Latest / AHF Podcast / Filling, Crown or Implant? The Case for Hip Resurfacing

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Filling, Crown or Implant? The Case for Hip Resurfacing · AHF Podcast

• 0:15
  Joseph M. Schwab: Hello and welcome to the AHF Podcast.
• 0:18
  Joseph M. Schwab: I'm your host, Joe Schwab.
• 0:20
  Joseph M. Schwab: Earlier this season, Justin Cobb came on the show to talk about his technique for anterior approach hip resurfacing.
• 0:28
  Joseph M. Schwab: And in a different episode, Sharat Kusuma and Craig Della Valle made the case that the hip resurfacing story isn't over.
• 0:36
  Joseph M. Schwab: Well, today I'm joined by someone who has stayed with hip resurfacing throughout its ebbs and flows and remains an important voice during what may be hip resurfacing's comeback tour.
• 0:50
  Joseph M. Schwab: Dr.
• 0:50
  Joseph M. Schwab: Paul Beaulé is a professor of orthopedic surgery at the University of Ottawa and one of the most recognized voices in both anterior approach hip arthroplasty as well as hip preservation.
• 1:02
  Joseph M. Schwab: We're gonna talk about what really went wrong in the metal-on-metal era, who's a good candidate for hip resurfacing today and who isn't, what the newer bearing designs could change, and how resurfacing fits with anterior approach.
• 1:18
  Joseph M. Schwab: So let's get into it.
• 1:19
  Joseph M. Schwab: Paul, welcome to the AHF Podcast
• 1:23
  Paul Beaulé: Thank you, Joe, and happy to be here
• 1:25
  Joseph M. Schwab: So, I- tell me a little bit, first of all, how did you come to hip resurfacing?
• 1:30
  Joseph M. Schwab: Who, who exposed you to it?
• 1:31
  Joseph M. Schwab: Who taught you?
• 1:32
  Joseph M. Schwab: How did you get there?
• 1:34
  Paul Beaulé: Well, it's a, a good story.
• 1:36
  Paul Beaulé: Uh, back in doing my residency in Ottawa in, uh, mid-'90s, one of our, uh, my key mentors, Merv Letts, a pediatric orthopedic surgeon, knew of Harlan Amstutz in Los Angeles because both had been president of their respective association.
• 1:51
  Paul Beaulé: Harlan was the AOAO- AOA, and, uh, Merv Letts, COA.
• 1:56
  Paul Beaulé: So, and then, uh, so I went to visit Harlan Amstutz, uh, back in 1997 to interview for his fellowship program, and I, I found the area interesting.
• 2:05
  Paul Beaulé: Harlan showed me his metal-on-metal resurfacing.
• 2:07
  Paul Beaulé: I'd never seen a resurfacing in my life.
• 2:10
  Paul Beaulé: So I said,"Well, that sounds interesting.
• 2:11
  Paul Beaulé: Los Angeles seems like a good fit." And, and the funny story, when I, when I came back, uh, to Ottawa and we're doing the final kind of, uh, months of training, we had a visiting professor by name of Marvin Tile, big name at pelvic and acetabular trauma from Toronto.
• 2:27
  Paul Beaulé: So I'm driving him around and, uh, he goes to me,"Paul, uh, so what are you doing, uh, next year after your residency?""Well," I said,"I'm gonna go work with Harlan Amstutz.
• 2:35
  Paul Beaulé: He's doing this very interesting operation, metal-on-metal hip resurfacing." And then there was a pause of silence by Marv Tile, and he goes,"Oh, he's st- he's still trying to make that work." And I said,"Oh boy, what did I get myself into?" So I said,"Well, at least I'll enjoy the weather in Los Angeles." And in the back of my mind as well, I knew Joel Matta was in Los Angeles as well, so I had a, a two-pronged approach.
• 3:01
  Paul Beaulé: I really wanted to be a, a, a, a-- all know about hip and pelvis surgery, so I said,"Look, I'll start with Harlan." Once I get there, I, I went to see Joel to interview with him to prepare my second fellowship right after.
• 3:13
  Paul Beaulé: So there was a sequence to that.
• 3:15
  Paul Beaulé: And I know Joel at the time-- I didn't know he did anterior, uh, total hips at the time.
• 3:20
  Paul Beaulé: I was going for Joel mainly for pelvic and acetabular trauma and PAOs, pelvic osteotomies.
• 3:25
  Paul Beaulé: So, uh, anyway, so that's how I, I got exposed to resurfacing.
• 3:28
  Paul Beaulé: I went with Harlan Amstutz, which he was really at the start of metal-on-metal resurfacing, same time as Derek McMinn.
• 3:34
  Paul Beaulé: Also, a partner of Harlan was Tom Schmalzried, who, uh, uh, was a big name in, uh, wear debris.
• 3:41
  Paul Beaulé: He trained with Harris.
• 3:42
  Paul Beaulé: And during my stint there, I was in Los Angeles for seven years, I really saw the evolution, uh, both of metal-on-metal resurfacing, large head metal-on-metal, and the introduction of the ASR.
• 3:54
  Paul Beaulé: So I'll stop there, Joe, but that's how I kinda got started into it, and maybe that'll give you more queries there.
• 3:59
  Joseph M. Schwab: Well, and, and we're certainly gonna start talking about metal-on-metal too, but a- as, so as your career sort of progressed, just kinda bigger picture, a lot of surgeons walked away from hip resurfacing.
• 4:10
  Joseph M. Schwab: You haven't.
• 4:11
  Joseph M. Schwab: What, what's, what's kept you?
• 4:14
  Paul Beaulé: Well, to me, it's the whole, uh, spectrum of hip pathology.
• 4:18
  Paul Beaulé: So here I trained with Harlan saying, you know,"TOL hips are not good.
• 4:22
  Paul Beaulé: We gotta do resurfacing because they're gonna fail." Okay.
• 4:25
  Paul Beaulé: I go train with Joel Matta.
• 4:27
  Paul Beaulé: Joel says,"Yes, TOL hips are bad.
• 4:29
  Paul Beaulé: I do PAOs." Okay.
• 4:32
  Paul Beaulé: These two worlds keep colliding because Harlan would say,"Well, PAOs are a tough operation.
• 4:37
  Paul Beaulé: They-- You know, it's hard to do." And Joel would say,"Well, you know, they're not that hard, and resurfacing, I'm not sure about that." So to me, it's that mix of both worlds where really educating me.
• 4:49
  Paul Beaulé: He said,"It's not one size fit all for all patients, that there is a right patient for each procedure," and that's how I've maintained my use of hip resurfacing
• 4:57
  Joseph M. Schwab: Hmm.
• 4:58
  Joseph M. Schwab: Well, so let's talk a little bit about the metal-on-metal era.
• 5:02
  Joseph M. Schwab: What-- From your perspective, what actually went wrong?
• 5:06
  Joseph M. Schwab: Was it the bearing itself?
• 5:08
  Joseph M. Schwab: Were there specific designs?
• 5:09
  Joseph M. Schwab: Was it component positioning, patient selection, surgeon volume?
• 5:14
  Joseph M. Schwab: There's all sorts of things that people will point to.
• 5:17
  Joseph M. Schwab: What's your perspective?
• 5:19
  Paul Beaulé: Well, you know, not to be too, uh, complacent, I'd say probably all of the above.
• 5:23
  Paul Beaulé: But what I would say when I was there, uh, and, and, and I'll let you know as well, in the same building where I was working, Harry McKellop was the engineer who developed Marathon highly crossing poly.
• 5:35
  Paul Beaulé: So in the early'90s, mid-90s, no one-- It was not quite clear which bearing would come out top because the polys, they, they had the bad episode of the Hylamer, which led to higher wear, really issues.
• 5:50
  Paul Beaulé: And then you had that metal on metal that seemed to have, from a tribological perspective, very good properties and didn't seem to be affected by the size of the head.
• 5:59
  Paul Beaulé: So it probably would provide, uh, good outcomes for, um, uh, instability because a lot of people were still using posterior approach, and hip instability was still a major problem.
• 6:10
  Paul Beaulé: But what happened is that you had a few small companies that had-- were at the forefront of resurfacings, and you had the big boys, Biomet, Zimmer, DePuy, that did not have a resurfacing yet.
• 6:24
  Paul Beaulé: But under the 510(k) of FDA, they said,"Well, we're gonna introduce a large head metal on metal total hip." And they said,"This is the best of both worlds.
• 6:36
  Paul Beaulé: We don't have to worry about technique of resurfacing because we don't have to worry about neck fracture.
• 6:41
  Paul Beaulé: You just do a total hip, and then you put on this large head metal on metal.
• 6:46
  Paul Beaulé: You don't have to worry about instability.
• 6:47
  Paul Beaulé: And because, quote-unquote, it's a hard-on-hard bearing, you don't have to worry about cup orientation." Well, there we go.
• 6:56
  Paul Beaulé: So now people were putting all these large head metal on metal in.
• 7:00
  Paul Beaulé: Cups were a bit vertical.
• 7:02
  Paul Beaulé: Then you introduced the problem of trunnion wear because of these high frictional torque on stems that were not made for these large head trunnion frictional torque, and you have a perfect storm.
• 7:16
  Paul Beaulé: And everything got lumped into the same bag, and metal on metal had a major issue
• 7:22
  Joseph M. Schwab: So, you know, it's interesting because when you start lumping hip resurfacing and large head metal-on-metal together, one of the things that it makes me think about is the role that registries kinda had to play in, um, uncovering these problems, reporting these problems, or identifying these problems.
• 7:45
  Joseph M. Schwab: What do you feel like registries got right, and what do you feel like they missed?
• 7:52
  Paul Beaulé: Well, I think the registries got it right with the ASR.
• 7:55
  Paul Beaulé: It was alread- already being picked up very quickly that the, uh, the, the ASR resurfacing prosthesis had higher failure rates.
• 8:04
  Paul Beaulé: And then the large head metal on metal, uh, you know, the, the issue is that y- you had the Metasul 28, 32 that was doing extremely well, and then at some point, people just didn't want to recognize that it was a, a bearing design issue or head issue.
• 8:20
  Paul Beaulé: And then you had the competing, uh, corporate industry interest with the highly cross-linked, which was really picking up.
• 8:29
  Paul Beaulé: So like anything in, in, in, in the world, you know, y- you win by not only showing that you're good, but really, uh, putting a negative spin on the other ones.
• 8:40
  Joseph M. Schwab: Mm-hmm.
• 8:40
  Paul Beaulé: So I think that's classic what we see in day-to-day social society.
• 8:45
  Paul Beaulé: You ostracize one to make yourself a bit be- better and until you catch up, and that's basically what happened
• 8:52
  Joseph M. Schwab: Hmm.
• 8:54
  Joseph M. Schwab: So, that's, that's an interesting perspective.
• 8:57
  Joseph M. Schwab: I like that.
• 8:58
  Joseph M. Schwab: So, so what lessons do you take away from that, um, about how we would introduce any sort of new implant nowadays, right?
• 9:10
  Joseph M. Schwab: Because there are still gonna be those competing interests
• 9:14
  Paul Beaulé: Yeah.
• 9:14
  Paul Beaulé: So a-again, it all comes back to not reinventing the wheel and understanding what really worked.
• 9:21
  Paul Beaulé: I'll use, uh, you the ex- example hip preservation.
• 9:25
  Paul Beaulé: I went to visit Reinhold Ganz, Jeff Mast, Joel Matta.
• 9:28
  Paul Beaulé: I'm practicing in LA.
• 9:30
  Paul Beaulé: I present at the local chapter of the Western Orthopedic Association, my early experience for impingement correction with surgical dislocation.
• 9:39
  Paul Beaulé: The first thing that people come to the mic say,"Why are you doing a surgical dislocation?
• 9:43
  Paul Beaulé: It's a horrible approach.
• 9:45
  Paul Beaulé: You know, blah, blah, blah." I said,"Well, wait a minute here.
• 9:49
  Paul Beaulé: I just came back, saw this new pathology, and the first thing I'm gonna do is change the approach, and because I know better?
• 9:57
  Paul Beaulé: No.
• 9:57
  Paul Beaulé: The first thing I'm gonna do is try to reproduce the results as described by the originator, and that I learned that from Joel Matta, who when he did pelvic and acetabular trauma, he did it like Letournel did and tried to reproduce his results before trying to improve things.
• 10:14
  Paul Beaulé: So I said to people,"The first thing we're gonna do is try to reproduce the result." Same thing with resurfacing.
• 10:19
  Paul Beaulé: Ch-- If you go and see and learn something, don't try modifying it right away.
• 10:24
  Paul Beaulé: Look at what the re-- the guy that's had the most experience, that had good acceptable result, and try to reproduce exactly what he got as results.
• 10:35
  Paul Beaulé: And once you've achieved that, obviously we're-- there's always room for innovation and improvement.
• 10:40
  Paul Beaulé: So that would be my recommendation is that don't try to change too many things at the same time.
• 10:46
  Paul Beaulé: And so this is where we're-- with the introduction of all these new resurfacings, well, there are a lot of things being changed at the same time, for technique, approach, bearing, cup design, size of the cup, fixation, material.
• 11:02
  Paul Beaulé: We really have to go in a stepwise fashion so that we understand what work and doesn't work.
• 11:08
  Paul Beaulé: So that would be my biggest concern is that people are trying to change too many things at the same time, uh, to thinking that they're gonna solve everything.
• 11:17
  Paul Beaulé: What was the problem with metal on metal?
• 11:19
  Paul Beaulé: If it-- the resurfacing was done well with either a BHR, Conserve Plus, they do extremely well.
• 11:26
  Joseph M. Schwab: Hmm.
• 11:26
  Paul Beaulé: If you got the cup orientation and a low wear environment, i.e., not too small of a cup and a well-positioned cup.
• 11:34
  Paul Beaulé: So-- And then the issue of metal on metal, well, then you, you have to address it.
• 11:38
  Paul Beaulé: So you can only be a-addressed by changing the bearing.
• 11:42
  Paul Beaulé: So once you change the bearing, one has to ask himself, are you gonna change everything else at the same time?
• 11:48
  Joseph M. Schwab: Hmm.
• 11:49
  Joseph M. Schwab: Interesting.
• 11:50
  Joseph M. Schwab: So, and we're gonna talk a little bit more about what you do nowadays, but given that you probably have patients that you're looking after who have a well-functioning metal-on-metal resurfacing, how do you follow them nowadays?
• 12:06
  Joseph M. Schwab: How, d- what sort of surveillance, if anything, do you do?
• 12:09
  Paul Beaulé: Well, we, we, we do like, you know, I've, as you, as I alluded to, 25 years of resurfacing experience with metal on metal, basically.
• 12:18
  Paul Beaulé: In Ottawa, that's what we've been doing since 2005, so we have 20 years plus.
• 12:24
  Paul Beaulé: So it's basically, you know, five-year follow-up, everything's well, come back if there's a problem.
• 12:28
  Joseph M. Schwab: Hmm
• 12:29
  Paul Beaulé: Because we have enough, um, re- retrospective information that we know it's not gonna be a surprise.
• 12:37
  Paul Beaulé: So it's no different than a highly crossing hip.
• 12:39
  Paul Beaulé: If you're doing well at five years and you don't have no symptoms, only come back if you have problems.
• 12:45
  Paul Beaulé: Because by that time, the body has adapted to the bearing, uh, and the biology has stabilized itself, so there's no real kind of late onset of, uh, any, uh, major silent issue, no different that you might see with a highly crossing toll hip
• 13:02
  Joseph M. Schwab: So you haven't seen any late problems with a hip resurfacing after 20 years, for instance?
• 13:08
  Paul Beaulé: And, and no major surprises.
• 13:09
  Paul Beaulé: If they have a problem, they'll come in,"My hip's hurting for the last six weeks", and you see the components loosen or there's a, a femoral, uh, like a, a, a fatigue fracture of the femoral neck, or there's some lucency around the acetabulum.
• 13:22
  Paul Beaulé: And, uh, so it's really no different than, you know, these late, uh, uh, presentation of trunnion wear with highly crossing poly where they're having pain and some instability symptoms.
• 13:34
  Paul Beaulé: So that's basically what we've done.
• 13:36
  Joseph M. Schwab: So, so let's look at your current practice.
• 13:38
  Joseph M. Schwab: Let's, let's talk about what you're doing right now, and I want you to start by describing who's the ideal resurfacing patient from your perspective?
• 13:49
  Paul Beaulé: So to me, it's really that patient-- I'll start a bit backwards.
• 13:55
  Paul Beaulé: So I have a combined hip preservation, hip arthroplasty practice.
• 14:00
  Paul Beaulé: Patient comes to me, not a candidate for hip preservation because of either, uh, too old, i.e., older than 45 or so, or too much arthritis.
• 14:13
  Paul Beaulé: Then first thing comes to mind, hip resurfacing.
• 14:17
  Paul Beaulé: Then I look at the anatomy, and if the anatomy is, uh, capable to get a press-fit monoblock shell and there's no significant leg-leg discrepancy of more than two centimeters, I would say, and no excessive femoral torsion issues like major anteversion that you can't correct with a resurfacing, then that's my go-to.
• 14:42
  Paul Beaulé: And then I will push that, uh, or offer that to the patient up to the age of 60.
• 14:49
  Paul Beaulé: And then there's that gray zone of the 65, 68-year-old that really are enamored with resurfacing, very active.
• 14:58
  Paul Beaulé: And I go,"Listen, I can do either operation if that's really what you want and understand that you're a bit higher risk of a femoral neck fracture.
• 15:09
  Paul Beaulé: Uh, I'll, I'll, I'll proceed." And people over 70, I say,"No way.
• 15:14
  Paul Beaulé: I, you know, uh, I can't rationalize this for you.
• 15:17
  Paul Beaulé: Go find another surgeon because I, I really feel that I'm, uh, not serving you well." Even though they may have a, a, a bias.
• 15:24
  Paul Beaulé: And most of the time people are pretty reasonable and, and they follow a physician's opinion, or they go somewhere else, which is okay too.
• 15:31
  Paul Beaulé: Doesn't mean it's an absolute answer, but at some point you gotta, uh, stand by a bit your results and your experience and not kind of, uh, just go-- do, uh, whatever is the flavor of the day type of thing.
• 15:43
  Joseph M. Schwab: So above the age of 70, that's fine.
• 15:45
  Joseph M. Schwab: That's one group.
• 15:46
  Joseph M. Schwab: Uh, th- in that below 70 group, we'll say 40-ish or so to, to 65, who shouldn't have one from your perspective?
• 15:58
  Paul Beaulé: Well, in that age, if they have a major femoral head deformity or wear of the head where, uh, the fixation on the femur is gonna be, uh, capricious, that would be it.
• 16:09
  Paul Beaulé: Uh, and then, uh, we're doing some interesting machine learning, uh, stuff algorithm in, uh, where, which are-- We have a large database of resurfacings and total hips, and we're trying to-- We're, we're seeing some signal where there's a particular patient profile in their mid-50s with some, uh, comorbidities of health, smoker, things like that.
• 16:32
  Paul Beaulé: Then when you look at their progression on the PAS, patient acceptable, uh, symptoms, resurfacing doesn't do as well.
• 16:39
  Joseph M. Schwab: Hmm.
• 16:40
  Paul Beaulé: So, uh, uh, the data's not out there, but there is a subgroup of patients that even though from an age, from a anatomy standpoint, you might say,"I could go either way," they actually might do better with a total hip
• 16:55
  Joseph M. Schwab: Hmm
• 16:56
  Paul Beaulé: because of the-- either the, uh, uh, you res- you really correct the full, uh, you know, with total hips a bit more kind of aggressive in removing the bone.
• 17:05
  Paul Beaulé: You restore a bit more mobility because of the, uh, you know, head and neck or offset a- area is a bit better, and, and the soft tissue may respond better, uh, with a total hip than a resurfacing implant.
• 17:17
  Paul Beaulé: So I would say present to you that there is actually a subgroup of patients in their mid to early 50s or late 50s, if you wanna use that, that have a particular health profile that will do better with a total hip in terms of recovery than a resurfacing.
• 17:36
  Paul Beaulé: And that's gonna be quite controversial, I think, as with the data comes out a bit better.
• 17:40
  Joseph M. Schwab: So are you hopeful at some point that you would be able to have an AI model that you could funnel a patient's information into, and then it's gonna go resurfacing or it's gonna go total hip?
• 17:51
  Joseph M. Schwab: Wow.
• 17:51
  Paul Beaulé: Yeah.
• 17:52
  Paul Beaulé: Yeah, I think so, and that's, that's the w- it's, uh, it's shared decision-making process.
• 17:57
  Paul Beaulé: I mean, there's no doubt a 35-year-old, you're much better off with a resurfacing.
• 18:00
  Paul Beaulé: It's like saying, you know, you're 32, you have dysplasia, and you don't have a lot of arthritis, but because the PL is so hard, we're just gonna do a total hip.
• 18:08
  Paul Beaulé: You say,"Well, that's, that's blasphemy.
• 18:10
  Paul Beaulé: What are you doing?" Like, you know, like, wow.
• 18:12
  Paul Beaulé: So if you have a 35-year-old with advanced arthritis and the bone's there, they, you, they get a resurfacing because that is in the best interest of the patient, both from the bone preservation standpoint, risk of a, a periprosthetic femur fracture long term, and if you do need another operation, that's the way to go
• 18:29
  Joseph M. Schwab: Hmm.
• 18:30
  Joseph M. Schwab: So, uh, when you're having that sort of arthroplasty, uh, resurfacing versus total discussion with a patient, how, how do you, how do you present it in front of them if it's really equivalent options?
• 18:44
  Joseph M. Schwab: You know, you consider it to be a patient with equivalent options.
• 18:47
  Joseph M. Schwab: How do you present it to them?
• 18:49
  Paul Beaulé: Well, I like to use the analogy of dentistry, uh, uh, because I go, say, look, your hip, let's say, is like a tooth and you got a cavity unfortunately, and it hurts.
• 18:59
  Paul Beaulé: So, you know, hip preservation is like a, a dental filling.
• 19:03
  Paul Beaulé: We kinda go scrape, fix a few things, patch it up, you're good to go.
• 19:08
  Paul Beaulé: If the cavity's too big, too much arthritis, we do the crown, which is the resurfacing arthroplasty.
• 19:14
  Paul Beaulé: And if there's not enough tooth and your gum is shit and the crown's not gonna hold, you're getting a dental implant, which is a total hip.
• 19:22
  Paul Beaulé: And the patients get it.
• 19:23
  Paul Beaulé: They're like,"Yeah, that makes total sense.
• 19:25
  Paul Beaulé: Yeah, sure.
• 19:26
  Paul Beaulé: I want the crown."
• 19:29
  Joseph M. Schwab: I have not heard this analogy before, but it is genius.
• 19:32
  Joseph M. Schwab: I love this.
• 19:34
  Paul Beaulé: It works
• 19:35
  Joseph M. Schwab: So, so what, roughly what percentage of your arthroplasty practice today is, is resurfacing?
• 19:43
  Paul Beaulé: 30%.
• 19:44
  Joseph M. Schwab: 30%.
• 19:46
  Joseph M. Schwab: Okay
• 19:46
  Paul Beaulé: So I still do a fair amount of total hips and 30% hip preservation.
• 19:51
  Paul Beaulé: So yeah, it's about like 60 where you would say young adult hip, uh, which is hip preservation, hip scopes, PAOs, and hip resurfacing.
• 20:00
  Paul Beaulé: And then, uh, the, uh, other 40% is really, uh, primary total hips, anterior approach, you know, et cetera.
• 20:07
  Paul Beaulé: Uh, that's what, uh, and most-- 90%, 95% are outpatient
• 20:11
  Joseph M. Schwab: And what, w- what's your hip resurfacing of choice?
• 20:14
  Joseph M. Schwab: What's your bearing surface of choice right now i- in the, in the resurfacing world?
• 20:18
  Paul Beaulé: So, you know, obviously I have several conflicts, just to be clear to the, uh, uh, uh, audience there.
• 20:24
  Paul Beaulé: We still do the metal on metal.
• 20:26
  Paul Beaulé: Uh, unfortunately, uh, and the Conserve Plus, which was the original design of Harlan Amstutz from the, the 19-- late'90s.
• 20:33
  Paul Beaulé: Unfortunately, like, uh, the Smith+Nephew, uh, MicroPort has stopped producing it, so we're finishing our inventory.
• 20:40
  Paul Beaulé: So now we've moved, I would say now it's almost, I would say 80, 90% the ceramic on ceramic resurfacing, uh, that we're using at this point
• 20:50
  Joseph M. Schwab: So, so let's talk about some of these newer bearing designs,'cause we've, like you mentioned, there's ceramic on ceramic, there's ceramic on polyethylene.
• 20:57
  Joseph M. Schwab: What, from your perspective and from your experience, what problem is each surface coupling trying to solve?
• 21:08
  Paul Beaulé: So I, I just, uh, as I-- well, I'll, I'll give you...
• 21:11
  Paul Beaulé: I have some props here.
• 21:12
  Joseph M. Schwab: All right
• 21:13
  Paul Beaulé: So I don't...
• 21:14
  Paul Beaulé: Oh, so here's the, uh, the original, uh, I need to make sure, metal-on-metal resurfacing implant.
• 21:21
  Paul Beaulé: I, I can see it better here.
• 21:22
  Paul Beaulé: That better.
• 21:23
  Paul Beaulé: Sorry about that.
• 21:23
  Paul Beaulé: Here's the original metal-on-metal resurfacing implant, the conser-- uh, which is a six-millimeter diameter difference.
• 21:29
  Paul Beaulé: You can see, and the coating is at the back.
• 21:31
  Paul Beaulé: Okay?
• 21:32
  Paul Beaulé: Here's the, uh, ceramic-on-ceramic, one of the design, the, the resurf that I'm a designer of, and the coating is at the back.
• 21:39
  Paul Beaulé: Okay?
• 21:40
  Paul Beaulé: And then y-you can look at the, uh, shell thickness of the two, you know, very similar in terms of how it looks.
• 21:48
  Paul Beaulé: You can see there's the edge, the bit smoothing.
• 21:51
  Paul Beaulé: Uh, hopefully, you can see that well.
• 21:53
  Paul Beaulé: Then you, you go with these modular or larger.
• 21:57
  Paul Beaulé: These were the original large head ceramic-on-ceramic, which was a modular insert into a shell.
• 22:03
  Paul Beaulé: And you can see s- the difference, for example, in terms of the diameter and the insert size of these implants.
• 22:11
  Paul Beaulé: So I, I think to me, it's all happening on the acetabular side.
• 22:17
  Paul Beaulé: How much bone you're resecting, what's the arc of cover, and how that interface between that monoblock shell and the bearing is gonna hold up.
• 22:32
  Paul Beaulé: You can see the coating here is added on versus with the metal-on-metal, it was a one-piece system.
• 22:40
  Paul Beaulé: Uh, you can see the cobalt's at the back.
• 22:42
  Paul Beaulé: It's all cobalt.
• 22:44
  Paul Beaulé: Uh, so I think that's gonna be, to me, uh, what we really need to follow very closely to make sure that it performs as well as the metal-on-metal in terms of fixation, bonding, and bone remodeling.
• 22:59
  Paul Beaulé: On the femoral side, you'll have two, uh, types of design.
• 23:04
  Paul Beaulé: You can have the...
• 23:04
  Paul Beaulé: This is the one we're currently using, which is a cere- cemented, uh, ceramic.
• 23:09
  Paul Beaulé: There's also press fit, which we've used with metal-on-metal, I don't have one here, which has worked extremely well.
• 23:16
  Paul Beaulé: Uh, so, uh, both are, are-- work well.
• 23:19
  Paul Beaulé: I think there's obviously the advantage of not dealing with cement and taking all the loose cement out once you've cemented it.
• 23:26
  Paul Beaulé: But we-we'll see how that all plays out in terms of, uh, fixation and, uh, bone remodeling.
• 23:32
  Paul Beaulé: But I think both will do well on the femoral side, and it's gonna be a bit dealer's choice in terms of how the bone looks and, uh, the preparation.
• 23:41
  Paul Beaulé: But I think it'll really all come down to on the socket performance, how much bone you're removing, and what kind of fixation you're getting there, uh, function-wise
• 23:53
  Joseph M. Schwab: So I know you're a big evidence guy.
• 23:56
  Joseph M. Schwab: Uh, at least the times I see you talk, you're very, very clear on providing outcome and, and outcomes and evidence.
• 24:02
  Joseph M. Schwab: So what has the evidence shown you so far on the current ceramic-on-ceramic designs that you're using?
• 24:10
  Joseph M. Schwab: And maybe as a, a follow-up question to that, when are we actually gonna know?
• 24:14
  Joseph M. Schwab: How long is it gonna take for us to figure out whether we're tracking along with the results of metal-on-metal or doing better than that?
• 24:23
  Joseph M. Schwab: Um, and, and what do we know so far?
• 24:27
  Paul Beaulé: So, uh, from a, uh, evidence, we, we did an RCT, uh, a decade ago comparing metal on poly, which was with the Pinnacle shell, versus the DeltaMotion, which is the large head ceramic.
• 24:41
  Paul Beaulé: Maxera made one.
• 24:42
  Paul Beaulé: I think Medacta has one now.
• 24:44
  Paul Beaulé: And we looked at the, um, uh, bone mineral density on the acetabular side using a, uh, what's called a region-free analysis DEXA technique.
• 24:55
  Paul Beaulé: Uh, Mark Wilkinson from Sheffield collaborated on that.
• 24:57
  Paul Beaulé: He-- They did all the analysis.
• 25:00
  Paul Beaulé: In that two years, we're able to show that there was no difference in the bone remodeling on the acetabular side comparing metal on poly to a large head ceramic.
• 25:10
  Paul Beaulé: So that to me, at two years tells me, okay, we're not really having a stress shielding issue using a high sensitivity model.
• 25:19
  Paul Beaulé: Obviously, we'll have to follow them long-term wise, but initially using that type of technique seems that it's working.
• 25:26
  Paul Beaulé: The other thing we find out in that series, uh, we looked at noise.
• 25:30
  Paul Beaulé: So, uh, it- it's, it's gonna be published soon in the Journal of Arthroplasty.
• 25:35
  Paul Beaulé: We follow them at ten years.
• 25:37
  Paul Beaulé: There's over, uh, close to forty in each cohort, and we asked them at ten years,"Do you have any noise in your joint?" And we used the, uh, Melbourne Orthopedic, uh, uh, uh, group, uh, questionnaire.
• 25:52
  Paul Beaulé: And obviously, as expected, the ceramic had a higher prevalence of noise at, uh, forty or fifty percent, with obviously squeaking being much higher.
• 26:02
  Paul Beaulé: But what's, what's more interesting is that in the metal on poly, fifteen percent had noise.
• 26:08
  Paul Beaulé: So to me, uh, this is self-reported.
• 26:12
  Paul Beaulé: There's no free lunch.
• 26:13
  Paul Beaulé: And, and, and so that to me is actually the more interesting aspect because, uh, we all know ceramic can make some noise.
• 26:20
  Paul Beaulé: But to say that metal on poly solves a noise issue, I would then counter,"Well, I'm sorry, gentlemen-- ladies and gentlemen, this is not the case." So noise is an issue, uh, is a known issue.
• 26:31
  Paul Beaulé: Uh, we didn't find any impact on quality of life, so we're doing the same study with the ceramic on ceramic.
• 26:36
  Paul Beaulé: We'll see where we go.
• 26:38
  Paul Beaulé: So I think that's, uh, first part of the kind of what do we know from the literature with full hips, uh, and ceramic bearings.
• 26:47
  Paul Beaulé: On the restricting, uh, aspect, obviously the-- why did we introduce ceramic?
• 26:52
  Paul Beaulé: Because we wanted to be-- provide capacity to offer this in females because we had stopped in females.
• 26:59
  Paul Beaulé: Registry clearly showed this was not a good thing for females.
• 27:04
  Paul Beaulé: So we just, uh, we published this a coup- uh, eighteen months ago or so, where we looked specifically in the multicenter reserve study, over six hundred patients, does gender or head size have an impact at five years?
• 27:19
  Paul Beaulé: Where in the registry, clearly the curves and the metal on metal were Spreading apart.
• 27:27
  Paul Beaulé: No difference whatsoever between females or-- and males or femoral head size 50 or smaller in the two cohorts.
• 27:36
  Paul Beaulé: And I think at five years, uh, uh, follow-up, I think that's pretty robust evidence saying that the bearing has made a difference in that, uh, patient population and sizing.
• 27:48
  Paul Beaulé: And that's all we can say.
• 27:50
  Paul Beaulé: Honestly, that's all we can say.
• 27:51
  Paul Beaulé: Uh, there's a safety aspect that we can do them in females.
• 27:55
  Paul Beaulé: We have to keep following these patients now.
• 27:57
  Paul Beaulé: We have five-year data, which is encouraging.
• 27:59
  Paul Beaulé: Obviously, uh, wherever the resurfacing has been implanted, there's registry data being in Australia that we'll see.
• 28:07
  Paul Beaulé: And that in Australia will be important because then you'll see when it is exposed to a very larger group of surgeons, is it able to tolerate that variability in technique understanding?
• 28:20
  Paul Beaulé: And that, I think, will come up in the next, uh, year or two.
• 28:23
  Paul Beaulé: And then we'll have to look individual single s-surgeon series, large series at 10, 15 years and see what's going on.
• 28:32
  Paul Beaulé: So-- But I would say right now at five years, it's promising.
• 28:36
  Paul Beaulé: Uh, we've actually been able to show a difference for females and smaller size.
• 28:39
  Paul Beaulé: So meaning that the hypothesis we put forth that ceramic bearings would solve some of the issues is proven.
• 28:47
  Paul Beaulé: Now, will it s-uh, stand, uh, the, the time test of the fixation on the acetabular side will be-- at as well as, uh, surgical technique.
• 28:57
  Paul Beaulé: Can we educate surgeons back again in understanding sizing and component placement is the next big phase
• 29:05
  Joseph M. Schwab: Hmm.
• 29:05
  Joseph M. Schwab: So it sounds like this, the, the evidence that you have is promising, but what would you need to see in order to tell you or to signal to you that it might be worth giving up on a specific design?
• 29:24
  Paul Beaulé: Well, I think if we start seeing, uh, decoupling or loosening of components prematurely, um, unfortunately, uh, that will be a major, uh, issue to stop implanting because there's-- You know, you can't, uh-- I think there's still gonna be femoral neck fractures.
• 29:45
  Paul Beaulé: Uh, there's still gonna be issues of, uh, you know, uh, cups being placed vertical, you know, like any operation.
• 29:53
  Paul Beaulé: But we-- if we see premature debonding at any of the interfaces, uh, or, or, um, you know, uh...
• 30:01
  Paul Beaulé: Could, could there be a, a, a soft tissue reaction, uh, to these bearings and modeling?
• 30:07
  Paul Beaulé: I don't know.
• 30:08
  Paul Beaulé: That would be an unknown.
• 30:09
  Paul Beaulé: Uh, but you always have to be, uh, mindful of that.
• 30:12
  Paul Beaulé: Uh, that would be to me, uh, red flags that unfortunately, uh, the design we put forward, uh, is not optimal for our patients
• 30:22
  Joseph M. Schwab: So I wanna switch topics just a little bit.
• 30:25
  Joseph M. Schwab: Uh, still on resurfacing, but we've got a, um, an audience that's really, uh, focused on anterior approach.
• 30:32
  Joseph M. Schwab: And so let's talk a little bit about how those two come together.
• 30:36
  Joseph M. Schwab: I mean, I know you are one that, uh, you're a surgeon that people talk about as going to, to learn how to do resurfacing well through an anterior approach.
• 30:48
  Joseph M. Schwab: Um, can you talk to me a little bit about how you came to that point, how you, uh, started to bring those two aspects of hip surgery together?
• 30:59
  Paul Beaulé: Well, again, I, I have to go back to my days working both with Harlan Amstutz and Joel Matta, and obviously I have to include Jeff Mast and the whole Bern Group.
• 31:08
  Paul Beaulé: So, you know, I'm there, uh, come and learn resurfacing.
• 31:11
  Paul Beaulé: Harlan's doing it to the posterior approach, but he only had started the posterior approach maybe two or three years before.
• 31:18
  Paul Beaulé: He was still doing a trans trochanteric extracapsular approach for his resurfacings.
• 31:26
  Paul Beaulé: And Pat Campbell, who was a, a basic science, uh, researcher, did a lot of implant retrieval.
• 31:32
  Paul Beaulé: Vascularity was a big deal at the time, huh, because some proponents said you cannot dislocate the native hip w- uh, calling-- causing avascular necrosis, and all resurfacing are doomed to fail.
• 31:43
  Paul Beaulé: Then comes Reinhold Ganz, surgical dislocation.
• 31:48
  Paul Beaulé: We can do this safely, do a lot of crazy surgery, and the head still lives.
• 31:53
  Paul Beaulé: So I'm there saying,"Hey, when I'm starting my practice, I'm doing my resurfacing through a surgical dislocation approach.
• 32:01
  Paul Beaulé: Because I know we've solved potentially the bearing issue of metal on poly with the first generation, but maybe vascularity is a major issue that we haven't really recognized or understood, because the early failures of the first generation of resurfacing were overwhelmed by polyethylene debris, and you couldn't really see the f- forest from the trees.
• 32:24
  Paul Beaulé: And there's a very good analogy in total hips, because initially, when total hips were failing, Hungerford said,"It's cement disease.
• 32:32
  Paul Beaulé: It's cement disease.
• 32:33
  Paul Beaulé: It's cement disease.
• 32:35
  Paul Beaulé: Go to cementless.
• 32:36
  Paul Beaulé: Oh my God, it's poly.
• 32:38
  Paul Beaulé: Whoa, we missed that." So I said to myself,"Okay, well, I'm not gonna do that." So I started with the surgical dislocation approach.
• 32:45
  Paul Beaulé: Obviously, Harlan was not pleased.
• 32:49
  Paul Beaulé: Uh, because he said,"Well, how dare you kinda not l- do it exactly like me?" I said,"Look, Harlan, you-- I, I just want to remind you, when you did your cementless metal on poly resurfacing, you were using a vascular-preserving approach." He was a bit stunned.
• 33:07
  Paul Beaulé: "Yeah, you were.
• 33:08
  Paul Beaulé: You were doing a trochanteric osteotomy that was extracapsular, and you were dislocating the hip anteriorly.
• 33:13
  Paul Beaulé: That's no different than what Har- Reinhold does.""Oh, okay, fine." So anyway, so I did that a- and my results were good on the fixation side.
• 33:22
  Paul Beaulé: Unfortunately, uh, compared to my hip preservation group, I had a much higher rate of non-union
• 33:29
  Joseph M. Schwab: Hmm
• 33:30
  Paul Beaulé: People were not restricting weight-bearing on their hips because the pain relief was so massive they couldn't be bothered to stay on crutches for six weeks or four weeks.
• 33:42
  Paul Beaulé: So then I said,"Look, uh, I'm having issues with trochanteric nonunion.
• 33:46
  Paul Beaulé: It was about 6% or 7%." And I said,"Well, I gotta do something, uh, different." And, uh, so I said,"Well, maybe the anterior approach, uh, as Judet had described would be, uh, helpful." I had been exposed to the anterior approach with Joel doing total hips, but not resurfacing.
• 34:01
  Paul Beaulé: So I went to, uh, the Mecca in Garches, in Paris, where, uh, Thierry Judet and, uh, Philippe Perriaux, his partner, were-- You know, the only approach they knew was the anterior approach, so when they started doing resurfacing there, there was nothing else to do.
• 34:16
  Paul Beaulé: So I s- uh, back in 2003, went and spent a few days with them, uh, understood the retractors, the positioning, and that's how I started
• 34:25
  Joseph M. Schwab: So, you know, v- especially for hip resurfacing, but also just for anterior approach in general, femoral exposure is kind of the classic hurdle, right?
• 34:33
  Joseph M. Schwab: So how do you-- K- kind of walk me through what your, um, you know, how you handle femoral exposure from a positioning, from a table, releases, instruments, and I know we could, we could go on and on about this, but if it, you know, as best you can, keep it, uh, keep the details short and sweet.
• 34:53
  Joseph M. Schwab: Yeah.
• 34:53
  Paul Beaulé: Yeah.
• 34:54
  Paul Beaulé: So I, a couple of things.
• 34:55
  Paul Beaulé: So again, uh, Joel Matta and the whole, uh, French school.
• 35:00
  Paul Beaulé: So I, I like the, the orthopedic positioning table.
• 35:03
  Paul Beaulé: I don't, I, I don't call it a track, it's a position table because it position the legs in a reproducible fashion and doesn't move.
• 35:10
  Paul Beaulé: So you have counter, uh, counter, uh, you have the other leg in the boot, so then when you dislocate the hip, the pelvis doesn't move.
• 35:18
  Paul Beaulé: That's critical.
• 35:19
  Paul Beaulé: And then when you do the, uh, dislocation of the head, again, I learned this from Judet and their group, is that you put a skid, a Weber spoon, and dislocate the hip in under no traction.
• 35:31
  Paul Beaulé: And if you look, uh, and Joel and I have looked at this video together, there was a meeting in Bern of the International Hip Society in the, uh,'80s, and there's a recorded video, I don't know if you've seen it, you've probably seen it, on the Bern website of s- of, uh, Robert Judet doing an anterior toll hip, cementless anterior toll hip.
• 35:51
  Paul Beaulé: And you look at that, it's like we've invented nothing.
• 35:54
  Paul Beaulé: Like, it, it like, look at that, it's like, it's exactly what we're doing.
• 35:58
  Paul Beaulé: So he, in his technique for toll hips, he would not do an inside your neck cut, he would dislocate the hip and do the cut in that perception.
• 36:07
  Paul Beaulé: He released the tensor in almost every case at the wing by about a centimeter or so, and then you would do a, a release of your pubofemoral, uh, ligament or capsule to permit the head and the, and the acetab to increase that space.
• 36:25
  Paul Beaulé: And that's basically it, my friends.
• 36:27
  Paul Beaulé: Dislocate the hip, pubofemoral release to increase the space between the head and neck, orth- orthopedic position table, bring the leg in extension, full external rotation, locked in position, then you look at your tensor relation to your head.
• 36:44
  Paul Beaulé: If it's too tight, go at the iliac wing, release a bit of the tensor, tensor falls away, and you've got your exposure
• 36:54
  Joseph M. Schwab: Are you doing-- how far posterior are you doing your capsular releases?
• 36:59
  Paul Beaulé: Zero
• 37:00
  Joseph M. Schwab: Zero.
• 37:02
  Joseph M. Schwab: So this is the
• 37:02
  Paul Beaulé: where the vet--
• 37:03
  Joseph M. Schwab: than the Justin Cobb philosophy
• 37:06
  Paul Beaulé: Yeah.
• 37:06
  Paul Beaulé: Well, I mean, if you're going to go anterior, you gotta be anterior, correct?
• 37:08
  Paul Beaulé: You can't do two approaches at the same time.
• 37:11
  Paul Beaulé: So I'd like to be consistent.
• 37:13
  Paul Beaulé: So I, I-- And where do the vessels come from?
• 37:15
  Paul Beaulé: From the back.
• 37:16
  Paul Beaulé: So, uh, I, I stay away from that area, and there's absolutely no need to, to release posteriorly.
• 37:23
  Paul Beaulé: Uh, you need to release that capsule medially, which, uh, exposes your acetabulum and gives you that room.
• 37:29
  Paul Beaulé: And then to better see the head, if, if the, if the patient's tensor is quite bulky or a bit, uh, uh, horizontal, uh, in relation to the neck, you release a bit of the tensor, and that gives you very, very good exposure of your head-neck area
• 37:44
  Joseph M. Schwab: So, s- a lot of surgeons come to anterior approach because of its stability benefits, its soft tissue benefits, those sorts of things, right?
• 37:51
  Joseph M. Schwab: The-- that's what the kind of classic teaching is.
• 37:55
  Joseph M. Schwab: Do those soft tissue advantages, those stability advantages of the anterior approach add any benefits in resurfacing, or do you trade one for another?
• 38:05
  Joseph M. Schwab: How-- Yeah, you clearly came-- you know, brought the two together not for the same reason that people are doing it in, in regular arthroplasty, right?
• 38:15
  Paul Beaulé: Yeah, yeah.
• 38:15
  Paul Beaulé: The main driver was, uh, vascularity, uh, and also, I mean, to some extent, the, the not having to really secure max or being a big, uh, resecting all the short external rotators, et cetera.
• 38:29
  Paul Beaulé: But-- And I, I really-- I think the other main advantage is you do really see well the acetabulum.
• 38:34
  Paul Beaulé: It, it's not that different when people-- You, you can see now the new trend in, in, uh, anterior hip is doing all your revisions through the front, and especially the acetabulum.
• 38:43
  Paul Beaulé: People feel like,"Wow, what great exposure," even with a retained femoral stem.
• 38:49
  Paul Beaulé: Well, uh, like, it's no different with the resurfacing.
• 38:52
  Paul Beaulé: You, you-- That head just tucks at the back, and you have a fantastic exposure of the acetabulum.
• 38:58
  Paul Beaulé: So, to me, in actual fact, I, I, I think from a, uh, orientation of your components and sizing, you're much better off with the anterior approach.
• 39:07
  Paul Beaulé: Because one of the issues, a lot of these patients have a cam deformity, okay?
• 39:12
  Paul Beaulé: We know that.
• 39:13
  Paul Beaulé: Or the head's retro tilted, and you need to restore or reorient yourself on the femoral neck.
• 39:22
  Paul Beaulé: And I think one thing that's being not well-recognized is that one of the risk factors for femoral neck fracture, which I thought might be vascularity, but I don't think it plays as big as a role, uh, as I thought, is notching of the neck
• 39:38
  Joseph M. Schwab: Hmm.
• 39:38
  Paul Beaulé: at the anterolateral aspect of the head neck junction, which is some of the hardest bone, and that's where all the stresses go through.
• 39:47
  Paul Beaulé: Torque, load.
• 39:49
  Paul Beaulé: And you say,"Okay, how is that relevant anterior to posterior?" Well, if you come from the back, all you see is the head, massive head, and that head sits on the back of the neck and retro tilted.
• 40:06
  Joseph M. Schwab: Hmm.
• 40:06
  Paul Beaulé: So, when you're trying to get your pin placement, your referencing is quite difficult because you can't really see that anterior neck.
• 40:14
  Paul Beaulé: Where's the osteophyte?
• 40:15
  Paul Beaulé: Where's the neck?
• 40:16
  Paul Beaulé: And what I think happens is that the pin ends up being placed too posteriorly on the neck or what appears to be right center of the head.
• 40:26
  Paul Beaulé: But remember, the head's retro tilted.
• 40:29
  Paul Beaulé: And you come in with your barrel reamer.
• 40:31
  Paul Beaulé: Where do you notch?
• 40:32
  Paul Beaulé: No different than a total knee.
• 40:34
  Paul Beaulé: You notch on that anterior cortex, and you create a major stress riser.
• 40:39
  Joseph M. Schwab: Hmm
• 40:40
  Paul Beaulé: And if your component is also a bit translated inferiorly, you've got that junction between prosthesis and neck right there, and that's where it breaks.
• 40:50
  Paul Beaulé: And I think the anterior approach permits you a better visualization of your true neck axis, restoring the head neck offset by removing the cam, and also ensuring that you size your component quite nicely, because you don't need to oversize a component because you know exactly where that anterior neck junction is.
• 41:12
  Joseph M. Schwab: And you came to that realization sort of after seeing this more frequently with anterior approach, or was this something you were thinking about as you brought anterior approach to hip resurfacing?
• 41:24
  Paul Beaulé: Well, the reason why I'm mentioning this is that, uh, Bill Walter from Australia is gonna publish this soon.
• 41:29
  Paul Beaulé: He's looked at the, uh, early sh- short-term, uh, femoral neck fractures in resurfacing in Australia, and the majority are males.
• 41:37
  Paul Beaulé: And they were looking at each other like,"Okay, well, that's bizarre.
• 41:39
  Paul Beaulé: You wouldn't think the male, they got good bone." But I said to Bill, I said,"Bill, these guys are cams, man.
• 41:47
  Paul Beaulé: That neck is retro-tilted.
• 41:48
  Paul Beaulé: I'm telling you, if they're going through the back, they're damaging the vascularity a bit.
• 41:52
  Paul Beaulé: The pin placement's not quite right.
• 41:54
  Paul Beaulé: It's a bit posterior, a bit inferior because they're-- can't see that anterior neck and not-- they're not able to center that component right on the neck, and they're now entering anterior superiorly and creating that stress riser." So I, I think like anything, uh, it's evolving my thinking, but that's my current kind of, uh, red flag or, or signal to people.
• 42:12
  Paul Beaulé: Be careful of that pin placement and sizing,'cause you're gonna create yourself some problems with neck fractures
• 42:20
  Joseph M. Schwab: So, I mean, obviously you're a proponent of hip resurfacing.
• 42:24
  Joseph M. Schwab: Um, we've had a few folks on who are proponents of hip resurfacing, but there are a lot of skeptics out there.
• 42:29
  Joseph M. Schwab: And so, uh, I'm, I wanna make the skeptics' case for a minute, and I'm just gonna give you some common sort of, quotes isn't the right word, but some common things that I've heard, and I just want you to react to them as best you can.
• 42:43
  Joseph M. Schwab: Doesn't have to be a long reaction, but how do you deal with somebody who says, for instance,"Total hip is so good, we don't have a problem left to solve.
• 42:51
  Joseph M. Schwab: Why are we trying to solve it with resurfacing?"
• 42:54
  Paul Beaulé: Why do hip arthroscopy and PAOs then?
• 42:59
  Joseph M. Schwab: All right.
• 43:00
  Joseph M. Schwab: The functional advantage of a hip resurfacing is so small and not proven in any randomized trial
• 43:10
  Paul Beaulé: What about periprosthetic femur fracture?
• 43:12
  Paul Beaulé: It's on the uprise.
• 43:14
  Paul Beaulé: Major issue.
• 43:15
  Paul Beaulé: I rather have a femoral neck fracture a- after a resurfacing than a B2 fracture after a total hip when I'm playing curling or sports in Canada
• 43:25
  Joseph M. Schwab: If you lived in Florida, you'd feel differently, is that right?
• 43:29
  Paul Beaulé: Football is a very dangerous sport too, I heard
• 43:32
  Joseph M. Schwab: Um, all right, so this goes into my next one.
• 43:35
  Joseph M. Schwab: Revising a failed resurfacing isn't as simple as advertised
• 43:41
  Paul Beaulé: Well, revising a total hip is much more difficult.
• 43:44
  Paul Beaulé: The one thing we do know, a revised resurfacing is not as good as a primary hip.
• 43:49
  Joseph M. Schwab: Hmm.
• 43:49
  Joseph M. Schwab: Hmm.
• 43:49
  Paul Beaulé: We know that.
• 43:50
  Paul Beaulé: But certainly, a revised resurfacing is a much more, uh, better of an option than a, uh, revision of a, uh, failed, uh, total hip, either as a fracture or a loosening.
• 44:00
  Paul Beaulé: And again, go back to the analogy.
• 44:02
  Paul Beaulé: You know, uh, you prefer having dentures to eat your steak or a crown?
• 44:07
  Paul Beaulé: So, uh, I mean, uh, y- you know, you can argue all these things.
• 44:10
  Paul Beaulé: I think with time, with better, uh, IMU devices, uh, Justin's done a lot of work on that.
• 44:16
  Paul Beaulé: There, there's no doubt that for high-level sports, high activity, the proprioception, the stability of a resurfacing surpasses a total hip, no-- hands down
• 44:26
  Joseph M. Schwab: So from this dental analogy, I'm gonna say that we shouldn't be doing resurfacing in vegans.
• 44:31
  Joseph M. Schwab: Is that, would you agree with that?
• 44:32
  Joseph M. Schwab: 'Cause they're not gonna be eating steak regardless.
• 44:37
  Paul Beaulé: so there's not-- they're not ever gonna allow, allow, allow the implant.
• 44:40
  Paul Beaulé: So I don't think we have to worry about them too much
• 44:42
  Joseph M. Schwab: All right, so one, one more quote for you.
• 44:45
  Joseph M. Schwab: It's,"The procedure's technically too demanding for the average volume surgeon.
• 44:50
  Joseph M. Schwab: It should be limited to high-volume centers, people who do lots of them."
• 44:54
  Paul Beaulé: Yeah, I, I don't necessarily disagree with that.
• 44:56
  Paul Beaulé: I, I'm not trying to create a club of resurfacing, but I, I think y- I, I, I think if you're a hip surgeon that do high volume total hips-- And we, we looked at this in Canada.
• 45:06
  Paul Beaulé: When resurfacing first came out, I had one of my fellows visit Don Garbuz at UBC, Emil Schemitsch in, uh, Lon-- in Toronto at the time, and a few other centers.
• 45:16
  Paul Beaulé: These individuals had never done resurfacing in their fellowship training, but they were well-proven, high-volume arthroplasty surgeon.
• 45:26
  Paul Beaulé: And their learning curve for resurfacing was under a 3% neck fracture, very acceptable compared to a, a low-volume surgeon.
• 45:35
  Paul Beaulé: So if you're a high-volume arthroplasty surgeon and/or do, uh, the full spectrum of hip surgery, uh, obviously you have to understand, visit surgeon, learn.
• 45:46
  Paul Beaulé: There should be no issues.
• 45:48
  Paul Beaulé: You should do a minimum volume like a PAO of 25 to 30 a year so that you maintain your skill set.
• 45:55
  Paul Beaulé: So it's no different than doing a pelviostotomy.
• 45:58
  Paul Beaulé: You need a minimal skill set and a good understanding of pel-- uh, hip anatomy
• 46:03
  Joseph M. Schwab: So what I, uh,'cause I clearly haven't covered all the objections to resurfacing, but what objection from your perspective do you think is the most legitimate?
• 46:13
  Paul Beaulé: Well, acetabular cup reaming.
• 46:15
  Paul Beaulé: I think, how much bone do you remove at the time of the initial implantation, and what impact does it have on the, uh, knee-- uh, bone reserve, I can-- if I can put it that way, and overall, uh, aspect.
• 46:28
  Paul Beaulé: So I think that's a, a real issue, and I think that's where you're gonna see a big difference between the, uh, design that you have there and also the surgical technique.
• 46:38
  Paul Beaulé: Because if you can't really come down close enough to head and neck area by understanding the need to correct the cam resection, the cam, uh, deformity, and if you don't know how to ream the socket appropriately or have a, as-acetabular socket that's bigger, uh, the anatomy will, uh, on this acetabulum will be compromised by over-reaming.
• 46:59
  Paul Beaulé: And what-- We haven't published this, but we, we did an interesting study where I looked at a series of about close to 30 hips where they had initially a resurfacing, came back 10, 15 years later on for arthritis on the other side.
• 47:14
  Paul Beaulé: The, uh, either too old or large head size, we had to do a total hip on the other side.
• 47:21
  Paul Beaulé: Okay?
• 47:22
  Paul Beaulé: Same surgeon, me and my colleague, uh, George Grammatopoulos.
• 47:27
  Paul Beaulé: Same approach 85% of the components were the same size With a resurfacing shell, that was a six-millimeter difference.
• 47:39
  Paul Beaulé: So femoral component of 46, shell 52.
• 47:44
  Paul Beaulé: So in the vast majority of cases, with a good technique and a appropriately sized, uh, resurfacing component, 85% of the patients will have the same acetabular size as a total hip.
• 47:58
  Paul Beaulé: And that supports the RCT from Montreal from a long time ago, from Pascal-André Vendittoli and Mar-Martin Lavigne, where they showed in their RCT no difference in median size of the acetabular component comparing total hip to resurfacing.
• 48:14
  Paul Beaulé: Again, that was with the Durom, which had a six-millimeter difference between the head and the acetabular
• 48:19
  Joseph M. Schwab: Yeah.
• 48:20
  Joseph M. Schwab: Hmm.
• 48:21
  Joseph M. Schwab: So you've been really generous with your time.
• 48:24
  Joseph M. Schwab: I just have a few, a, a, a couple small kinda questions about what do you think the next few decades are gonna look like?
• 48:31
  Joseph M. Schwab: So where's resurfacing gonna be in, let's say, 10 years or maybe 20 years?
• 48:38
  Paul Beaulé: Well, I, I think it-- hopefully it will be in the armamentarium of the hip surgeon, where patient at the right age, you may need a hip scope, you may need a PAO or a resurfacing or a total hip.
• 48:56
  Paul Beaulé: That how it, it should be.
• 48:58
  Paul Beaulé: You don't just have a hammer and everything looks like a nail.
• 49:01
  Paul Beaulé: You look at the anatomy, you look at the disease condition, how much arthritis it is, and then you provide the best operation for that patient in their, uh, health condition of their hip and overall general health.
• 49:16
  Paul Beaulé: That I think should be the role of resurfacing, and that's been my approach for, uh, over, uh, a quarter of a century
• 49:24
  Joseph M. Schwab: So we've talked a little bit about the people who are skeptical of hip resurfacing.
• 49:29
  Joseph M. Schwab: Is there a study that you could envision, or maybe even one that's running currently, that would help settle the debate for people about where resurfacing should sit within the armamentarium of the hip surgeon?
• 49:43
  Paul Beaulé: Well, let me be a bit, uh, cynical about this.
• 49:46
  Paul Beaulé: Um, there have been several RCTs of the anterior approach compared to the posterior approach, and people are still non-believers out there, Joe, so I don't know what to tell you.
• 49:57
  Paul Beaulé: I, I, I, I, I, I, I, I mean, I, I am Catholic.
• 50:01
  Paul Beaulé: I'm not gonna go on a crusade.
• 50:02
  Paul Beaulé: I can tell you that didn't work out very well for us, and not gonna do that for hip resurfacing.
• 50:07
  Paul Beaulé: I, I think, yeah, as long as we provide a good operation for the patient, do it well, and, and match the disease condition, that really-- what really matters to me.
• 50:17
  Paul Beaulé: So it's really understanding the pathology.
• 50:19
  Paul Beaulé: It's not being on one camp or the other.
• 50:21
  Paul Beaulé: It's really, you know, doing-- understanding the pathology.
• 50:25
  Paul Beaulé: If you understand the pathology, like a dysplastic hip, you shouldn't do a scope.
• 50:31
  Paul Beaulé: If you have a 35-year-old male with good bone and arthritis, you should be doing a hip resurfacing for that patient or refer them to some patient because they're gonna be-- do extremely well with that operation, have great function, and really have a lot of options 15, 20 years, 30 years down the road if they need a total hip.
• 50:52
  Joseph M. Schwab: I had a partner at my previous practice who would say,"I can teach it to you, I can't learn it for you." And this, this is sort of the idea behind, we can have all the RCTs, but if you're just not a believer, you're not a believer.
• 51:05
  Paul Beaulé: Correct.
• 51:06
  Paul Beaulé: Correct
• 51:06
  Joseph M. Schwab: what would you tell a young surgeon who wants to learn resurfacing now?
• 51:12
  Joseph M. Schwab: What would be your one, two, three, you know, list of things to do?
• 51:17
  Paul Beaulé: I think it'd be n- no different, uh, potentially than the PAO or the anterior approach itself, you know?
• 51:22
  Paul Beaulé: Either find a fellowship where they do some volume of it so you can get your hands-on soon, or, and, or, uh, uh, go to educational courses.
• 51:33
  Paul Beaulé: Uh, I know the Anterior Hip Foundation has a fellowship.
• 51:36
  Paul Beaulé: ISHA also has a hip preservation fellowship.
• 51:39
  Paul Beaulé: Go and educate yourself.
• 51:40
  Paul Beaulé: I've had a lot of surgeons, and I think, uh, Joel's had this, Justin's had this.
• 51:44
  Paul Beaulé: Go spend time.
• 51:45
  Paul Beaulé: Reinhold and Bern, you are always welcome to go and watch.
• 51:50
  Paul Beaulé: And Jeff Mast wa- was also a proponent of that.
• 51:53
  Paul Beaulé: Go spend time with people.
• 51:55
  Paul Beaulé: Look at them.
• 51:56
  Paul Beaulé: Take the time to actually do a cadaver course or go to your lab, anatomy lab at your own institution, and do it and work on it, and then either have a surgeon accompany you for your first cases, and if you've done your first cases, go visit someone again.
• 52:12
  Paul Beaulé: I, I can tell you certainly for the anterior approach, after I'd been doing it for a few years, I went to see Frédéric Laude in Paris.
• 52:18
  Paul Beaulé: My God, it was like, okay, that I'll do.
• 52:21
  Paul Beaulé: That I'll do.
• 52:22
  Paul Beaulé: Went to see Joel again.
• 52:24
  Paul Beaulé: So we're never too old to learn, a- and I think that's the key message.
• 52:29
  Paul Beaulé: Uh, and take the time.
• 52:31
  Paul Beaulé: Uh, if you don't wanna take the time, then, uh, don't bother because i- i- i- you're, you're not being, uh, uh, respectful for your profession.
• 52:39
  Paul Beaulé: Uh, uh, you know, we're, we're, we're independent practitioner.
• 52:42
  Paul Beaulé: We're responsible for our continued medical education, so we need to take that seriously and put the time into it
• 52:50
  Joseph M. Schwab: I can't think of a better place for us to, to pause the conversation than there.
• 52:54
  Joseph M. Schwab: Paul, I really appreciate you joining us, um, today on the AHF podcast and talking with our listeners about your experience in hip resurfacing
• 53:04
  Paul Beaulé: Merci beaucoup, and please come and join us in Ottawa.
• 53:08
  Paul Beaulé: ISHA is gonna be here in twenty twenty-seven, so we're gonna have a good time, and I-- and we're gonna try to talk about a bit of anterior hip or if you wanna see some anterior hip resurfacing, February is the best time of year to come to Ottawa
• 53:21
  Joseph M. Schwab: Thank you for joining me for this episode of the AHF Podcast.
• 53:25
  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.
• 53:33
  Joseph M. Schwab: Please also drop any topic ideas or feedback in the comments, and you can find us on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube at Anterior Hip Foundation, all one word.
• 53:49
  Joseph M. Schwab: Episodes of the AHF Podcast come out on Fridays.
• 53:52
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and it sounds like resurfaced