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Anterior Approach Revision (S+N Surgeon Roundtable) · AHF Podcast

0:21
Joseph M. Schwab: Hello and welcome to the AHF Podcast.
0:24
Joseph M. Schwab: I'm your host, Joe Schwab.
0:26
Joseph M. Schwab: Today's episode is the third in our series of six surgeon roundtables recorded in partnership with Smith+Nephew, conversations that bring together surgeons who do this work every day, peer-to-peer, with one goal: practical, reproducible techniques you can actually take back to your operating room.
0:45
Joseph M. Schwab: Last time, we tackled instability.
0:48
Joseph M. Schwab: Today, we take on the case that used to get the anterior approach laughed out of the room: revision.
0:56
Joseph M. Schwab: Is the approach really extensile, or is that just something we tell ourselves?
1:01
Joseph M. Schwab: Which failed hips should go posterior?
1:04
Joseph M. Schwab: How do you plan an incision you can extend?
1:07
Joseph M. Schwab: What do you do with the old scar and the old capsule?
1:11
Joseph M. Schwab: And how do you find your orientation when the landmarks aren't the same?
1:17
Joseph M. Schwab: When the acetabulum is compromised, how do you choose between augments, a cup cage, dual mobility, and constraint without letting the most constrained option become your default?
1:28
Joseph M. Schwab: Well, three guests join me for this conversation.
1:31
Joseph M. Schwab: Dr.
1:31
Joseph M. Schwab: Eric Cohen, who has studied recovery after anterior approach revision and makes the case that a big reconstruction can still be a muscle-sparing one.
1:41
Joseph M. Schwab: Dr.
1:41
Joseph M. Schwab: Kris Alden, who teaches complex anterior approach revision and hasn't done a posterior revision in about 15 years.
1:49
Joseph M. Schwab: And Dr.
1:50
Joseph M. Schwab: Molly Hartzler, who trains residents and fellows and insists the first principle isn't technique at all, it's exposure and diagnosis.
2:01
Joseph M. Schwab: By the end, you'll have a clear sense of where each of them draws the line and one mistake nearly every surgeon makes when they start revising from the front.
2:10
Joseph M. Schwab: And as always, with these roundtables, it gets concrete pretty fast.
2:14
Joseph M. Schwab: So let's join the conversation.
2:18
Joseph M. Schwab: Eric, I wanna start with you because you're pretty well, um, well known for talking about minimally invasive surgery and rapid recovery, and when we're talking about anterior approach revision, what do you see as the biggest sort of misconception about revisions from anterior approach?
2:40
Eric Cohen: Yeah, I think the biggest misconception with anterior approach revisions is that it's only minimally invasive, that it's not ensile.
2:47
Eric Cohen: That's like the biggest knock you'll hear from other surgeons is that, oh, the anterior approach, uh, you can't do everything for.
2:53
Eric Cohen: But I think we all know on this call that you can go from the a SIS all the way down the femur to the lateral knee, um, through anile anterior approach?
3:02
Eric Cohen: incision.
3:03
Eric Cohen: You can even do a total femur.
3:04
Eric Cohen: Um, so I think you can do it all through an anterior approach, uh, revision.
3:08
Eric Cohen: Um, that being said, it's also, in my opinion, minimally invasive.
3:12
Eric Cohen: So if you're doing a complex acetabular surgery, um, we found that anterior approach revisions recover quicker, have quicker discharges and faster discharges home.
3:23
Eric Cohen: We've actually done that research at Brown and found that, And so it really drives, I think more and more anterior revisions being done.
3:31
Joseph M. Schwab: And Kris, I wanna ask you, because I first met you when you were teaching a complex anterior approach revision course up in Milwaukee.
3:39
Joseph M. Schwab: You were in Chicago at the time, and I know you do a lot of complex anterior approach revisions.
3:45
Joseph M. Schwab: Is there something I don't want to give away how long ago that was, but is there something that might have changed in your career that you're actually more conservative about now than you were then?
4:01
Kris Alden: Uh, you know, I would say the only.
4:09
Kris Alden: Thing I can probably think of, uh, would be probably screw placement.
4:12
Kris Alden: I'm probably, you know, with the, with the cups that have evolved, uh, they're just, we get fantastic fixation.
4:20
Kris Alden: So I, I find, uh, you know, using those, you know, sup I used to do super long screws that would basically kind of reach up into the SI joint.
4:31
Kris Alden: Uh.
4:31
Kris Alden: Or just short of it.
4:32
Kris Alden: But anyways, obviously I haven't found that to be really necessary.
4:36
Kris Alden: Um, I've used less, um, augments, uh, I've just done more biologic fixation and the cups have, you know, held up extremely well.
4:46
Kris Alden: So I think packing, you know, allograft And you know, bone chips in and you can recreate a lot of, uh, huge, massive acetabular defects.
4:55
Kris Alden: Well, and, um, so I've, I've kind of gotten more conservative as, as far as acetabular work is concerned.
5:02
Joseph M. Schwab: And actually just to follow up on that, do you think it's the type of, uh, coating surfaces, the type of, uh, interface materials, or is it the different.
5:11
Joseph M. Schwab: Screw configurations that are available to you now that sort of led to that decision, or maybe a combination.
5:19
Kris Alden: Yeah, I, I think, I definitely think it's both.
5:21
Kris Alden: So I used to have a very low threshold, uh, when dealing with, um, you know, uh.
5:28
Kris Alden: Pelvic dust, discon, discontinuities to do, um, you know, a cup cage.
5:33
Kris Alden: Uh, I had a low threshold for that.
5:35
Kris Alden: Uh, I haven't done a, I've found that to be really necessary.
5:39
Kris Alden: Sometimes you could do those distracting, um, you know, um, you know, the, and, And bone grafted and put the cup in and you get great fixation and great stability.
5:50
Kris Alden: So that's been a big change over the last, well, I won't say the year either.
5:56
Kris Alden: You know, since we talked.
5:59
Joseph M. Schwab: And Molly, I want to ask you,'cause you also treat sort of a wide range of complex, uh, hip pathologies, multiple types of complications, and you also train residents and fellows.
6:12
Joseph M. Schwab: So when it comes to approaching teaching anterior approach revision.
6:19
Joseph M. Schwab: What's the first principle you try to instill in your trainees, maybe even before you start telling'em anything about technique?
6:30
Molly Hartzler: Well, I, I think the probably.
6:32
Molly Hartzler: The most important thing that I want them to understand is that they really need to understand the anatomy and sort of just basic principles of how to get ensile.
6:43
Molly Hartzler: And that's, you know, true of any approach.
6:45
Molly Hartzler: Um, because you know, the hardest things about revision surgery are often seeing and exposing what you need to be able to get to in order to actually execute the surgery.
6:55
Molly Hartzler: Um, so careful planning obviously is important and then.
6:59
Molly Hartzler: You know, uh, one of the things that was taught to me, uh, when I was in training and I instill into them, is that there's often not anything fancy that you do.
7:07
Molly Hartzler: You just have to continuously revisit your steps until you can see what it is that you need to see.
7:13
Joseph M. Schwab: So let's actually, let's stick with that for a minute and let's talk about those steps.
7:17
Joseph M. Schwab: So, when a patient presents to you with a failed total hip, you're gonna be, uh, thinking about doing a revision on them.
7:24
Joseph M. Schwab: How do you sort of mentally sequence your options Maybe.
7:29
Joseph M. Schwab: Maybe you're thinking about it in terms of, uh, how invasive you're gonna be.
7:34
Joseph M. Schwab: Maybe you're thinking about it in terms of how complex the reconstruction is gonna be.
7:39
Joseph M. Schwab: Um, but how do you think about what your options are before approach even enters the conversation?
7:47
Molly Hartzler: Well, uh, you know, getting a firm diagnosis of what actually is going on with the patient.
7:52
Molly Hartzler: That's the first one.
7:53
Molly Hartzler: You know, if you have something like an infection or a fracture or something that's grossly loose, those things are easy, you know, to figure out and then start sequentially planning that in in your head.
8:03
Molly Hartzler: Um, you know, there are some patients that, you know, the, the problem is not quite as obvious, and so making sure that you're carefully testing, I always tell the trainees, you aren't gonna do a revision on something.
8:15
Molly Hartzler: You're not sure what's going on.
8:16
Molly Hartzler: You know, I don't do exploratory surgery.
8:19
Molly Hartzler: Um, and then from there, uh, you know, the sequence and plans, you know, kind of unfold based on the diagnosis.
8:28
Molly Hartzler: Things that I'm thinking about.
8:29
Molly Hartzler: I'm thinking about the patient's body habitus.
8:32
Molly Hartzler: I'm thinking about bone stock.
8:34
Molly Hartzler: I'm thinking about what things I need to access during the surgery.
8:36
Molly Hartzler: Do I need to get up onto the ileum?
8:38
Molly Hartzler: Do I need to get down onto the femur?
8:39
Molly Hartzler: Do I need difficile access?
8:42
Molly Hartzler: Um, and you know, kind of sequencing things in my head.
8:46
Molly Hartzler: And then obviously having the, you know, plan A through whatever number we might need to have ready to go.
8:54
Joseph M. Schwab: Kris, do you think about that sequence any differently?
8:56
Joseph M. Schwab: Is there a a way that you approach it that is different from what Molly described?
9:02
Kris Alden: Actually, I would say very, very similar.
9:05
Kris Alden: So obviously you wanna make sure the problem is in the hip, not around the hip.
9:10
Kris Alden: Uh, and then, uh, you know, have plan, have, have a backup plan so that you know, stem A, B, or C, you know, different cup options.
9:19
Kris Alden: Um, and, and go from there.
9:21
Kris Alden: Try to restore the anatomy and hopefully get the patient walking and feeling better.
9:27
Joseph M. Schwab: E Eric, are there any red flags that you see early on specifically that might raise your concern about what approach you want to do?
9:38
Eric Cohen: Yeah, I think it ultimately depends, you know, what the problem is and, uh, what the patient's history is.
9:44
Eric Cohen: So, you know, those patients that have a.
9:46
Eric Cohen: Parasitic fracture two weeks out, or an infection three or four weeks out with a prior posterior approach, you know, that's best treated with a prior posterior approach.
9:55
Eric Cohen: Um, I'm not going to anterior on that.
9:57
Eric Cohen: Um, if they have a very retroverted cop that I think is gonna be hard to get to uh, to take out, I think that, you know, might be, um.
10:06
Eric Cohen: Red flag of not to try an anterior approach.
10:08
Eric Cohen: And then, you know, the evaluation in the office.
10:11
Eric Cohen: So if it's a larger patient and there's a rash in the groin, I think that's best treated prior to doing, you know, an any anterior approach.
10:18
Eric Cohen: Or if it's an urgent surgery, then you say, well, maybe I'm gonna do?
10:21
Eric Cohen: an anterior lateral or posterior approach for, for, for that patient at that time.
10:26
Joseph M. Schwab: And actually this is a good moment to just take a quick pause and I want to ask you guys, um, just show of hands, who does anterior approach for absolute.
10:36
Joseph M. Schwab: Every single revision that they do.
10:40
Joseph M. Schwab: Okay, so you guys all, Kris, I was expecting your hand to go up sooner than that
10:45
Kris Alden: I haven't done a, i, I think there might be a little lag, but yeah.
10:48
Kris Alden: I haven't done a posterior revision in, uh, probably 15 years.
10:55
Kris Alden: Yeah.
10:55
Joseph M. Schwab: 15 years.
10:56
Joseph M. Schwab: Okay.
10:56
Joseph M. Schwab: And Molly and Eric, that's not the case for you guys.
10:59
Joseph M. Schwab: You're a bit more selective in what you choose to, what approach you choose to use.
11:05
Joseph M. Schwab: Yeah.
11:06
Joseph M. Schwab: Okay.
11:07
Joseph M. Schwab: So.
11:08
Joseph M. Schwab: Based.
11:09
Joseph M. Schwab: So Kris, I'm gonna ask you this since you know you're predominantly going to go anterior approach sort of regardless, but based on your experience in complex anterior approach revisions, are there scenarios that you feel absolutely everybody should be doing this from an anterior approach?
11:28
Joseph M. Schwab: And are there other ones that even though you've gotten to the point where you feel comfortable doing it.
11:34
Joseph M. Schwab: Um, maybe if you were advising a colleague or a trainee might give you pause to say, do this from an anterior approach.
11:44
Kris Alden: Uh, well, I would say like the only general scenario where there's potential problems is if there's like massive pelvic hardware.
11:51
Kris Alden: You need to get that out, and it's a
11:53
Joseph M. Schwab: I.
11:54
Kris Alden: posterior column.
11:56
Kris Alden: Fracture and there's hardware.
11:58
Kris Alden: Um, but even in those situations where I'm not going to, uh, I.
12:02
Kris Alden: can often bur out the hardware from inside the acetabulum.
12:06
Kris Alden: So even in those situations, I've done an anterior, uh, primary anterior revision.
12:12
Kris Alden: Uh, but if there's like something catastrophic about the posterior column that is gonna really make anterior extremely complicated, then obviously go posterior And do what you have to do.
12:27
Joseph M. Schwab: And is it just in the last 15 years, you haven't seen anything that complicated or.
12:32
Joseph M. Schwab: Is it, you've been so comfortable with the approach and maybe the technology that you're able to use maybe shells, certain types of, uh, augments or your comfort in doing a cup cage has made it so that's still possible to handle from the front.
12:49
Kris Alden: Yeah, I would say, um, a cup cage.
12:53
Kris Alden: Sorry.
12:54
Kris Alden: It popped out, um, a cup cage.
12:57
Kris Alden: I just think it's, it's actually, I think in, it's easier to do from an anterior approach than posterior.
13:03
Kris Alden: Plus you have fluoro in there so you know exactly where all the screws are going, you know, where the hardware is, uh, you know, you can find everything.
13:12
Kris Alden: Um, just so much easier.
13:14
Kris Alden: So I would say that, um, you know, when I first started doing anterior revisions, I, it was a little bit of, um.
13:23
Kris Alden: Trial and error.
13:24
Kris Alden: And it was, um, sometimes I really, you know, just excoriated myself, like, why am I doing this?
13:31
Kris Alden: Uh, but you know, once you get over that learning curve, it's actually just a fantastic approach, uh, for any revision.
13:39
Kris Alden: Uh, as you know, Eric said, even total femurs and cup cages and things like that.
13:45
Joseph M. Schwab: And, uh, just to follow up on that with Molly, um, as you're approaching something with sort of acetabular bone loss or maybe some difficulty on the acetabular side.
13:57
Joseph M. Schwab: How much has the change in as tabular component technology over the years affected how you approach those types of revision scenarios?
14:09
Joseph M. Schwab: I think, for instance, as something like the Readapt cup, which, um, you know, uh, has that changed the way you've approached acetabular revision scenarios?
14:23
Molly Hartzler: I'm gonna say no.
14:23
Molly Hartzler: And in interest of full disclosure, you know, I'm just in my seventh year of practice, so there haven't been huge technology changes in the time that I, I've been in practice myself.
14:34
Molly Hartzler: Um, you know, in terms of things that would.
14:39
Molly Hartzler: Kind of nudge me away from going anterior, it's that big posterior bone loss that if, if I think that I need to get, you know, something bulky back there, like a big augment or something that will sort of, you know, nudge me towards going the posterior approach so that I can really get, you know, a wide pelvic exposure instead of having the patient laying on the area of concern.
15:01
Molly Hartzler: Um.
15:02
Molly Hartzler: But you know, I agree with the assertion that the technology is great and the, you know, the stick and the in-growth are wonderful.
15:11
Molly Hartzler: And so, you know, there are lots of times when I'll have, you know, cage and augments and things on backup, and I'm just perfectly happy with a revision cup.
15:21
Joseph M. Schwab: Eric, I, I wanna shift a little bit and talk a little bit about instability when that's the primary indication for a revision.
15:29
Joseph M. Schwab: Um, does that factor into whether or not you're considering doing it from anterior versus posterior?
15:36
Joseph M. Schwab: Um, do you consider sort of the reliability of achieving your goals of correction?
15:43
Joseph M. Schwab: Um, versus when do you think exposure becomes the limiting factor?
15:49
Eric Cohen: Yeah, I mean, I, I love doing anterior approach revisions for instability.
15:53
Eric Cohen: Um, I'll do those actually supine on a flat table.
15:56
Eric Cohen: Um, so I can test stability and drop both anterior and posterior.
16:00
Eric Cohen: Um, and, uh, exposure is really not a problem with the anterior approach.
16:05
Eric Cohen: I think the advantage of the anterior approach and oftentimes instability can be solved with the.
16:10
Eric Cohen: Changing acetabular cup orientation or version, the advantage is the acetabulum.
16:15
Eric Cohen: And so having fluoroscopy there to make sure I get my version and cut abduction correct, um, not disrupting the posterior structures, I think is just a huge advantage.
16:26
Eric Cohen: And, and then like I said before, I think they have a quicker recovery'cause we're still using that muscle sparing approach.
16:32
Eric Cohen: Um, the only time.
16:33
Eric Cohen: Is the, the really retroverted cup I think is very difficult to take out through an anterior approach just'cause you have to drop your hand, uh, very down towards the bed, um, and get coline and in a large muscular thigh with a tensor.
16:47
Eric Cohen: I think, I think that can be difficult.
16:50
Eric Cohen: And the same can be said about an over verted cup.
16:52
Eric Cohen: You know, if you were trying to do a posterior approach with a really over inverted cup, all of a sudden you come down and you're looking just at the back of the cop.
16:59
Eric Cohen: And you really can't get your hand up and around to get coline to revise that cup.
17:03
Eric Cohen: So, you know, I think looking at the whole picture is important, but if I can do an anterior revision, I sleep much better at night.
17:10
Eric Cohen: I think the dislocation rate's lower.
17:12
Eric Cohen: Uh, I know I'm gonna get my cup position.
17:15
Eric Cohen: I can use fluoro for the placement of those screws, just like Kris said.
17:18
Eric Cohen: And, um, it's, it's really been great in my hands.
17:22
Joseph M. Schwab: So in my training originally with posterior approach, you know, the idea of instability was that it was mostly a soft tissue problem.
17:32
Joseph M. Schwab: Uh, so, you know, lack of soft tissue, uh, tension and, um, everything that you were doing to improve instability was, um, changing the soft tissue tension with anterior approach.
17:44
Joseph M. Schwab: What I, we seem to have learned is that it seems more often to be a component positioning problem, and I, that's at least my impression.
17:53
Joseph M. Schwab: But Molly, I would ask you, is that what you see or do you see something different?
17:59
Molly Hartzler: Um, I think it's, it can be both.
18:01
Molly Hartzler: I do often see component positioning issues.
18:05
Molly Hartzler: Um.
18:07
Molly Hartzler: They're, you know, every once in a while you'll see somebody who comes in and they're just under offset or whatever.
18:13
Molly Hartzler: Uh, but I agree, I think a lot of it is not getting the inversion on the cup that we really need.
18:18
Molly Hartzler: And, you know, we, we understand a lot more about hip spine and how stiffness in the back really forces more an abnormal motion through the hip.
18:25
Molly Hartzler: Um, and so I think our understanding continues to evolve.
18:30
Joseph M. Schwab: So let's talk a little bit about exposure in anterior pro revision.
18:34
Joseph M. Schwab: And Kris, I wanna start with you because I do remember, I remember many things that you taught at this course that I was at, but one of the things that I remember most was.
18:45
Joseph M. Schwab: Looking at your exile exposure, and my partner, who is a huge skeptic of anterior approach at the time saying.
18:52
Joseph M. Schwab: That doesn't look minimally invasive to me, and I thought it's a revision course.
18:56
Joseph M. Schwab: It's okay for it to not look minimally invasive, but as you're doing anterior approach revision, there are a lot of critics who will say exposure is an issue.
19:05
Joseph M. Schwab: And they say it in all sorts of ways, but how do you start to plan exactly where your exile exposure goes so you don't get trapped in the middle of a case?
19:19
Kris Alden: So if it's, um, like for example, just last week I did a periprosthetic fracture.
19:28
Kris Alden: the, almost the entirety of the femur, and I revised the cup and the, and the stem.
19:33
Kris Alden: It was a, just a debacle.
19:35
Kris Alden: But anyways, uh, I will basically kind of prep out from, you know, right below the ribcage to the, you know, tole plateau.
19:47
Kris Alden: And I'll make sure that I can access everything that I could possibly need.
19:53
Kris Alden: And then some, um, you know, I just think it's.
19:57
Kris Alden: I've never been somebody that said, oh, this is MIS, but it, it is stile, just as the posterior approach is stile.
20:06
Kris Alden: Uh, so in the same way you can get access, the, the benefit is the patient's supine.
20:11
Kris Alden: Um, you have fluoro there, you know exactly where things are going.
20:15
Kris Alden: You, you can judge leg length offset version.
20:19
Kris Alden: You can put the stem where you want, you put the cup where you want, um, you know, you have fluoro in there.
20:25
Kris Alden: It's just a.
20:26
Kris Alden: Fantastic way to do a revision and, you know, so, you know, I, I, I think it's just makes life easy and, and you can, you know, rest assured that you're gonna, you know, get a excellent reconstruction and give the patient the benefit, uh, without all the downside of a approach to your approach.
20:47
Joseph M. Schwab: Molly, I want to ask you, does your approach planning change if somebody comes in with a bikini incision versus the more traditional longitudinal incision?
20:58
Molly Hartzler: No.
20:58
Molly Hartzler: Um, I have revised somebody with a prior bikini through a longitudinal incision.
21:03
Molly Hartzler: No problems with wound healing.
21:06
Molly Hartzler: Um, yeah.
21:09
Joseph M. Schwab: And if they had a recent bikini incision, let's say they're, um, you know, two weeks out and they're having instability problems and you really feel like something needs to change, how do you approach that?
21:23
Molly Hartzler: If I had a, a fresh bikini and I was gonna do just a, a cup revision, I would still go back in through a bikini approach.
21:31
Molly Hartzler: Um, I, you know, one of the things that, that is nice about this approach is that.
21:37
Molly Hartzler: You can, if you needed to have a, another secondary incision, you could place that with a bikini.
21:44
Molly Hartzler: So, you know, if I, if I was doing a revision through a bikini approach and I was like, oh no, suddenly I need, you know, better access to my femur, you could simply do like a sub-bass type approach.
21:57
Molly Hartzler: So, you know, and I agree.
21:59
Molly Hartzler: I think the argument against revising that it's not mentally invasive is, is crazy.
22:04
Molly Hartzler: You know, you're not touching your posterior soft tissues.
22:07
Molly Hartzler: I think that's one of the biggest, um, you know, the biggest advantages because we know that revision and instability go hand in hand from the posterior approach cause of all of the dissection you have to do to get down.
22:19
Molly Hartzler: Um, and I agree that having fluro, you know, is such a, such a, um, advantage because a lot of times in these revisions we just don't have bon landmarks.
22:30
Molly Hartzler: And being able to very easily see what you're doing, you know, it's such an advantage.
22:36
Joseph M. Schwab: So Eric, what I'm hearing is bikini incision.
22:39
Joseph M. Schwab: You might want to consider, um, sort of additional incisions if you need to extend it, but lateral, uh, or more traditional longitudinal incisions are much more exile.
22:50
Joseph M. Schwab: Is that your threshold?
22:52
Joseph M. Schwab: Do you approach that differently?
22:54
Joseph M. Schwab: How do you think about planning your revision exposure?
22:59
Eric Cohen: Yeah, absolutely.
23:00
Eric Cohen: I mean, I agree with Molly.
23:01
Eric Cohen: If it's a fresh bikini incision with, you know, instability, I would go back through that.
23:06
Eric Cohen: Um, usually the cup is over abducted and over verted because the surgeon didn't bring their hand down.
23:13
Eric Cohen: Uh, they're fighting kind of the thigh and soft tissues.
23:16
Eric Cohen: And so using offset, um.
23:18
Eric Cohen: Cup inserters and reamers is really key for that approach.
23:21
Eric Cohen: Um, if I have a choice and there's, uh, no prior incision, uh, for a revision, I'll do a vertical incision because that's, that is the extensa incision.
23:29
Eric Cohen: Bikini is not extensa.
23:31
Eric Cohen: If it's a well-heeled bikini incision, that's two years out, um, and I need a revision, I would go vertical as well.
23:39
Eric Cohen: Remember, you know, perpendicular to an incision.
23:42
Eric Cohen: Really.
23:42
Eric Cohen: Uh.
23:43
Eric Cohen: Heals just, fine.
23:44
Eric Cohen: Uh, you can go directly, uh, perpendicular to that incision and it'll, it'll heal fine.
23:48
Eric Cohen: And so you can bring that all the way up to a SIS past the bikini incision and, and it'll heal.
23:53
Eric Cohen: Okay.
23:53
Eric Cohen: So I don't really hesitate to use a vertical incision if someone's very far out from, uh, bikini.
23:59
Joseph M. Schwab: This episode of the AHF Podcast is brought to you by Smith+Nephew, a global medical technology company helping patients live without limits.
24:09
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Joseph M. Schwab: The REDAPT femoral stem combines intuitive instrumentation with reproducible stem positioning and rock-tight flutes to support axial and rotational stability for secure diaphyseal fixation.
24:45
Joseph M. Schwab: On the acetabular side, the REDAPT system includes variable-angle locking screws with an optimized screw hole pattern shown in testing to deliver more than seven times the rigidity of constructs with non-locking screws.
25:00
Joseph M. Schwab: That added rigidity may help reduce micromotion and, in turn, support bone ingrowth.
25:07
Joseph M. Schwab: The system also offers modular and fully porous shell options, along with snap-in and cemented XLPE liners, dual mobility options, and acetabular augments.
25:19
Joseph M. Schwab: For added stability, the OR3O Dual Mobility system is designed to increase range of motion and jump distance.
25:27
Joseph M. Schwab: It features OXINIUM technology with XLPE for strong wear performance, evidence of reducing taper corrosion and minimizing risk of trunnionosis, and without cobalt chrome or nickel components.
25:43
Joseph M. Schwab: The OXINIUM DH liner also includes an 18-degree locking taper and an alignment peg designed to prevent malseated liner insertion.
25:54
Joseph M. Schwab: Together, the REDAPT system and OR3O Dual Mobility provide surgeons with a flexible, stability-focused approach to revision total hip arthroplasty with the simplicity and reproducibility needed in complex reconstruction.
26:10
Joseph M. Schwab: To learn more about Smith+Nephew revision hip solutions, visit smithandnephew.com.
26:18
Joseph M. Schwab: Now, back to the show I'm gonna go around and I want to ask you all kind of the same question as you're going back and doing revision scenarios, let's say in reasonably well-heeled or moderately well-heeled incisions.
26:30
Joseph M. Schwab: Not something fresh.
26:32
Joseph M. Schwab: Are you doing scar excisions and revisions?
26:35
Joseph M. Schwab: Are you going right through the scar?
26:37
Joseph M. Schwab: If that's the approach you're gonna do, and just re approximating those tissues, how are you thinking about that?
26:42
Joseph M. Schwab: And Kris, let's start with you.
26:46
Kris Alden: Um, yeah, I would say that in general, uh, I will go through, I'll use the old anterior incision if it's a longitudinal.
26:55
Kris Alden: That's the approach I do.
26:56
Kris Alden: Uh.
26:57
Kris Alden: And then just kind of depends on what the soft tissues look like, but I will excise the scar and kind of just makes it a little more cosmetic.
27:07
Joseph M. Schwab: Molly, how about you?
27:10
Molly Hartzler: I agree.
27:11
Molly Hartzler: I, you know, if there's something odd about the scar, it's, you know.
27:16
Molly Hartzler: Uh, you know, really wide or very thin.
27:20
Molly Hartzler: Um, if they've had prior wound healing problems through that incision, sometimes they'll like size it just to get fresh tissue edges.
27:26
Molly Hartzler: Um, if it's just a pretty normal scar, I'll go through it and not really worry about it.
27:33
Joseph M. Schwab: And Eric.
27:35
Eric Cohen: Yeah, I do exactly what Molly does.
27:37
Eric Cohen: Um, a normal incision heals very fine.
27:40
Eric Cohen: I just go straight through it, but anything odd, all excise.
27:43
Eric Cohen: And then I treat all of these revisions with, uh, you know, wound vac postoperatively to, to help with healing.
27:49
Eric Cohen: In that case, you know, the multi, multi operated patient.
27:53
Joseph M. Schwab: And along with this, so there's the scar obviously on the skin, but then there's the deep scar tissue.
27:59
Joseph M. Schwab: And again, I want to go around the table.
28:01
Joseph M. Schwab: Um, I want to hear from a standard primary approach.
28:05
Joseph M. Schwab: Are you a capsulotomy or a capsulectomy?
28:08
Joseph M. Schwab: And when you go back in for a revision, are you a capsulotomy or capsulectomy?
28:13
Joseph M. Schwab: And Kris, let's start with you.
28:17
Kris Alden: Uh, I retain the capsule and then I repair at the end, um, all the time.
28:23
Kris Alden: I think it just a helps with stability and soft tissue preservation in the revision setting, uh, the capsule is often very bulky and redundant, So I will debulk the capsule.
28:35
Kris Alden: And I think that just helps with exposure.
28:37
Kris Alden: Uh, but then I obviously repair at the end as well.
28:40
Joseph M. Schwab: So you, you'll repair a capsule regardless.
28:42
Joseph M. Schwab: Revision or primary scenario.
28:44
Joseph M. Schwab: Okay.
28:45
Kris Alden: Yes.
28:45
Kris Alden: I think it helps with stability.
28:47
Kris Alden: I, I could be wrong, but that's just my own, you know, whatever.
28:53
Joseph M. Schwab: Until somebody proves otherwise, you're willing to continue doing it.
28:57
Joseph M. Schwab: How about you, Molly?
29:00
Molly Hartzler: I am a capsulectomy in both.
29:02
Molly Hartzler: Uh, scenarios.
29:03
Molly Hartzler: I was taught capsulotomy with repair, um, and I'd say probably about three to four years and maybe three years I stopped doing that and I just excise now.
29:15
Joseph M. Schwab: Okay, and Eric.
29:18
Eric Cohen: So I'm, I'm the opposite.
29:19
Eric Cohen: I was, uh, taught cap select.
29:21
Eric Cohen: You know, capsulectomy and now I'm just capsulotomy and repair.
29:25
Eric Cohen: I'm not sure it makes a difference, to be perfectly honest on a primary approach.
29:29
Eric Cohen: Um, I like having the capsule just to kind of guide my reamer and have it tagged so from, you know, an efficiency standpoint for me, it's makes it easier.
29:40
Eric Cohen: So that's why I do it on revisions.
29:42
Eric Cohen: I debulk just like Kris said, and try to keep the capsule, although I've gone more and more to like Molly and taking more of the capsule to aid in my exposure because I think, you know, that thick capsule really is a hindrance to a.
29:56
Eric Cohen: Not only acetabular, but femoral exposure.
29:58
Eric Cohen: And then when you take it out, um, you can just see better, you get better exposure.
30:02
Eric Cohen: And so, um, if we're saying, well, there's not really an advantage with stability, the anterior approach is in inherently stable by not disrupting the posterior structures, then you could argue, you know, you could just take the capsule out.
30:14
Eric Cohen: So I think on a revision, it's again, you kind of maximalist ideas.
30:19
Eric Cohen: Um, and so I, I'm moving more towards, uh, removing more and more of the capsule.
30:25
Joseph M. Schwab: So speaking of Maximalist ideas, you know, one of the things in revision that makes some people nervous is you start to lose.
30:33
Joseph M. Schwab: Use some of your landmarks, right?
30:35
Joseph M. Schwab: And we're very reliant on our landmarks for understanding how we're doing our reconstructions.
30:40
Joseph M. Schwab: So, Kris, when landmarks are unreliable for you, how do you go about sort of retargeting your orientation of the femoral component of the acetabular component in a way that to you feels reproducible?
30:58
Kris Alden: Uh.
30:58
Kris Alden: Yeah, that's a, that's a good question.
31:00
Kris Alden: I would say having fluoro in there, uh, and trying to reconstruct the hip, um, in a way that promotes optimizes stability.
31:10
Kris Alden: So I will check range of motion.
31:14
Kris Alden: While they're, you know, on table and make sure that there's no impingement of the components.
31:20
Kris Alden: Uh, so I just try to optimize it using fluoro and, and, and really at the end of the day, kind of stability is the primary objective in a revision setting.
31:30
Kris Alden: Uh, so using the, uh, fluoro and then optimizing stability to promote a good outcome.
31:37
Joseph M. Schwab: Are you doing stability testing?
31:39
Kris Alden: Yeah, so I will kind of take the hip through a range of motion if there's any kind of questions in my mind about whether there's, uh, any degree of impingement.
31:48
Kris Alden: If the neck, uh, cup, you know, that if there's a little bit of space when they're externally rotated 90 degrees and extended, you know, then I know I pretty well know that the stability is optimized.
32:01
Kris Alden: And then also, you know, it depends.
32:03
Kris Alden: I, I would use, do mobility in sort of that revision type setting where stability is questionable.
32:08
Kris Alden: Um, and then, um, finally, you know, make sure that soft tissue envelope posteriorly is still intact.
32:15
Kris Alden: Try to reinforce that as much as possible.
32:18
Joseph M. Schwab: Eric, from your perspective, are there any intraoperative either imaging, pearls or stability checking pearls that have made a big difference for you?
32:29
Eric Cohen: Yeah, I think intraoperative imaging is really important.
32:32
Eric Cohen: As we said earlier, um, the most common error I see and one of the most common referrals from outside surgeons for instability is the kind of hip spine relationship with an outlet pelvis.
32:42
Eric Cohen: And so.
32:43
Eric Cohen: Operating on outlet pelvis, I think you can easily make the mistake to put the cup where you think it should be on a regular ap, which is if you do that, is under averting and under abducting the cup.
32:54
Eric Cohen: And so, um.
32:56
Eric Cohen: That's gonna cause poster instability.
32:58
Eric Cohen: And so I think, you know, I get functional standing AP pelvis x-rays on everybody, and that's kind of what I match intraoperatively for the imaging.
33:07
Eric Cohen: Um, and then I make adjustments based on that knowing, uh, more outlet pelvis is gonna need a more abducted verted cup and know inlet pelvis is gonna look, you know, less abducted and less verted to that, you know, true AP pelvis.
33:20
Eric Cohen: Um, there's a, there's a great paper.
33:22
Eric Cohen: At University of Utah, talking about the empty is issue, fossa sign, and the idea is that it's under inverted, under abducted cup.
33:30
Eric Cohen: And I, I kind of like, I love that article looking at that X-ray because it kind of keys you in to like, hey, like I'm not putting my cup where it's right.
33:37
Eric Cohen: So the biggest error is just not recognizing what your pelvis is doing and just doing what you always do.
33:42
Eric Cohen: So I think looking real critical at your fluoro is really important, um, to, to not make that mistake.
33:49
Joseph M. Schwab: Molly, are there things that you do to, let's say, avoid false confidence when you're looking at the images or you're looking at the patient and things look aligned, but maybe they aren't me?
34:02
Joseph M. Schwab: Meaning your imaging and your stability aren't quite matching up.
34:08
Molly Hartzler: Um, I mean, I, I do essentially what Eric does where I have my functional standing, you know, pelvis, and then I'm matching that and sort of double checking, you know, if I.
34:20
Molly Hartzler: Feel like things are are weird, you know, I'll get like a series of x-rays just to see how things look, um, with the pelvis in different positions.
34:30
Molly Hartzler: And then I'm also double checking against the patient's anatomy, you know, in the revision setting.
34:34
Molly Hartzler: Obviously that can be a little bit different.
34:37
Molly Hartzler: Uh, but you know, the, just making sure that it, if I think that my version's correct, but I'm like, way averted.
34:46
Molly Hartzler: Really, really tucked, just kind of double checking against the, the patient's bone stock, things like that.
34:51
Joseph M. Schwab: Hmm.
34:53
Joseph M. Schwab: Um, let's shift gears a little bit more and go back to talking about some acetabular revision, because there's always some things that we have to consider when we're revising an ace tablum.
35:05
Joseph M. Schwab: Things like, are we gonna fill the defect?
35:08
Joseph M. Schwab: What are the biomechanics of the hip gonna be?
35:10
Joseph M. Schwab: Like, what's the orientation of the components gonna be like?
35:13
Joseph M. Schwab: And um, Eric, I wanted to ask you, how do you balance those things when you're considering doing an acetabular revision?
35:23
Eric Cohen: Yeah, I think it's a tough balance.
35:25
Eric Cohen: I think ultimately it depends on what kind of acetabular revision you're doing.
35:29
Eric Cohen: You know, is it the massive acetabular bone loss?
35:31
Eric Cohen: Is it just some superior lateral bone loss?
35:34
Eric Cohen: I mean, ultimately, I think the key is cup stability.
35:38
Eric Cohen: Um, you know, in a massive osteolysis or a massive bone loss case, sometimes you're gonna need to make the cup vertical, uh, just to fill the defect and get, get good inferior screws, ischial screws, uh, superior screws.
35:51
Eric Cohen: And then you can use, you know, something like, uh.
35:54
Eric Cohen: Poly cemented poly or a polar cup and cement that in, in the correct, you know, orientation, um, that you need for stability.
36:02
Eric Cohen: So I think, you know, number one is a kind of implant fixation and, you know, filling that defect.
36:08
Eric Cohen: And then number two is using your armamentarium to kind of get back to where you need to be.
36:13
Eric Cohen: Um, again, if it's just that superior lateral defect, then I think you could kind of get the, you know, the trifecta of, of a stable cup.
36:22
Eric Cohen: Appropriate orientation and offset, uh, by putting that, you know, superior, augment, and then putting your cup and unitizing the two, I think then, You know, you do it all in one.
36:30
Eric Cohen: Um, but it really depends on what kind of defect you're looking at.
36:34
Joseph M. Schwab: You know, Kris, you talked about having your low threshold for putting in, uh, a cup cage construct, which generally speaking is gonna be parts that come from dis different systems or different manufacturers, but able to work together, um, to get your reconstruction.
36:50
Joseph M. Schwab: Over time, how valuable has it been to you to sort of have a system available where Shells and augments are designed to kind of work together rather than sort of mixing solutions?
37:03
Kris Alden: Absolutely.
37:04
Kris Alden: I mean, it's, it's nice just having sort of like one system that are, that are sort of optimized.
37:10
Kris Alden: Um, that always hasn't been the case historically.
37:13
Kris Alden: This is going back a long time.
37:14
Kris Alden: But, you know, there are times where I'd have, uh.
37:17
Kris Alden: You know, a different vendor for a stem, a different vendor for a cup, and then, you know, the cage would come from a third vendor.
37:24
Kris Alden: Uh, you know, and, and that's a horrible situation to be In So it's nice just to have like sort of a one stop system that would basically address any sort of pelvic or thermal, uh, deficiency that you have to fix.
37:41
Joseph M. Schwab: In cases that have say, compromised soft tissue.
37:45
Joseph M. Schwab: So we talked a little bit about bony defects, um, but soft tissue defects.
37:50
Joseph M. Schwab: Eric, how do you decide when you want to consider a more, um, constrained acetabular system or a dual mobility solution?
37:59
Joseph M. Schwab: You kind of mentioned it very briefly, but walk us through your thought process on that.
38:06
Eric Cohen: I think, you know, it really comes down to the patient and, uh, kind of the pre-op, uh, planning on this.
38:12
Eric Cohen: Um, I'll kind of, for the most part decide pre-op and then confirm intraop what I think I need on, have it all available.
38:19
Eric Cohen: But, you know, if you're dealing with a really elderly patient, uh, who might have some abductor deficiency, um.
38:25
Eric Cohen: You know, that's when you consider like a doability or constrained liner.
38:29
Eric Cohen: I think constrained liner's like the last choice, uh, because we know they don't last very long.
38:33
Eric Cohen: Right.
38:34
Eric Cohen: You know, they're gonna fail at 10 years.
38:36
Eric Cohen: The failure rate's very high.
38:37
Eric Cohen: So if you have a very elderly patient, you may be more inclined to use a constrained liner versus a younger patient.
38:42
Eric Cohen: I think, um, uh, stay away from those and you know, really if you address.
38:47
Eric Cohen: The problems of cup orientation, stem version, offset and length, uh, kinda like Molly, mentioned, I think you could achieve soft tissue stability.
38:55
Eric Cohen: I also will counsel these patients and say, Hey, you.
38:57
Eric Cohen: You might need a little extra offset or a little extra length to, you know, get this hip stable for soft tissue tensioning.
39:03
Eric Cohen: So, um, the only time I'm using constrain liners is like in the very elder, elderly, frail patient with abductor deficiency who's not a candidate for an abductor reconstruction.
39:13
Eric Cohen: We're just trying to get them, you know, moving and outta the hospital and not keep coming back for sedations and, and relocations.
39:19
Eric Cohen: Otherwise, I think, uh, large fal heads are dual mobility.
39:22
Eric Cohen: In the revision setting is kind of the tried and true.
39:26
Eric Cohen: Uh, they decreased dislocation and so, um, that's, those both will be, be my options depending on the case.
39:34
Joseph M. Schwab: ask
39:35
Kris Alden: I would just add one thing, the last two constrained cups, uh, you know, that I did, were basically, uh, a fused spine, like severely, you know, along.
39:48
Kris Alden: Spine fusion, multiple surgeries on their hip and chronic dislocators.
39:54
Kris Alden: Uh, you know, I, I, I think soft tissue reconstructions have been historically kind of, uh, an unrewarding, um, you know, endeavor.
40:05
Kris Alden: Uh, you know, that I've done, you know, gmax transfers, uh, you know, and I just think trying to recreate that abductor attention is just uh, I, I just think it's.
40:17
Kris Alden: In my opinion, And I could be wrong, I think it's an unsolved problem in orthopedic surgery.
40:22
Kris Alden: So in those, in those situations, I will basically go to a constrained liner and I usually know that pre-op I, I, you know, so, but otherwise, kind of like what Eric said, dual mobility has been a fantastic way to resolve instability.
40:39
Molly Hartzler: For me, um, ra very, very rare on the primary side.
40:43
Molly Hartzler: If I have patients with, you know, like was mentioned, like essentially an aquilo spine, um, I think it's a nice option to have.
40:51
Molly Hartzler: Um, obviously it's an option that potentially has downsides to it.
40:57
Molly Hartzler: Um.
40:59
Molly Hartzler: On the revision side, I, I guess it just really depends on how I feel intraoperatively.
41:03
Molly Hartzler: It's something that's readily available.
41:05
Molly Hartzler: Um, you know, if I can get a big cup, big, big femoral head in there and feel relatively good about my construct, I'll skip it.
41:14
Molly Hartzler: Um, but if there are questions, I'll go to a dual mobility.
41:17
Molly Hartzler: And I would add to the, uh, discussion on the constrained liner side that one of the things I try to impress upon my fellows and residents is that.
41:24
Molly Hartzler: Those solutions will not overcome a Malpositioned cup.
41:28
Molly Hartzler: And so, you know, the right thing to do most of the time for these patients is to revise the cup.
41:33
Molly Hartzler: You know, you see patients that will get constrained liners and then continuously impinge and break them and they'll have, you know, I've treated patients that have had, you know, eight, 10 constrained liners.
41:44
Molly Hartzler: They really just needed their cup revised.
41:47
Molly Hartzler: So.
41:49
Joseph M. Schwab: Kris, one last question for you.
41:51
Joseph M. Schwab: Looking back, what's one mistake you see surgeons make when they first start doing revision through an anterior approach?
42:01
Kris Alden: Uh, I, I would say being impatient with femoral exposure.
42:06
Kris Alden: I think any stem, uh, you know, and any stem really could be done through the anterior approach for femoral revision.
42:14
Kris Alden: Uh, and I think sometimes early on in their, you know, sort of experience, they'll have the STEM fit their exposure.
42:24
Kris Alden: And that's kind of, that's kind of a fallacy and, uh, kind of a mistake.
42:28
Kris Alden: So I.
42:28
Kris Alden: would just say be patient.
42:31
Kris Alden: Get your femoral exposure.
42:33
Kris Alden: And don't stress, uh, but really any STEM could be done.
42:38
Kris Alden: A, a long, two 40 modular stem is something that's very attainable to the interior approach.
42:43
Joseph M. Schwab: Hmm.
42:45
Joseph M. Schwab: You know, we sort of were touching on this subject a little bit with this, with, um, the different acetabular options.
42:52
Joseph M. Schwab: Um, but Eric, tell me, how do you balance restoring stability without over constraining and sacrificing motion or maybe implant longevity?
43:05
Eric Cohen: Yeah, I think it's an intraoperative decision, uh, kinda like Molly said about deciding what you need.
43:12
Eric Cohen: Um, where are you impinging, what can you change about your implant?
43:16
Eric Cohen: Not only.
43:17
Eric Cohen: Offset and linked, um, but cut position or st stem position and trying to maximizing that.
43:22
Eric Cohen: And then I think you could go the least constrained possible.
43:26
Eric Cohen: Uh, so I, I prefer large femoral heads.
43:29
Eric Cohen: Um, uh, for most cases.
43:31
Eric Cohen: Um,
43:33
Joseph M. Schwab: And when you're saying large femoral heads, can you put a size to that?
43:36
Eric Cohen: Sure.
43:37
Eric Cohen: 36 and up.
43:38
Eric Cohen: Uh, so on the primary side, if I can get a 36 uh, head, I'll use a 36 head.
43:44
Eric Cohen: Um, and that's pretty much what I'll use for all my primaries.
43:47
Eric Cohen: Um, if a revision side, I'll pretty much take the biggest head that I can get, uh, possible.
43:52
Eric Cohen: Uh, so if I get a 40 head, I'll go 40.
43:54
Eric Cohen: Head on that.
43:55
Eric Cohen: Um.
43:56
Eric Cohen: And then dual mobility is like, if I just need a little extra, um, stability and I'm, I'm not so sure about the patient or their compliance, uh, then, you know, I think that's the dual mobility decision.
44:08
Eric Cohen: But every decision has trade-offs, right?
44:11
Eric Cohen: So for dual mobility, if you have a dislocation, then the problem is, um, you gotta reduce it.
44:18
Eric Cohen: And a reduction in the ER of a dual mobility is not easy.
44:22
Eric Cohen: Oftentimes it requires an open reduction.
44:24
Eric Cohen: So I think, uh, you know, there has to be some thought about who to use it on.
44:28
Eric Cohen: Um, and so that's kind of, kind of my thought process on trying to decide.
44:32
Eric Cohen: It.
44:33
Eric Cohen: It's, it's a, it's an intraoperative decision case by case basis.
44:39
Joseph M. Schwab: Um, Molly, I kind of want to ask you, uh, I've got closing questions for both of you, but I'm gonna start with you.
44:46
Joseph M. Schwab: For someone who's early in their anterior approach revision journey, what's the one, maybe guardrail, um, you believe they should try to avoid compromising on regardless of experience or comfort level?
45:06
Molly Hartzler: You know, that's tough because I think one of the things that's very valuable when you're moving forward in the complexity of your anterior approaches is having somebody around that you could potentially call on for help if you needed it.
45:23
Molly Hartzler: But I also don't think that that is a non-negotiable because there are people who are in practices where they're the only surgeon.
45:32
Molly Hartzler: Um, I.
45:34
Molly Hartzler: You know, in that practice that does an interior approach or is getting a little bit more brave with complex anterior.
45:40
Molly Hartzler: Um, and so, you know, I wouldn't say you have to have a more experienced partner there with you, but it, it's very nice if you know that you're gonna do something complicated and you have somebody around that you could potentially call on Interoperatively to sort of plan it that way.
45:53
Molly Hartzler: Um, but I guess, you know, the other thing that I would say is just, you know, you, you're not gonna wanna leave that or feeling like you've compromised.
46:03
Molly Hartzler: So really make sure that you're planning these scenarios all the way out.
46:06
Molly Hartzler: Like what's the worst thing that could possibly happen and how do you address that during an anterior approach, should it happen?
46:13
Molly Hartzler: Um, you know, the, the, the worst things and you know, I've had is scenarios where people in my system will call me intraoperatively because something has gone wrong and they're, you know, panicked'cause they don't really know what to do about it.
46:28
Molly Hartzler: Um.
46:29
Molly Hartzler: And so just sort of make, making sure that you've thought these things through.
46:34
Molly Hartzler: Um, and you, you have your backup plans just in case.
46:39
Joseph M. Schwab: Um, and Eric, last question for you.
46:42
Joseph M. Schwab: I, I've been around long enough that I remember when anterior approach revision.
46:47
Joseph M. Schwab: Was really regarded by most people as just kind of crazy.
46:51
Joseph M. Schwab: Like it didn't make a whole lot of sense.
46:53
Joseph M. Schwab: It wasn't, uh, it, it wasn't supported by the literature.
46:56
Joseph M. Schwab: It was something that made people real uncomfortable.
47:00
Joseph M. Schwab: But that's the past.
47:01
Joseph M. Schwab: And what I'm curious about from your perspective is as our techniques and our implants and our planning tools have evolved and continue to evolve.
47:12
Joseph M. Schwab: Is there something that excites you most about what we might be able to do in the future in anterior approach revision, and what do we still need to approach with maybe a little bit more respect and caution?
47:27
Eric Cohen: Yeah, I mean, I think I'm, what I'm most excited about is probably what you're most excited about is the continued adoption of.
47:33
Eric Cohen: The anterior approach revision, uh, just like we have seen primary anterior approach, uh, exponentially be adopted over the past 10 years, I think we're gonna see the same with anterior approach revisions as some of the positive outcomes are really, you know, uh, can't be debated at this point.
47:49
Eric Cohen: And so with more adoption leads for more interest in innovation, uh, which I think anter Hip Foundation is also, uh, pushing and driving, uh, that's better implants.
48:00
Eric Cohen: Better instruments designed for the anterior approach.
48:03
Eric Cohen: You know, for the past 10, 15 years, 20 years, everyone's been using instruments and implants that weren't designed for the anterior approach.
48:10
Eric Cohen: And now more and more are coming out, you know, the triple taper stems, um, revision, you know, revision monoblock stems, um, and um, custom acetabular implants that are designed to be put in through the anterior approach, you know, are now getting a lot of, uh.
48:28
Eric Cohen: Uh, adoption.
48:29
Eric Cohen: And so really the sky's the limit with continuing to design retractors, implants and instruments, you know, for our approach.
48:36
Eric Cohen: Uh, and it just continues to make it easier and really drives patient outcomes.
48:40
Eric Cohen: You know, I, I think what we need to be cautious, cautious about is always put the patient first.
48:45
Eric Cohen: And yes, it's important to push the envelope, but we always gotta decide like.
48:49
Eric Cohen: Is this in the best interest of the patient?
48:51
Eric Cohen: And that's how I approach every revision and trying to decide what approach I'm gonna do.
48:55
Eric Cohen: I obviously love the anterior approach, but for me, sometimes I do do a different approach, you know, to be honest.
49:01
Eric Cohen: So I think always putting the patient first and um, and think being thoughtful about the design of, uh, implants and instruments, uh, for that will only continue to drive this forward.
49:13
Joseph M. Schwab: Well, I would like to thank you all for joining us today for, uh, this round table and for sharing your expertise, uh, with our listeners and, um, of course you're welcome back to the AHF podcast anytime.
49:25
Joseph M. Schwab: Thank you so much.
49:27
Molly Hartzler: Yeah.
49:27
Molly Hartzler: Thank you.
49:29
Joseph M. Schwab: Thank you for joining me for this episode of the AHF Podcast, and thank you to our sponsor, Smith+Nephew.
49:36
Joseph M. Schwab: As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content and conversations just like this.
49:45
Joseph M. Schwab: Please also drop any topic ideas or feedback in the comments below.
49:49
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/@anteriorhipfoundation, all one word.
50:05
Joseph M. Schwab: Episodes of the AHF Podcast come out on Fridays.
50:09
Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy