matched it, you know, fairly close, uh, to our clan.
• 23:27
  Bob Sershon: The cups probably the sides are too bigger than what we templated, but in these larger patients, depending on where they put the calibration marker, uh, you could, you could be way off.
• 23:37
  Bob Sershon: Um, so, so just be aware of that as well.
• 23:43
  Bob Sershon: This is where I think the, other than the wound healing being.
• 23:48
  Bob Sershon: Being better.
• 23:49
  Bob Sershon: Um, this is where I think Bikini really helps with large patients and very muscular patients.
• 23:57
  Bob Sershon: Uh, you know, to cook convinced me to switch over to this, uh, maybe a year or two ago, I can't remember.
• 24:03
  Bob Sershon: But, um, he said, Bob, one of the craziest things is that the femoral prep is easier and I, it, it just, it never made sense to me.
• 24:11
  Bob Sershon: I said, I have a horizontal incision that's limiting how proximal I get.
• 24:16
  Bob Sershon: How can the femur.
• 24:17
  Bob Sershon: Easier.
• 24:19
  Bob Sershon: And it is, and I, I think a lot of it is because of that medial Mueller that I have there, the white handle, uh, on the, on the image, it allows you to, to pull a little bit more medial and present the femur laterally, which is probably the more limiting factor with getting femoral exposure to these large patients.
• 24:39
  Bob Sershon: Um, so I, I find the femur on these patients to actually not be very challenging at all.
• 24:45
  Bob Sershon: Um.
• 24:46
  Bob Sershon: Not, I shouldn't say at all to not be as, as, as challenging, uh, than, than with a standard incision.
• 24:55
  Bob Sershon: Um, I use all my standard retractors, uh, standard sequential releases, you know, capsule and a still type, you know, piriform ish or external rotators, kind of the normal trajectory.
• 25:06
  Bob Sershon: All of us.
• 25:07
  Bob Sershon: Uh, follow.
• 25:08
  Bob Sershon: Um.
• 25:09
  Bob Sershon: And then one of the, you know, the big helps here is I, I usually just do these cases.
• 25:16
  Bob Sershon: Um, like if the fellow's not in the room, just with my pa she's on the other side of the table.
• 25:20
  Bob Sershon: And, um, if you're alone in doing these cases, like the fellow's not there, in my case, just have your tech come and give a little hip check to add up to the hip a little bit.
• 25:30
  Bob Sershon: Um, you know, right at the distal thigh that goes.
• 25:34
  Bob Sershon: That is just so helpful for, for bringing the femur, um, into a more, you know, I guess distally, abduct, a deducted and approximately abducted, uh, space.
• 25:44
  Bob Sershon: So, um, then you, you know, you get everything in and you go to closure and what's amazing.
• 25:55
  Bob Sershon: That I noticed early on is once you take the retractors out, that the picture to the left here, maybe, hopefully my mouse is working.
• 26:04
  Bob Sershon: That's nothing.
• 26:06
  Bob Sershon: We haven't put anything in there yet.
• 26:08
  Bob Sershon: It, it just, it closes on itself.
• 26:10
  Joseph M. Schwab: Yeah.
• 26:12
  Bob Sershon: Yeah.
• 26:12
  Bob Sershon: And it's just amazing in these larger patients, it's a long, you know, it's along the lines of tension.
• 26:18
  Bob Sershon: It just closes on itself.
• 26:19
  Bob Sershon: So then, you know, here's, you know, our running four oh closure.
• 26:23
  Bob Sershon: Um, and then we'll put on usually either a, you know, silver impregnate dressing or a just a tepa tegaderm.
• 26:30
  Bob Sershon: Uh, if we're not really worried in patients with a really large panis, I like to put something on that's just gonna be.
• 26:37
  Bob Sershon: Super watertight and I could leave on for two weeks at a time.
• 26:41
  Bob Sershon: Um, I'll give them another one of these dressings here and tell'em, Hey, in two weeks when you, or 10 days when you take that off, slap another one on, um, just to keep any of the, the, the bacterial burden underneath the panis, away from that wound.
• 26:58
  Bob Sershon: Um, what are you doing for your, for your dressings in these patients?
• 27:02
  Joseph M. Schwab: So exactly the same.
• 27:04
  Joseph M. Schwab: Um, you know, the question that I was gonna ask is some people talk about doing things like vacuum assisted, uh, dressings, you know, vac dressings over the top ones that people can go home with.
• 27:15
  Joseph M. Schwab: Uh, some people, um, some surgeons that I've talked to will put, um.
• 27:21
  Joseph M. Schwab: Essentially a, a, a large, almost kind of diaper in the area over the, uh, over the dressing itself to just act as a barrier and, and act as, you know, to prevent, um, any friction maybe from, uh, moving the dressing or curling up the dressing or anything like that.
• 27:40
  Joseph M. Schwab: What I was gonna ask is, do you let them shower with this?
• 27:45
  Joseph M. Schwab: Yep.
• 27:47
  Bob Sershon: Yeah, right off the bat.
• 27:48
  Bob Sershon: Um, are you keeping them from doing that or
• 27:50
  Joseph M. Schwab: Not at all.
• 27:51
  Joseph M. Schwab: I, I encourage him to shower.
• 27:54
  Bob Sershon: Yeah, the, the VAC dressings, um, you know, there's reasonable data that is showing that, that it helps in these higher risk wounds.
• 28:02
  Bob Sershon: So, I, I, I can't argue too much against it.
• 28:06
  Bob Sershon: I just, in my population, for whatever reason, um, it almost promoted drainage.
• 28:12
  Bob Sershon: And I, I, I don't, I don't, I can't explain it.
• 28:16
  Bob Sershon: That's just my experience.
• 28:17
  Bob Sershon: I'm not gonna poo the wound vax.
• 28:19
  Bob Sershon: So, um, so that's, that's one.
• 28:22
  Bob Sershon: The other thing is, you know, the VAX would malfunction and they'd be beeping and we'd get a bunch of calls from patients.
• 28:27
  Bob Sershon: So we, we kind of moved away from that.
• 28:30
  Bob Sershon: What I used to do on these patients, which is kind of cruel, is I'd put'em in a pelvic girdle
• 28:36
  Joseph M. Schwab: Oh
• 28:36
  Bob Sershon: uh.
• 28:37
  Bob Sershon: Yeah.
• 28:38
  Bob Sershon: Yeah.
• 28:39
  Bob Sershon: I, I like a, almost a corset.
• 28:41
  Joseph M. Schwab: Yeah.
• 28:42
  Bob Sershon: it, I, that's when I was doing a standard incision.
• 28:45
  Bob Sershon: I'll tell you what, it, it worked, but they, they didn't like me for it.
• 28:49
  Joseph M. Schwab: to, to minimize swelling, basically.
• 28:51
  Joseph M. Schwab: Minimize any sort
• 28:52
  Bob Sershon: well, to hold the panis up
• 28:54
  Joseph M. Schwab: oh.
• 28:54
  Joseph M. Schwab: Okay.
• 28:54
  Bob Sershon: to like, to, you know, like you, you see those cartoons where, you know, you got this spat guy and you know, this like good looking woman walks by and he puts the girdle on her and he makes his chest bluff up.
• 29:04
  Bob Sershon: It's like, that's.
• 29:05
  Bob Sershon: That's kind of what we were doing.
• 29:07
  Bob Sershon: And, uh, I, I just, it was, I found it.
• 29:10
  Bob Sershon: I, I don't know.
• 29:11
  Bob Sershon: Patients didn't love it.
• 29:12
  Bob Sershon: We'll put it that way.
• 29:14
  Joseph M. Schwab: you're, you're not using any skin glue on this.
• 29:16
  Joseph M. Schwab: It doesn't look like Right.
• 29:17
  Joseph M. Schwab: It's just the Monocryl and then dressing.
• 29:20
  Bob Sershon: Uh, no.
• 29:20
  Bob Sershon: We, we did, um, use derma bond.
• 29:23
  Joseph M. Schwab: Okay.
• 29:24
  Bob Sershon: We put derma bond on all of it.
• 29:26
  Bob Sershon: Yeah.
• 29:26
  Joseph M. Schwab: Okay.
• 29:27
  Joseph M. Schwab: All right.
• 29:29
  Bob Sershon: Fortunately, haven't had any.
• 29:31
  Bob Sershon: On the bikinis, uh, and the large patients.
• 29:33
  Bob Sershon: I haven't had any of those adhesive reactions.
• 29:36
  Bob Sershon: I, I do worry about that.
• 29:38
  Bob Sershon: Um.
• 29:39
  Bob Sershon: So if people just wanna do the silver impregnated, they're, they're fine to do that.
• 29:43
  Bob Sershon: Um, but this is, this is her four week follow up, right?
• 29:47
  Bob Sershon: So, um, incisions healing.
• 29:50
  Bob Sershon: Well, you know, she's, she's doing well.
• 29:52
  Bob Sershon: She was really deconditioned before this, so, um, you know, she's, she's still getting around with a cane and things like that.
• 29:58
  Bob Sershon: But just'cause she's gassed and, uh, no hip pain, right?
• 30:02
  Bob Sershon: I mean, doing really well.
• 30:03
  Bob Sershon: Super thankful.
• 30:04
  Bob Sershon: Um, and that's, you know.
• 30:06
  Bob Sershon: That's how you get through it.
• 31:20
  Bob Sershon: Then you get, you know, cases like this.
• 31:24
  Bob Sershon: Um, and this, this poor woman, I mean, you know, she's 50, you know, 52, um, horrific hip.
• 31:34
  Bob Sershon: That clearly has been a problem for a long time.
• 31:38
  Bob Sershon: And, uh, I, I said, when did you first.
• 31:42
  Bob Sershon: Try to get a hip replacement.
• 31:43
  Bob Sershon: Like, how long have you been living like this?
• 31:45
  Bob Sershon: 'cause she, she came in in a wheelchair and, uh, oh.
• 31:48
  Bob Sershon: For a decade.
• 31:50
  Bob Sershon: You know, no one would touch me for a decade.
• 31:53
  Bob Sershon: Yeah.
• 31:53
  Bob Sershon: Um.
• 31:55
  Bob Sershon: Just'cause she, they kept telling her, you're too young, or You're too heavy, you're too young, you're too heavy.
• 31:59
  Bob Sershon: And, uh, and just a total shame and lost like prime decade of her life to this.
• 32:05
  Bob Sershon: Uh, but these are really tough cases because the joint, you could see, I, I should have taken the templates off here, but, uh, the, the joints almost auto fused.
• 32:16
  Bob Sershon: Um.
• 32:17
  Bob Sershon: Really no range of motion.
• 32:19
  Bob Sershon: When she tries to stand up to walk, she's leaning forward like 30, 40 degrees.
• 32:24
  Bob Sershon: 'cause she's got such a terrible flexion contracture and now her back's affected.
• 32:28
  Bob Sershon: And, um, you know, and then she had one of these not super mobile panes to go on top of it.
• 32:36
  Bob Sershon: Um, which, you know, just, just that makes it so, so much more difficult, um, in, in any situation.
• 32:44
  Bob Sershon: So for her.
• 32:46
  Bob Sershon: You know, we just did much of the same.
• 32:47
  Bob Sershon: So, so this is just showing here.
• 32:49
  Bob Sershon: Okay.
• 32:50
  Bob Sershon: You get him on your back, you, you try to reproduce as best he can.
• 32:53
  Bob Sershon: The, the AP view.
• 32:55
  Bob Sershon: Um, and she started, which I wanna show you, and I'm curious of your thoughts on this.
• 33:00
  Bob Sershon: You know, she started over an inch short and, uh, I mean, what, what's your threshold here for, for lengthening when it's been about a decade with a hip?
• 33:11
  Bob Sershon: Probably not this bad, but definitely shortening.
• 33:15
  Joseph M. Schwab: Yeah, boy, it, it depends on a number of factors, but if this was a a true, if this was a pediatric situation, I, I would probably aim to make up only about a half to two thirds of it.
• 33:27
  Joseph M. Schwab: But if it's been over the last 10 years and she had, or you feel confident she had sort of a demonstrably normal hip before that, I, I think this is one that you could probably get all the way back.
• 33:41
  Joseph M. Schwab: Um.
• 33:42
  Joseph M. Schwab: And obviously, I mean, it looks to me like she's in fixed external rotation too, right?
• 33:47
  Joseph M. Schwab: So, yes.
• 33:49
  Joseph M. Schwab: So that can.
• 33:51
  Joseph M. Schwab: I, I have found that that can, um, affect a little bit the measurement of, uh, of leg length, at least with the, the line, uh, you know, using lines, um, just because you're, you're catching a different, uh, profile of the lesser tro canner, um, you know, depending on what, uh, what landmarks you're using.
• 34:12
  Joseph M. Schwab: So this is one I would say I'm prepared to make her even.
• 34:18
  Joseph M. Schwab: I'm prepared to not make her exactly even, but to give her back at least two thirds.
• 34:23
  Joseph M. Schwab: Um, but I'm prepared to use a lot of fluoroscopy and any tools that I can get, um, to, to help me understand exactly how much length I've given her back.
• 34:34
  Bob Sershon: Yeah.
• 34:35
  Bob Sershon: Yeah.
• 34:35
  Bob Sershon: And that's, and this also, you know, the, the external rotation, uh, really screws up any ability to measure offset.
• 34:43
  Bob Sershon: Um, which, so you, you.
• 34:46
  Bob Sershon: You go, okay, let's get her close to the other side.
• 34:49
  Bob Sershon: At least you got a fairly normal, uh, left side hip here.
• 34:52
  Bob Sershon: So, um, yeah, so that was our goal was to make up as, as much of it as we could, so long as soft tissue tension, um, allows, because what I don't like doing, uh, having, having done it once or twice is the hip's hard to reduce, and you pull manual traction and then you lock it and you do one or two clicks of fine traction.
• 35:13
  Bob Sershon: You push the hip in.
• 35:15
  Bob Sershon: That's just that, that's too tight.
• 35:18
  Bob Sershon: Like, like I, I, I probably in my mind, shouldn't have done that, uh, trying to chase leg lanes on people.
• 35:24
  Bob Sershon: Um, so now I just, I go until it's a little bit difficult to reduce and I, I leave it there.
• 35:31
  Bob Sershon: Um, but whatever they get is what I get.
• 35:34
  Bob Sershon: So.
• 35:35
  Bob Sershon: So here you go on those, this is one of those, you know, fluoroscopy showing you getting down there, um, you know, trying to Alize and, and this was a patient where, and maybe these are a little bit different fluoroscopic views from bringing the fluoro in and out.
• 35:51
  Bob Sershon: But I, I brought this up because I specifically remember on this patient just wailing as hard as I could to get that cup seated.
• 36:00
  Bob Sershon: And taking it out reaming, taking it out, reaming, and it just kept sticking.
• 36:07
  Bob Sershon: Um, so I probably, I feel like you can't see the airball here, you know, but I feel like that cup should have been, you know, two, three millimeters.
• 36:17
  Bob Sershon: Even more medial based on the fluoro shot.
• 36:20
  Bob Sershon: And maybe it's some optics playing into here with different fluoro shots, but, um, that's something that you gotta pay attention to as well.
• 36:28
  Bob Sershon: There's nothing behind the cup, there's nothing stuck.
• 36:30
  Bob Sershon: But I felt that I was just getting such a good press fit here, um, that I, I was comfortable leaving it not, not putting any screws.
• 36:38
  Bob Sershon: Is that
• 36:39
  Joseph M. Schwab: line to line or do you ream?
• 36:41
  Joseph M. Schwab: Uh, one under two under.
• 36:42
  Bob Sershon: one, one under every, every time.
• 36:45
  Bob Sershon: Yeah.
• 36:46
  Bob Sershon: Yeah.
• 36:47
  Joseph M. Schwab: as far as the, the, the surface of your, uh, acetabular component, high friction acetabular component.
• 36:54
  Joseph M. Schwab: Like a, a grip or a a, a TM or something like that.
• 36:59
  Joseph M. Schwab: Something high friction.
• 37:00
  Bob Sershon: PPS.
• 37:02
  Joseph M. Schwab: PPS.
• 37:03
  Bob Sershon: Yeah.
• 37:04
  Bob Sershon: Yeah.
• 37:05
  Bob Sershon: So, um, and again, I could have one line to line on this and, uh, you know, really.
• 37:12
  Bob Sershon: Uh, you know, went to town, hitting it down.
• 37:14
  Bob Sershon: But once you get the bite, and I feel you're shaking the whole pelvis on this large patient and the cup's not moving, all right.
• 37:21
  Bob Sershon: Like, you, you, you're done.
• 37:22
  Bob Sershon: Stop, stop wasting time.
• 37:24
  Bob Sershon: Like, get out of there.
• 37:25
  Bob Sershon: Um, so, you know, and then these are her.
• 37:29
  Joseph M. Schwab: is better, right?
• 37:31
  Bob Sershon: exactly.
• 37:32
  Bob Sershon: Um, and then you could see here, like I, I still, I bring this up'cause I still don't see.
• 37:38
  Bob Sershon: A big radiolucent line around the cup here.
• 37:40
  Bob Sershon: I mean, I see one in zone two.
• 37:42
  Bob Sershon: Um, but, but you know, not down here.
• 37:44
  Bob Sershon: So I don't know, maybe it was floral playing tricks on me, but, uh, uh, but, but, but the point, the point is here is, you know, she, this lady crippled, I mean, totally crippled for, uh, better part of a decade.
• 37:56
  Bob Sershon: No one will touch her.
• 37:57
  Bob Sershon: You come, you do all the steps I showed you on the prior one, um, and then, you know, four weeks out you get a completely different looking x-ray and they're so thankful and grateful for it.
• 38:06
  Bob Sershon: Um.
• 38:07
  Bob Sershon: But to your point earlier, I made up about two thirds of this.
• 38:12
  Bob Sershon: Um, she's still got a little bit more external rotation, as you could see compared to her, her other side, uh, and clinically was a little bit short still, so she might need a lift, but I could not, that's the longest ball I could get on there.
• 38:26
  Bob Sershon: Um, I I, I probably could have done the trick where you pull the manual, lock it, do a couple clicks of fine and gotten one more ball.
• 38:35
  Bob Sershon: Uh, but at that point.
• 38:37
  Bob Sershon: Not, not worth it.
• 38:38
  Bob Sershon: Not worth it in my opinion, so,
• 38:41
  Joseph M. Schwab: Interesting.
• 38:42
  Joseph M. Schwab: Yeah.
• 38:42
  Joseph M. Schwab: This, this is one where rather than doing more, um, a lift is probably gonna be.
• 38:48
  Joseph M. Schwab: Uh, reasonable for you and she might not even notice the difference.
• 38:51
  Joseph M. Schwab: I don't know.
• 38:51
  Joseph M. Schwab: How far out has she noticed?
• 38:53
  Bob Sershon: she didn't notice at all.
• 38:55
  Joseph M. Schwab: Yeah,
• 38:55
  Bob Sershon: Like by we, we saw her back at four weeks.
• 38:57
  Bob Sershon: I asked my pa, um, who sees all my four weeks, I said, and I said, Annie, did she noticed that?
• 39:02
  Bob Sershon: She goes, oh my God, no.
• 39:03
  Bob Sershon: She's just happy she could walk,
• 39:05
  Joseph M. Schwab: I was about to say, especially if she was in a wheelchair for that long.
• 39:08
  Joseph M. Schwab: It's, those are, those are folks who don't notice leg length discrepancies that much.
• 39:13
  Bob Sershon: Yeah.
• 39:14
  Bob Sershon: And I don't know if she came in on a walker or cane.
• 39:16
  Bob Sershon: I can't, I, I, I should have looked at that.
• 39:18
  Bob Sershon: Um, but it was like a substantial over four weeks already, um, increase in, in quality of life there.
• 39:26
  Bob Sershon: So,
• 39:26
  Joseph M. Schwab: That's, that's amazing.
• 39:27
  Joseph M. Schwab: That's great.
• 39:28
  Bob Sershon: yep.
• 39:29
  Bob Sershon: Yeah.
• 39:29
  Bob Sershon: So, uh, so that's, that's the bikini there.
• 39:32
  Bob Sershon: And we didn't do anything special.
• 39:33
  Bob Sershon: Just, you know, a, well, a ael and.
• 39:36
  Bob Sershon: Dermabond seen his last case.
• 39:38
  Bob Sershon: So, um, if we got time, this is the, you
• 39:41
  Joseph M. Schwab: We got time for this for sure.
• 39:44
  Bob Sershon: yeah.
• 39:45
  Joseph M. Schwab: Another standard primary.
• 39:48
  Bob Sershon: Yeah.
• 39:48
  Bob Sershon: Yeah.
• 39:49
  Bob Sershon: This is one of the cases that, uh, I was gonna present there, um, at, at a HF, um, which, you know, the, the time thing, I totally understood that.
• 40:00
  Bob Sershon: I mean, you've got, you know, Aldo and your acid medias up there given like a.
• 40:05
  Bob Sershon: Unbelievable, you know, chorus, and I'm sitting there going, I, these guys are, are just animals.
• 40:11
  Bob Sershon: Totally unreal at what they're doing.
• 40:13
  Bob Sershon: Um, so I just, you know, I, I could tackle this stuff, but they're just total wizards.
• 40:18
  Bob Sershon: It, it, it's just incredible.
• 40:20
  Bob Sershon: So, um, but uh, yeah, so, so this lady, uh, she had DDH, uh, had a primary hip done in Puerto Rico.
• 40:31
  Bob Sershon: 20 ish years earlier was sub Yeah.
• 40:36
  Bob Sershon: Subsequently revised, uh, about a decade before this.
• 40:41
  Bob Sershon: To a, um, uh, for, for acetabular loosening.
• 40:45
  Bob Sershon: Uh, it was one of the implants where the, the back coating had come apart and, uh, clearly had a loose cup and then, you know, had a, a revision and then that came loose and was repeat revision.
• 40:57
  Bob Sershon: Um, which in those settings, I'm always worried about some subclinical infection, uh, versus.
• 41:03
  Bob Sershon: Metabolic disease, like do they have p acnes or, um, pseudomonas?
• 41:08
  Bob Sershon: Do they have some like slow growing indolent bug in there?
• 41:12
  Bob Sershon: Uh, so anyway.
• 41:13
  Bob Sershon: She had a revision.
• 41:15
  Bob Sershon: Um, that, that actually I did.
• 41:19
  Bob Sershon: Okay.
• 41:19
  Bob Sershon: So I brought this up.
• 41:20
  Bob Sershon: This was my, my public shaming for myself.
• 41:23
  Bob Sershon: Um, and, uh, so we, we did this.
• 41:27
  Bob Sershon: I got.
• 41:28
  Bob Sershon: Great fixation, like one of those hips where you're going, I don't even really need to put screws in here, but I'm going to'cause it's a revision.
• 41:35
  Bob Sershon: So, you know, I don't follow the principles that, you know, I, you know, kind of always tell my fellows of, you know, you want inferior fixation, superior fixation.
• 41:44
  Bob Sershon: So she, she, you know, goes and has one of, not a fall, but what I think is worse than a fall, which is one of these like hard stumbles where they plant really hard, um.
• 41:58
  Bob Sershon: And felt like immediate pain.
• 42:00
  Bob Sershon: Uh, went to the er, got x-ray, ct, um, you know, didn't, didn't show anything, and then literally walks into the four week visit like this on a cane.
• 42:12
  Joseph M. Schwab: Wow.
• 42:13
  Bob Sershon: and we're going, what happened?
• 42:16
  Bob Sershon: Like how, how did we go from like very robust, great fixation to this hard stumble?
• 42:22
  Bob Sershon: And then so, you know, really she had no pain.
• 42:24
  Bob Sershon: She was probably doing a little bit too much and, you know, fell, stumbled, caused, you know, what I thought was an acute discontinuity, but it was really just a fracture through the anterior column.
• 42:34
  Bob Sershon: And, um, and, and here we are now, right?
• 42:38
  Bob Sershon: So.
• 42:39
  Bob Sershon: You've got, uh, you know this lady.
• 42:41
  Bob Sershon: BMI 40, multiple prior surgeries, complete absence of the anterior column, cups in the pelvis, tenting the vessels, um, and, and that, and this has all been done anterior, by the way, the most recent surgery.
• 42:56
  Bob Sershon: So, so now here you are four weeks out.
• 42:59
  Bob Sershon: I mean.
• 42:59
  Bob Sershon: Your decision is go back in through that, which of course we did.
• 43:02
  Bob Sershon: Um, or, you know, if you're not comfortable with it, go through the back, through her prior incisions.
• 43:07
  Bob Sershon: So, you know, the, the planning on this one.
• 43:11
  Bob Sershon: Um, and these, these are all the, you know, the pearls.
• 43:14
  Bob Sershon: And this is from her case actually.
• 43:15
  Bob Sershon: I, I said let's, let's, you know, take some pictures and show people this, this complex reconstruction.
• 43:20
  Bob Sershon: So.
• 43:21
  Bob Sershon: Um, so, you know, the pearls, I, you just do your normal incision.
• 43:25
  Bob Sershon: I, I usually go two finger breaths, ladder lateral to the a SIS, even even in the obese.
• 43:30
  Bob Sershon: Um, and then you want to just extend that.
• 43:33
  Bob Sershon: So if the A SIS is right here labeled, you know, you could see I came pretty far proximal right along the crest right there.
• 43:41
  Bob Sershon: Uh, and right off the bat on these cases, I'll, I'll go ahead and, and find TFL.
• 43:47
  Bob Sershon: You know, small cuff, you could probably see about a centimeter of a cup of tissue there.
• 43:52
  Bob Sershon: Um, that, that, I'll leave, I'll peel it off, off the outer column right away.
• 43:57
  Bob Sershon: Um, I don't know if, if, if you go to it right away or if you wait, I mean, what's your preference on these?
• 44:03
  Joseph M. Schwab: So, um, definitely right away if I'm planning on doing significant, uh, femoral work, I feel like the TFL uh, peeling that off gives you a better, uh, femoral mobility.
• 44:14
  Joseph M. Schwab: Um, but, uh, for a large up and in like this, I would say I might wait and, um, but chances are pretty good that you're gonna do some sort of.
• 44:24
  Joseph M. Schwab: Ensile, uh, maneuver in order to to, to get good access for what you want to do.
• 44:30
  Bob Sershon: Yep.
• 44:30
  Bob Sershon: Yeah.
• 44:31
  Bob Sershon: Um, and I knew I was gonna do a cage on it.
• 44:33
  Bob Sershon: So for me, just right off the bat, I mean, to enhance femoral.
• 44:38
  Bob Sershon: Mobilization, um, as well, just to get it outta the way.
• 44:41
  Bob Sershon: Let that femur fall.
• 44:42
  Bob Sershon: Posteriorly, uh, that really helped.
• 44:45
  Bob Sershon: I mean, I didn't even need a posterior retractor for the case.
• 44:47
  Bob Sershon: The femur was just floating out of the way.
• 44:49
  Bob Sershon: It was, it was beautiful.
• 44:51
  Bob Sershon: Um, and then, you know, so, so you elevate, you know, indirect erectus, do all your capsular releases.
• 44:57
  Bob Sershon: I mean, she had already had all this done.
• 44:59
  Bob Sershon: Um.
• 45:00
  Bob Sershon: Posterior pocket for the ion if you need it.
• 45:02
  Bob Sershon: So let's say you're going in the first time, you can peel off some of that posterior scar tissue, posterior capsule to allow the ion to kind of tuck back behind the posterior, um, acetabulum.
• 45:13
  Bob Sershon: Um, what I'll normally do then, so I do all this before I even.
• 45:18
  Bob Sershon: Dislocate the hip.
• 45:20
  Bob Sershon: Uh, I like to knock the head off into the cup.
• 45:22
  Bob Sershon: I mean, there's a million different ways to skin the cat, but, you know, two, three clicks of fine traction normally is enough, and you could just hit that thing off into the cup, pull it out, you know, right away.
• 45:33
  Bob Sershon: Um, what I don't do until after I've done that the majority of the time is in, uh, is released the inferior capsule, um, you know, pubic, femoral, whatever you wanna call it.
• 45:46
  Bob Sershon: It, it just, because I, I don't know how mobile the femurs gonna be till I try to tuck it back behind the posterior acetabulum.
• 45:54
  Bob Sershon: And, uh, I've had some cases where I haven't had to release any of it and I've had others where I can't even get the trion, um, outta the socket because it's so tight inferiorly.
• 46:06
  Bob Sershon: And that is just such a great trick, um, that you know.
• 46:11
  Bob Sershon: Nobody showed me, right?
• 46:13
  Bob Sershon: I mean, I just started doing these on my own.
• 46:15
  Bob Sershon: Um, these like bigger anterior revisions.
• 46:18
  Bob Sershon: So, uh, you know, that, that's one thing that I tell everyone.
• 46:21
  Bob Sershon: If you're gonna do that, maybe wait until you knock the head off and you're trying to get the truing outta the way just to see what kind of room do you need.
• 46:28
  Bob Sershon: Um.
• 46:29
  Bob Sershon: And, uh, you know, of course, uh, you know, fluoro is your, is is your tool, uh, throughout all of this.
• 46:35
  Bob Sershon: If you're lost, you need to know your landmarks.
• 46:37
  Bob Sershon: Where, where am I in a revision setting?
• 46:39
  Bob Sershon: Not a common question you get from the fellows.
• 46:42
  Bob Sershon: Um, and, uh, you know, one of the actually great articles that I found, um, this is probably just from a couple years ago.
• 46:52
  Bob Sershon: It was, you know, from the guys outta Utah, you know, Lucas, uh, Jeremy, those guys out there just goes over.
• 46:58
  Bob Sershon: This exact technique.
• 47:00
  Bob Sershon: Uh, they've got pictures like this, uh, in the article.
• 47:04
  Bob Sershon: It, it is super helpful.
• 47:06
  Bob Sershon: I, I gave this to our fellows.
• 47:07
  Bob Sershon: Um, I think I found this be like right before the case.
• 47:12
  Bob Sershon: Uh, and even I got a couple pearls out of it.
• 47:14
  Bob Sershon: So it was, it was super helpful.
• 47:16
  Bob Sershon: It was this half cup cage construct from the front.
• 47:19
  Bob Sershon: Um.
• 47:20
  Bob Sershon: So anyway, we, we get in there, we do that, you know, we do that exposure that I showed you.
• 47:25
  Bob Sershon: Um, getting that cup out of the pelvis can be a challenge.
• 47:29
  Bob Sershon: Um, this is one where, you know, you could have vascular on standby, uh, and maybe that's not a bad idea.
• 47:36
  Bob Sershon: Uh, you could get a CT Angio two if you, you know, you really think that that's acutely up and in there.
• 47:42
  Bob Sershon: Maybe you got the vessels.
• 47:44
  Bob Sershon: Um, and you know, for your reconstruction, even though it's a bigger patient, I think the principles all were remain the same.
• 47:51
  Bob Sershon: You know, again, anile exposure so that you could really see the inferior part of the acetabulum come all the way up over your, over your anterior acetabulum.
• 47:59
  Bob Sershon: I mean, she had nothing there, so there was really nothing to release.
• 48:03
  Bob Sershon: Um, and, and do your reconstruction that way.
• 48:06
  Bob Sershon: And you know, this time, you know, we got a couple screws.
• 48:10
  Bob Sershon: You know, in inferiorly, whether or not that would've saved her the first time.
• 48:14
  Bob Sershon: I don't, I don't know.
• 48:16
  Bob Sershon: I mean, it, it seemed like she just had a, basically a pelvic fracture that knocked the whole construct loose.
• 48:20
  Bob Sershon: But, um, and then after you get this in, I actually really like using fluoro, uh, for like a, even a trial cage to see where the trial's gonna sit.
• 48:30
  Bob Sershon: Um, and the other nice part about a cage, at least for me in this situation, is it can distalize.
• 48:38
  Bob Sershon: Your joint line.
• 48:40
  Bob Sershon: Right.
• 48:40
  Bob Sershon: So, um, that allowed me to actually put a full cup in here, distalize it.
• 48:45
  Bob Sershon: I think I got a 40 head in her.
• 48:48
  Bob Sershon: Um, and, and it, it ended up working out, you know, pretty well.
• 48:52
  Bob Sershon: I think this is her x-ray, uh, over a year out at this point.
• 48:57
  Joseph M. Schwab: Very nice.
• 48:58
  Bob Sershon: Right.
• 48:59
  Bob Sershon: Yeah.
• 48:59
  Bob Sershon: And, and this is, she actually lost a ton of weight.
• 49:02
  Bob Sershon: I, I saw her, it was like, I know you, but, uh, like, you know, I, I know you, but if, if, if I, if I hadn't, you know, she, she lost like, she's like BMI of 30 or like close to 30.
• 49:14
  Bob Sershon: So she's one of these patients that actually.
• 49:17
  Bob Sershon: You know, it became way more active and, and made healthier and, and lost weight.
• 49:22
  Bob Sershon: You know, it was just kind of a, a, you know, kind of an inspirational story for, for others that are in her situation.
• 49:28
  Bob Sershon: Um, and yeah, I mean,
• 49:31
  Joseph M. Schwab: nothing to do with the stem on that one, right?
• 49:34
  Joseph M. Schwab: You, you were able to maintain the original stem.
• 49:37
  Bob Sershon: Yeah.
• 49:38
  Bob Sershon: Well, thank God, you know, that that adds,
• 49:42
  Joseph M. Schwab: Um, did you have to go up and into the inner table of the pelvis at all?
• 49:46
  Joseph M. Schwab: Were you up and into the inner table or were you not?
• 49:49
  Bob Sershon: I didn't need to.
• 49:50
  Bob Sershon: Um, I mean, this is a, this is a good case though.
• 49:53
  Bob Sershon: If you don't wanna use a cup cage, uh, you, you can go in the inner table, put an augment there.
• 50:00
  Bob Sershon: Uh, I mean, that's probably what, I don't wanna speak for him, but I mean, that's probably what Aldo would've done, um, you know, running this, run this by him.
• 50:08
  Bob Sershon: What, what, what would you have done with, uh, you know, this big old defect?
• 50:12
  Joseph M. Schwab: I mean, I, I think it's, uh, I, I, so I think a cup cage, you know, potentially, uh, if you're, if you have the opportunity to plan for it, like a custom tri flange would also be a possibility.
• 50:24
  Joseph M. Schwab: But since this kind of happened acutely, you want to get in there as quickly as possible.
• 50:28
  Joseph M. Schwab: And, and maybe you don't have the time to have something custom made.
• 50:31
  Joseph M. Schwab: But I, I think this is a great application, um, of a cup cage, uh, and clearly.
• 50:37
  Joseph M. Schwab: You know, at being a year out and seeing her post-op films, that's what she needed.
• 50:42
  Joseph M. Schwab: Right.
• 50:42
  Joseph M. Schwab: Uh, I mean, that worked out really, really well.
• 50:45
  Bob Sershon: Yeah.
• 50:46
  Bob Sershon: Yep.
• 50:47
  Bob Sershon: Um, so, you know, she's, she's doing fine now.
• 50:51
  Bob Sershon: No worse for the wear and, and hopefully this construct, you know, I always worry about, you know, Mayo's got good data on cementing cups.
• 50:59
  Bob Sershon: Um.
• 51:00
  Bob Sershon: Uh, in, into revision constructs.
• 51:02
  Bob Sershon: Uh, but I, I worry long term.
• 51:05
  Bob Sershon: I mean, she's, I think I said she's in her fifties.
• 51:07
  Bob Sershon: You know, how, how long does that cemented cup really, uh, really last?
• 51:12
  Bob Sershon: Um, I don't know.
• 51:13
  Bob Sershon: I, I, I'm assuming at some point she'll, she'll knock it loose.
• 51:17
  Bob Sershon: Uh, but that's hopefully not a horrific revision because now you've got ingrowth of your, you know, your, um, porous metal shell and your, your cage isn't going anywhere.
• 51:28
  Bob Sershon: So.
• 51:28
  Joseph M. Schwab: I mean, if she just needs another cup cemented in, that's not the end of the world.
• 51:32
  Joseph M. Schwab: Um,
• 51:33
  Bob Sershon: That's a win.
• 51:34
  Bob Sershon: That's a win.
• 51:35
  Joseph M. Schwab: that is a win.
• 51:36
  Joseph M. Schwab: And this, so her original, um, I'm gonna come back to just us, but her original, um, revision surgery done by you, that was an anterior approach, but that was a traditional.
• 51:49
  Joseph M. Schwab: Incision that you used, right?
• 51:51
  Joseph M. Schwab: For that, uh, for that revision.
• 51:53
  Joseph M. Schwab: And you chose to do that for her revision specifically.
• 51:57
  Bob Sershon: yes.
• 51:58
  Bob Sershon: I tried to do all of my, um, revision acetabular work from the front.
• 52:04
  Bob Sershon: Uh, I just, I, I feel at this point it's easier for me.
• 52:09
  Bob Sershon: Um, the, the femur falls out of the way.
• 52:13
  Bob Sershon: You get a great view of everything.
• 52:15
  Bob Sershon: Um, you can use fluoro, which is a huge, huge plus compared from the back where you're taking plain films.
• 52:24
  Bob Sershon: Um.
• 52:24
  Bob Sershon: Uh, yeah, I mean, I, I, I, I pretty much do it.
• 52:28
  Bob Sershon: All the exceptions are.
• 52:30
  Bob Sershon: Like, let's say it's a headliner exchange on someone that's had a prior posterior, they've got a ton of aversion built into their cup, their STEM's a little bit verted.
• 52:39
  Bob Sershon: I start going, Hmm, I mean, our data, you know, bill Hamilton and our institution published saying that, that the dislocation rate's about the same regardless of approach after a headliner.
• 52:51
  Bob Sershon: So those are ones where I'll still go through the back, but anything where I'm swapping out parts at this point, I, I really try to go through the front for everything.
• 52:59
  Joseph M. Schwab: And as far as using the traditional incision for that original, um, uh, revision as opposed to a bikini incision, do you ever use the bikini incision for revision?
• 53:08
  Joseph M. Schwab: If you're just focusing on acetabular work, does that dissuade you from that?
• 53:13
  Joseph M. Schwab: Wh where, what are your thoughts there?
• 53:16
  Bob Sershon: I, this specific case basically made me say I'm probably not doing bikinis from the front for on a revision.
• 53:24
  Bob Sershon: Right.
• 53:25
  Bob Sershon: I, I don't.
• 53:26
  Bob Sershon: I don't foresee a scenario where I would've been happy with myself.
• 53:30
  Bob Sershon: Uh, haven't done that through the front, even though I thought her first case was a pretty straightforward revision.
• 53:36
  Bob Sershon: It's just, you know, things, things happen.
• 53:39
  Bob Sershon: Um, so
• 53:41
  Joseph M. Schwab: She's definitely made it a lot farther on this second revision than she did on the first revision, it sounds like.
• 53:47
  Joseph M. Schwab: So the, the proof is in the pudding.
• 53:49
  Joseph M. Schwab: That's great.
• 53:50
  Joseph M. Schwab: Um, well Bob, hey.
• 53:51
  Joseph M. Schwab: Thank you so much.
• 53:52
  Joseph M. Schwab: So first of all, uh, uh, thanks for being a good sport and, uh, coming and joining us at the a HF annual meeting.
• 53:59
  Joseph M. Schwab: And thanks for being an even better sport and coming and giving your talk.
• 54:03
  Joseph M. Schwab: Hopefully we gave it the, the time and attention to do it justice.
• 54:06
  Joseph M. Schwab: And, and I think what I would impart to our listeners is that if they've got, um, super obese, morbidly obese patients, they should be sending'em to you at the Anderson clinic.
• 54:16
  Joseph M. Schwab: Isn't that, that's that.
• 54:20
  Bob Sershon: Yeah.
• 54:21
  Bob Sershon: Yeah.
• 54:21
  Joseph M. Schwab: No.
• 54:21
  Joseph M. Schwab: But hopeful.
• 54:22
  Joseph M. Schwab: Yeah, hopefully they walk away from this with, uh, uh, an understanding of what's possible and, um, and, you know, hopefully, um, if they have any questions about, uh, your thoughts on a patient and what might be reasonable, uh, that they could reach out to you and.
• 54:40
  Joseph M. Schwab: And that's one of the things we encourage as part of the Anterior Hip Foundation is sort of that, uh, collegiality in, in answering questions.
• 54:47
  Joseph M. Schwab: I'm sure, uh, I'm sure pa uh, uh, providers out there watching or, or listening to this would appreciate that
• 54:54
  Bob Sershon: Oh yeah.
• 54:55
  Bob Sershon: I mean that, that's one of the awesome things that I found at the meeting.
• 54:58
  Bob Sershon: I've already abused that privilege on multiple guys, Laura, at the meeting.
• 55:01
  Bob Sershon: So, um, it's, it's great.
• 55:05
  Joseph M. Schwab: It was great to have you as part of the meeting.
• 55:07
  Joseph M. Schwab: It's great to have you as, uh, a guest on the A HF podcast and, uh, thank you very much for your presentation today.
• 55:14
  Joseph M. Schwab: Super impressive stuff and I look forward to seeing more from you in the future.
• 55:19
  Bob Sershon: Thank you.
• 55:19
  Bob Sershon: Appreciate it.
• 55:23
  Joseph M. Schwab: Well, thank you for joining me for this episode of the A HF podcast.
• 55:28
  Joseph M. Schwab: As always, please take a moment to like and subscribe so we can keep the lights on.
• 55:34
  Joseph M. Schwab: And keep sharing great content just like this.
• 55:37
  Joseph M. Schwab: Please also drop any topic ideas or feedback in the comments below.
• 55:43
  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.
• 55:57
  Joseph M. Schwab: All one word.
• 55:59
  Joseph M. Schwab: episodes of the A HF Podcast come out on Fridays.
• 56:03
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and not too obese.