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Operation FUBAR: One-in-Six-Million Bone · 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: Joining me today is Dr.
• 0:28
  Joseph M. Schwab: Jeff Berry, and I'm really pleased to welcome him to the show.
• 0:32
  Joseph M. Schwab: Jeff is an orthopedic surgeon at UCSF, where he directs the Hip and Knee Arthroplasty Fellowship and co-directs the Arthroplasty for the Modern Surgeon course held up in Napa in August of 2026.
• 0:46
  Joseph M. Schwab: His practice centers on adult hip and knee reconstruction with particular expertise in anterior approach hip replacement, as well as complex revision surgery, which makes him exactly the right person to have on for an episode like this one.
• 1:01
  Joseph M. Schwab: Jeff, thanks so much for coming on the AHF Podcast, and welcome to Operation FUBAR
• 1:09
  Jeff Barry: Thanks so much for having me.
• 1:10
  Jeff Barry: Uh, I, I guess it's an honor to be here for this, but, uh, we'll, we'll see if, uh, if you s- you agree af- after we go through these cases.
• 1:19
  Joseph M. Schwab: So, um, you have a case prepared for us, is that right?
• 1:22
  Jeff Barry: Yeah, it's, it's, it's a patient prepared for you.
• 1:24
  Jeff Barry: It's actually two cases, so
• 1:26
  Joseph M. Schwab: All right, perfect.
• 1:27
  Joseph M. Schwab: Well, let's, let's get right into it.
• 1:29
  Joseph M. Schwab: Here we go
• 1:31
  Jeff Barry: Yeah.
• 1:31
  Jeff Barry: So I, I called this one, uh, please don't be so nice to me because it, it kinda goes with a theme that I, I think as surgeons, we kinda find that the nicest patients are often the ones that have the, the worst outcomes, and if, if you happen to be an asshole, somehow you're protected against, against the bad things happening.
• 1:47
  Jeff Barry: So this is, this is a very nice patient.
• 1:49
  Joseph M. Schwab: I think a lot of surgeons can relate to that for sure
• 1:51
  Jeff Barry: yeah, yeah, a little foreboding.
• 1:53
  Jeff Barry: So, you know, this is a 75-year-old, also a retired nurse, which is another bad predictor, uh, being in healthcare.
• 2:00
  Jeff Barry: Um, she lives alone.
• 2:01
  Jeff Barry: Her daughter accompanies her to visits.
• 2:03
  Jeff Barry: Um, she is the nicest woman in the world, um, and was having hip pain for two years, worse over the last four months.
• 2:09
  Jeff Barry: So previously gardened, did her own shopping.
• 2:12
  Jeff Barry: Now she's limited mostly to a wheelchair, um, a walker for very short distances.
• 2:18
  Jeff Barry: But eyeballs very frail, so, so definitely, you know, older than stated age in terms of appearance.
• 2:24
  Jeff Barry: She has leukemia, uh, with very low platelets, uh, osteoporosis that's gone through a vanity treatment, um, CHS, u-uses O2 at night and, and has kind of a scattering of, of medical comorbidities.
• 2:38
  Jeff Barry: So, you know, just, just right off the bat, kind of a, a less healthy patient, not one that we're not used to here at UCSF.
• 2:45
  Jeff Barry: Like, we get a lot of patients like this.
• 2:47
  Jeff Barry: But, um, you know, you, you kind of temper your, your expectations right off the beginning, right off the bat.
• 2:53
  Jeff Barry: Um, and these were her X-rays.
• 2:54
  Jeff Barry: So she came with two sets of X-rays, one that she had had for her referral, and then the ones that we got in our clinic.
• 3:00
  Jeff Barry: And you can see just in a couple months how, how this hip has progressed on the right side, that, you know, femoral head has collapsed.
• 3:06
  Jeff Barry: Um, you can see some generalized osteopenia, osteoporosis, um, but, you know, a fairly straightforward surgical indication for this one
• 3:16
  Joseph M. Schwab: And this is a six-month timeframe between those two images.
• 3:18
  Joseph M. Schwab: Is that right?
• 3:19
  Jeff Barry: Exactly.
• 3:20
  Jeff Barry: Exactly.
• 3:20
  Jeff Barry: So I, I met her in February, so that's the one on the, the, the right there and, and, um, yeah, this is a very...
• 3:26
  Jeff Barry: You know, she started having pain years ago, but, but really acutely started in, in that August-ish period and then came to me in February with a, with a collapsed hip.
• 3:36
  Jeff Barry: Um, so this was our plan for her.
• 3:38
  Jeff Barry: You know, in these, these kind of collapse cases or, or, you know, sick patients, you know, I kinda treat this like a femoral neck fracture patient.
• 3:47
  Jeff Barry: Um, so I'm gonna do it on a HANA table.
• 3:49
  Jeff Barry: Uh, I'm-- I almost always do a full femoral release just right off the bat whenever I'm exposing these patients.
• 3:56
  Jeff Barry: I, I know that ahead of time.
• 3:57
  Jeff Barry: I'm gonna be really aggressive in that to avoid undue tension on, on the troch or, or other, other parts of the femur.
• 4:04
  Jeff Barry: Um, we're gonna do a hybrid fixation.
• 4:07
  Jeff Barry: We're gonna cement the stem, um, and use a press-fit socket.
• 4:10
  Jeff Barry: Um, and I'm gonna talk to anesthesia ahead of time about kinda cement and, and what the risks of that are, make sure that, that they're aware of, you know, keep the O2 all the way up, be a little more aggressive on the fluids.
• 4:21
  Jeff Barry: Um, and then for this patient, they got really low platelets.
• 4:23
  Jeff Barry: We're gonna make sure we got platelets available if we need to, uh, transfuse and, and just kinda be, be set up for the surgery.
• 4:29
  Jeff Barry: But this is going on a regular OR day.
• 4:31
  Jeff Barry: You know, I'm usually running two rooms.
• 4:33
  Jeff Barry: This is the hip, so it's earlier in the day.
• 4:35
  Jeff Barry: Um, just kinda slotting into the schedule like normal, um, but being a little more careful just, just because we know the bone's not gonna be great.
• 4:42
  Joseph M. Schwab: And did you talk with her about time in the hospital as well?
• 4:45
  Joseph M. Schwab: Is this something that you would send home the same day?
• 4:48
  Joseph M. Schwab: Is this something that you'd plan to keep in the hospital?
• 4:50
  Joseph M. Schwab: What, what are your thoughts on that?
• 4:52
  Jeff Barry: Yeah, this is definitely someone we're gonna keep overnight.
• 4:54
  Jeff Barry: Um, you know, someone on O2 at night, someone we're, we're gonna cement, low platelets.
• 4:59
  Jeff Barry: We're maybe a little worried about bleeding afterwards.
• 5:01
  Jeff Barry: We're gonna just keep an eye on her.
• 5:02
  Jeff Barry: She also lives by herself.
• 5:04
  Jeff Barry: Um, she has family available, but, you know, that, that's not someone that in our, our shop we're sending home the same day.
• 5:11
  Jeff Barry: Um, so she- she's, she's aware of that and aware of the risks.
• 5:14
  Jeff Barry: You know, you talk about everything with these patients, especially the, the lung risks were actually probably our biggest discussion.
• 5:19
  Jeff Barry: Someone on O2 at night, um, gonna go through a, you know, unnecessary cemented hip.
• 5:25
  Jeff Barry: Um, th- that, that's the bulk of our risk discussion more than anything.
• 5:30
  Jeff Barry: Um, yeah, so we, we do the case.
• 5:33
  Jeff Barry: You know, it starts off fine.
• 5:34
  Jeff Barry: We do our CUP.
• 5:35
  Jeff Barry: No, no issues there.
• 5:36
  Jeff Barry: Um, and then this is kind of how I normally will position a femur.
• 5:41
  Jeff Barry: So this isn't this case, but just a video I usually-- I made for the residents that has our entire procedure.
• 5:45
  Jeff Barry: So I use a hook, I use a femoral hook.
• 5:48
  Jeff Barry: I'll rotate out to 120 degrees on the HANA table.
• 5:52
  Jeff Barry: Um, make sure that kind of the, the medial calcar is clear of any soft tissue attachments.
• 5:57
  Jeff Barry: Um, put a medial retractor and, and kind of use that to lateralize the femur a little bit.
• 6:03
  Jeff Barry: Um, and then I'll use the hook to kinda lift up and make sure we're keeping things away from the-- getting stuck behind the pelvis as you go down and under with traction off.
• 6:10
  Jeff Barry: So that's kinda my normal workflow.
• 6:11
  Jeff Barry: I think that's probably how a lot of people with a, with a HANA table would, would do that initial femoral, uh, exposure or, or leg over and under.
• 6:20
  Jeff Barry: Um, and so in this case, you know, we put the hook in, we rotate the leg out, we go down and under.
• 6:25
  Jeff Barry: And I don't hear anything.
• 6:27
  Jeff Barry: I don't see anything weird happen.
• 6:29
  Jeff Barry: But then when I go to look at the femur, all I'm staring at is a tube.
• 6:32
  Jeff Barry: Like the entire top half of the femur just shears, sheared right off in the going down and under of the hip.
• 6:39
  Jeff Barry: Um, which, yeah, so this is, this is like I was just You know, oh shit, like what, where'd the rest of the femur go, right?
• 6:48
  Jeff Barry: Um, and so, you know, this is, uh, you know, it's just stayed right where it was.
• 6:53
  Jeff Barry: I'm kind of like feeling around, like I'd done my full capsule release, which I normally do.
• 6:57
  Jeff Barry: I keep the capsular flaps.
• 6:59
  Jeff Barry: I tag them.
• 7:00
  Jeff Barry: I've taken that off the top before I go down and under.
• 7:02
  Jeff Barry: I don't usually do the, the conjoins or the piriformis release until it's down and under.
• 7:07
  Jeff Barry: And that's how I've done it for thousands of cases.
• 7:10
  Jeff Barry: This is the first one where it decided to, to not cooperate here.
• 7:14
  Jeff Barry: Um, and so as I'm exposing this and looking at it, I'm like starting to check the bone a little bit better.
• 7:19
  Jeff Barry: I knew it was bad when I made the femoral neck cut, but this is where it's like, this is really, really bad bone.
• 7:24
  Jeff Barry: Um, when you're pushing on the cortical bone, you can see it flexing on the anterior and the posterior of the, of the proximal femur.
• 7:31
  Jeff Barry: You know, you're just staring at this open tube.
• 7:34
  Jeff Barry: Um, and I try to show kind of what-- I didn't have a great X-ray obviously, or a picture interop, but you know, this is kind of where that looked like.
• 7:40
  Jeff Barry: You'd have a femoral neck cut and the whole top of the troch just kind of comes off.
• 7:44
  Jeff Barry: I've definitely had like little tip evulsions, things like that over the years of the trochanter doing DA, but this is like the entire troch below the vastus ridge just, just straight off and down.
• 7:55
  Jeff Barry: Um, yeah.
• 7:57
  Jeff Barry: And so, so this is kind of like, you know, I, I kind of think of the, the response to, uh, trauma for a surgeon as either the Michael Jordan response or the Chris Farley response.
• 8:08
  Jeff Barry: One is you can either like, some people just freeze up and they just start kind of crying on the inside.
• 8:14
  Jeff Barry: That's the, that's the Jordan meme response.
• 8:16
  Jeff Barry: Or, or I'm kind of more of the latter, which is the Chris Farley response of just like, what the?
• 8:21
  Jeff Barry: You know, just I have to like, I just get really a little bit upset and mostly at myself, right?
• 8:27
  Jeff Barry: Like you feel like you've done something that, that created this when in reality, this is like me, you know, this bone, you'll, you'll find in a second, this bone is horrible.
• 8:37
  Jeff Barry: Um, but you know, it's kind of like, what do you do next?
• 8:41
  Jeff Barry: How are you gonna process this?
• 8:42
  Jeff Barry: Everyone has some sort of initial internal response and how are you then gonna, gonna move forward from it, I think is, is part of surgery and, and, and kind of just, you know, you learn yourself and how, how you're gonna move forward.
• 8:56
  Joseph M. Schwab: Well, and is, is your team seeing Chris Farley or are they seeing Michael Jordan?
• 8:59
  Joseph M. Schwab: Are they seeing somebody else?
• 9:02
  Jeff Barry: I hope Chris Farley's mostly on the inside.
• 9:04
  Jeff Barry: I, I think I definitely let it out a little bit sometimes.
• 9:07
  Jeff Barry: You know, my, uh, my helmet in the OR, we have our names on them, like we all have our own helmets, and mine has a little, little fire n-next to it, like a, flame.
• 9:16
  Jeff Barry: Um, so there's definitely a little bit.
• 9:17
  Jeff Barry: I'll blame my hair color on that one, but but, uh, but yeah, there's a little bit of a Chris Farley.
• 9:23
  Jeff Barry: But, but I think, like, it's important that once this happens, you do have to take a step back and be like, you know,"Okay, what the hell are we gonna do next?" Um, and so, like, like, one of my, uh, attendings in training would always, like, say,"If you have something go wrong, like, turn-- like, put a lap in the wound, turn around, go to the back table, like, do whatever you have to say to yourself in your head, and then just kinda list out what the options are and what, what you should do next." So for me, it's kind of like, are we just gonna keep going, like, just leave the troche where it is?
• 9:54
  Jeff Barry: Are we gonna abort and change things?
• 9:56
  Jeff Barry: Are we gonna call for a troche plate and try to fix this thing?
• 9:59
  Jeff Barry: Um, and at the same time, in the back of my mind, I'm thinking about the frailty of this patient that, like, you know, they got no platelets.
• 10:04
  Jeff Barry: They're kinda oozy, the whole case.
• 10:07
  Jeff Barry: Their BMI is eighteen.
• 10:08
  Jeff Barry: They're probably under-- malnourished and kinda very frail.
• 10:12
  Jeff Barry: I'm about to throw cement into them in a, in a pulmonary patient.
• 10:16
  Jeff Barry: So, you know, all this is kinda going through my mind.
• 10:20
  Jeff Barry: Um, but, uh, so we decided to proceed with a cemented stem.
• 10:25
  Jeff Barry: I kinda just used that tube and cemented into it.
• 10:28
  Jeff Barry: You can kinda see this is an intraop film.
• 10:30
  Jeff Barry: You can see how bad that bone is up top.
• 10:32
  Jeff Barry: You can't really even see what's going on up there.
• 10:34
  Jeff Barry: Um, but we just left the troche where it was.
• 10:37
  Jeff Barry: I didn't trial because I didn't wanna break the femur further.
• 10:40
  Jeff Barry: And this, this X-ray is really deceiving, um, in the cortical thickness there, but you, you'll see later kinda what, what the bone quality actually was.
• 10:48
  Jeff Barry: And, and I kinda went with less is more here.
• 10:50
  Jeff Barry: So, you know, the abductor sleeve was still intact.
• 10:53
  Jeff Barry: Um, the, uh, the bone is so bad that even if I put screws in it, I don't think it's gonna hold.
• 10:59
  Jeff Barry: Um, and I, I took a bunch of that femur, sent it to path just, just to be sure I wasn't doing something or getting into something really weird.
• 11:08
  Jeff Barry: Um, and, and we just cemented in.
• 11:10
  Jeff Barry: So, you know, this is the PACU, and, and no one will know the struggle, right?
• 11:14
  Jeff Barry: Like, this is, this is one of those cases where you, you talk to your buddies, they're like,"Look at this case I just did.
• 11:19
  Jeff Barry: Like, this was crazy.
• 11:20
  Jeff Barry: Like, the troche just was gone.
• 11:22
  Jeff Barry: The bone was horrible.
• 11:23
  Jeff Barry: All my retractors are pushing through the bone," and, like, it, it looks like a cemented hip.
• 11:26
  Jeff Barry: I don't know what you're talking about.
• 11:28
  Jeff Barry: Um, but, but this was, you know, a, a mess on this side.
• 11:32
  Jeff Barry: Um, and, and, you know, this is the PACU X-ray.
• 11:34
  Jeff Barry: We slowed her down a little bit, how to use a walker.
• 11:36
  Jeff Barry: I knew the troche was off.
• 11:37
  Jeff Barry: She's low demand.
• 11:38
  Jeff Barry: I let her go.
• 11:40
  Jeff Barry: Um, and, you know, at, at four weeks, this is what she looks like.
• 11:43
  Jeff Barry: You can kinda see that, that troche missing a little bit and the cement over there.
• 11:46
  Jeff Barry: And, and at four months, you know, on a lateral, the troche's actually moving with it.
• 11:50
  Jeff Barry: Like, it, it's kinda moving as a unit.
• 11:52
  Jeff Barry: Like, she's walking with a walker.
• 11:53
  Jeff Barry: She's super, super happy and just so grateful and like,"Oh, this is great." When in reality, like, intraop, this is one where you're staring at this hole And you're like,"I don't know what I'm gonna do here." Um, so
• 12:05
  Joseph M. Schwab: so, so let me ask you, at this point, are you feeling like,"Man, I am pretty damn good that I got this," or was this a,"I can't believe I slipped by on w-
• 12:15
  Jeff Barry: This is
• 12:16
  Joseph M. Schwab: based on everything I saw"?
• 12:18
  Jeff Barry: Yeah, this is a, like, Neo in the Matrix moment where you're like, you feel like you dodged the bullet, you know, and you're kind of like,"Whoosh, got lucky on that one." And, you know, it, it-- like, in the moment, I, I think you get a little bit hung up on, like, what is the-- what's gonna happen here?
• 12:32
  Jeff Barry: But if you just kinda work through step by step by step, thing, things go okay.
• 12:37
  Jeff Barry: And, um, you know, th-this is, uh, every surgeon has these cases where, like, you're trying to describe what happened, the drop, and the X-rays don't really match up.
• 12:46
  Jeff Barry: You're like,"Uh, this doesn't look that, that crazy." But when things are so bad or, or so s- the bone is so bad, you, you feel very, uh, humbled at, at, at how bad bone can get, I guess, is, is what I'm trying to say.
• 13:01
  Jeff Barry: Um, so that-- this, this side was arguably, like, you know, this, this was, this was a little bit stressful of a side, but, you know, she did really well.
• 13:09
  Jeff Barry: She did really well.
• 13:09
  Jeff Barry: Um, and so
• 13:11
  Joseph M. Schwab: much happier than having, uh, a, uh, a rapidly progressive osteoarthritic hip, right?
• 13:18
  Jeff Barry: Yeah, exactly.
• 13:18
  Jeff Barry: Exactly.
• 13:19
  Jeff Barry: And she, you know, went from pretty independent to a wheelchair, and now she's back to, to fairly independent.
• 13:24
  Jeff Barry: So, so very happy in the whole.
• 13:26
  Jeff Barry: Um, after the surgery, I sent her to get a DEXA scan, and this is the scores that she got on her other femur.
• 13:33
  Jeff Barry: So, um, her left femur had a T-score of-5.1.
• 13:38
  Jeff Barry: Um, and so, like, just, just to review kind of what T-scores are, you know, T-score is a standard deviation below normal bone.
• 13:46
  Jeff Barry: So 5.1 standard deviation is below normal.
• 13:48
  Jeff Barry: You're like,"Ah, five, that's not, not so much." But if you think about how a normal distributed standard deviation is, 5.1 is actually one in six million.
• 13:57
  Jeff Barry: So in the SFA area, there's like a population of 7.6.
• 14:00
  Jeff Barry: This patient's from a little farther away, but still get to the point of like, this is horrendous bone.
• 14:05
  Jeff Barry: And, and I don't know why the X-ray doesn't show, but, you know, it, it looks bad, but it's not the worst bone I've seen.
• 14:11
  Jeff Barry: But this, this, uh, bone density test is really showing that, hey, this is, this is horrible, horrible bone.
• 14:20
  Jeff Barry: Um, and so, you know, uh, Bill Griffin, who was one of my, my mentors in, in, uh, in fellowship at OrthoCarolina, used to say all patients are like satellites.
• 14:29
  Jeff Barry: You know, you launch them out into space, and eventually they're all gonna kinda come back out of orbit.
• 14:35
  Jeff Barry: It's just a matter of when.
• 14:37
  Jeff Barry: and so, y- yeah.
• 14:39
  Jeff Barry: So the, you know, the enemy of good outcomes is follow-up.
• 14:42
  Jeff Barry: Um, and, and this patient comes back a year later, and this is, this is one of those ones that you see on the schedule, and it says just, you know, follow-up hip pain, and you're just like,"Oh, crap." Like, what, what is this gonna be?
• 14:54
  Joseph M. Schwab: Oh, no
• 14:56
  Jeff Barry: so she's back in a wheelchair, and she says,"I haven't been able to walk for three months," but she says it's her left hip that hurts.
• 15:03
  Jeff Barry: And so you're like,"Okay, okay, we got it.
• 15:05
  Jeff Barry: All right." So i- looking at this film and being able to compare to others, a- she actually has a missed femoral neck fracture.
• 15:12
  Jeff Barry: So she, she was diagnosed-- She lives kind of in the boonies and, um, was diagnosed with just hip pain and arthritis and sent back to us to get evaluated.
• 15:19
  Jeff Barry: But she's actually had a femoral neck fracture, kind of a valgus impacted femoral neck fracture, um, for the last three months.
• 15:26
  Jeff Barry: You can kinda see in that inferior cortical area on there that it's, it's a, it's, it's definitely off and, and kinda shifted down.
• 15:34
  Jeff Barry: So again, this is, this is one that, you know, are like,"Okay, round two, here we go.
• 15:38
  Jeff Barry: We're gonna do this again." Um, you know, and I got...
• 15:42
  Jeff Barry: You know, this time we're gonna be ready.
• 15:44
  Jeff Barry: We get the whole game plan together.
• 15:45
  Jeff Barry: We're gonna use a multi-hole cup right off the bat,'cause we know the socket bone's gonna be bad, and maybe we need some extra screws.
• 15:52
  Jeff Barry: This time I'm not gonna break the troch off, so it's not my normal workflow.
• 15:56
  Jeff Barry: But before I even drop the leg down, I'm gonna do all the femoral releases, like no stress on the trochanter We know we're not going to trial the cemented stem, so I got to get that neck cut good right off the bat.
• 16:08
  Jeff Barry: And I'm just going to be careful every single step of the way, and I'm going to make sure we got everything in the hospital in case we need to do something weird.
• 16:15
  Jeff Barry: Okay, so this is the game plan.
• 16:19
  Jeff Barry: This is as we're getting ready to hit the cup in.
• 16:21
  Jeff Barry: I ream and hit the cup in under fluoro and go into my 90s movies and things.
• 16:28
  Jeff Barry: It's wide open.
• 16:29
  Jeff Barry: All you got to do is tap it in.
• 16:30
  Jeff Barry: Just tap it in nice and gently.
• 16:33
  Jeff Barry: I'm walking the resident or the fellow like, I'm going to hit this one in.
• 16:36
  Jeff Barry: Just going to hit it nice and gently.
• 16:38
  Jeff Barry: Just tap it in.
• 16:39
  Jeff Barry: All right, tap it in.
• 16:41
  Jeff Barry: A little tap, tip, tip, tappy, tapperoo.
• 16:46
  Jeff Barry: God damn.
• 16:48
  Jeff Barry: Dang it.
• 16:48
  Jeff Barry: You know?
• 16:49
  Jeff Barry: And, and this is like, you're like,"Shit." Um,
• 16:53
  Joseph M. Schwab: Hmm.
• 16:54
  Jeff Barry: cup, cup goes straight into pelvis.
• 16:56
  Jeff Barry: And, and so this is like, this is pretty, pretty common thing, I think, for us as surgeons is like we know, um, we're, we're worried about a certain part of a case, right?
• 17:08
  Jeff Barry: You know there's gonna be a complicated part of the case, and this one is like the femur.
• 17:11
  Jeff Barry: Like most of my thought is on the femur.
• 17:14
  Jeff Barry: I know that's gonna be tough.
• 17:15
  Jeff Barry: The bone's bad.
• 17:16
  Jeff Barry: DEXA's minus five.
• 17:18
  Jeff Barry: This is a one in six million crap bone.
• 17:21
  Jeff Barry: And then you, you-- I, I wasn't totally distracted.
• 17:24
  Jeff Barry: Like I knew it was gonna be bad.
• 17:25
  Jeff Barry: I'm, I'm being gentle, and still something happens on the other side.
• 17:29
  Jeff Barry: Um, and so then you're just like, you're very much, you know, in the like, you know, I'm, I'm the,"God dang it," you know?
• 17:38
  Jeff Barry: Like, what the heck?
• 17:40
  Jeff Barry: Um, I swear I'm a good surgeon usually.
• 17:45
  Jeff Barry: But, uh, but yeah, this is, this is like one of those ones, and now you're, you're back to this kinda Jordan or, or Farley response and, or, or Happy Gilmore response.
• 17:54
  Jeff Barry: Um, and you know, you gotta take a step back and be like,"Okay, what am, what am I gonna do now?" Like this is, this is bad bone.
• 18:02
  Jeff Barry: I just put a revision cup.
• 18:03
  Jeff Barry: I was using a multi-hole cup.
• 18:04
  Jeff Barry: Like I was being gentle, and it just went straight in So, you know, I, I'm, I'm thinking through my options, like, do I wanna do a different cup?
• 18:15
  Jeff Barry: Do I need to do, like, kind of a tumor-style rebar screws and cemented cup?
• 18:20
  Jeff Barry: I do that not infrequently for some, for some metastatic cancer stuff.
• 18:25
  Jeff Barry: Do I wanna come back another day?
• 18:27
  Jeff Barry: Do I wanna put a cage in, um, or cement a cage in?
• 18:31
  Jeff Barry: Do I want to do a cup cage?
• 18:32
  Jeff Barry: Like, like, what do I wanna do?
• 18:33
  Jeff Barry: Okay, and again, in the back of my mind, I got this medical frailty and this, this kind of not super healthy patient, and I, I still have to do the cemented femur, which I was worried about to begin with, right?
• 18:44
  Jeff Barry: So you got all these things, things swirling.
• 18:47
  Jeff Barry: Um, you know, I try to assess the defect, which you can tell from this X-ray is really easy to, easy to see.
• 18:54
  Jeff Barry: The shin rock just-- you know, the bone is so bad, so bad.
• 18:58
  Jeff Barry: Um, but it, but it seemed like the anterior column was out, and the medial wall had kind of blown through, but my posterior column was still intact.
• 19:05
  Jeff Barry: So, you know, that-- I, I do a ton of revisions.
• 19:08
  Jeff Barry: Like, that, that doesn't-- that problem I can, I can do.
• 19:12
  Jeff Barry: I got a column intact.
• 19:13
  Jeff Barry: I got some pinch I can get from the ischium to the, to the ilium.
• 19:17
  Jeff Barry: I, I can, I can figure this one out.
• 19:19
  Jeff Barry: Um, we, we were able to take a multi-hole revision cup, um, go bigger.
• 19:26
  Jeff Barry: You know, I didn't, didn't ream.
• 19:28
  Jeff Barry: I kinda under-reamed by probably f- I think it was, like, four millimeters in this one, just kinda tap a, a revision cup in there.
• 19:35
  Jeff Barry: Still soft as hell.
• 19:36
  Jeff Barry: And, and I love locking screws in, in revision cups.
• 19:39
  Jeff Barry: Um, this cup has locking screws, and I just filled it up like a Sputnik.
• 19:44
  Jeff Barry: You know, I, I, like, tell the fellows, it's like,"Just put the screws everywhere." Even if it's a 15 screw that's, like, you know, two millimeters of cortical bone, put it in, use it as a stud out of this, this Sputnik cup, and just get as much fixation as you possibly can in every position.
• 20:00
  Jeff Barry: Uh, from the DA, like, it's really nice to be able to check all these screws to make sure they're not, like, egregious, but, you know, a bunch of these are not, not really in, in that good a bone.
• 20:10
  Jeff Barry: But I'm putting it wherever the s- the screw hole was.
• 20:13
  Jeff Barry: And, um, you can see from that first X-ray to the second one, like, I kinda rotated the cup a little better to get, get where some bone was.
• 20:19
  Jeff Barry: Um And, and yeah, this is, this is still a sinking feeling when every time you put the, the depth gauge in, it just kind of goes and you have no idea.
• 20:30
  Jeff Barry: Like it'll just go right through the cortical bone and you're just like, what, what, you know, you have to use C-arm almost to, to see where your screws are.
• 20:37
  Jeff Barry: But lock it up, you know, locking screws.
• 20:39
  Jeff Barry: This is kind of like an internal cage in my mind is like, I think these locking cups can take away the need for a cage in some situations because it is kind of this fixed angle device in all directions.
• 20:52
  Jeff Barry: So, so that's why the Illica, you know, this, this is one where when you're using C-arm a lot, you get, you get kind of these funky things.
• 21:01
  Jeff Barry: And if you look at the pubic area here, like this is the, I haven't touched anything.
• 21:04
  Jeff Barry: I just kind of moved the C-arm a little bit.
• 21:07
  Jeff Barry: It looks like this thing's moving all over the place, but it's just because those screws aren't actually in the, in the pubis.
• 21:11
  Jeff Barry: They're kind of like in front or behind.
• 21:13
  Jeff Barry: And so it just, it looks like it's, it's a mess, but you know, it seemed to have good fixation.
• 21:20
  Jeff Barry: I was able to kind of grab it, shake it with a Coker, wasn't, wasn't falling out.
• 21:24
  Jeff Barry: So I'm okay with that moving forward.
• 21:28
  Jeff Barry: You know, these are our PACU films.
• 21:32
  Jeff Barry: I put her on 50% weight bearing for a bit.
• 21:34
  Jeff Barry: I hate to, I hate to limit people after primary, but, but you know, this, this bone necessitates that.
• 21:39
  Jeff Barry: Let it grow in a little bit.
• 21:42
  Jeff Barry: We actually got away with the femur, no problems this time, right?
• 21:45
  Jeff Barry: So we did all the releases.
• 21:46
  Jeff Barry: We're, we're worried about stuff.
• 21:47
  Jeff Barry: We, we got away with the femur and no issues, but
• 21:51
  Joseph M. Schwab: Of course
• 21:51
  Jeff Barry: you know, yeah, of course.
• 21:53
  Jeff Barry: But, but the cup was definitely a, a little bit of a nightmare.
• 21:58
  Jeff Barry: So, you know, this is, this is her at three months.
• 22:00
  Jeff Barry: She's walking again.
• 22:01
  Jeff Barry: She's more limited by her pulmonary function actually than, than things.
• 22:04
  Jeff Barry: And she's very happy.
• 22:05
  Jeff Barry: Both times she had to go to the ICU post-op.
• 22:07
  Jeff Barry: I didn't really go to that very much, but her blood pressures were just low.
• 22:10
  Jeff Barry: It was a long case.
• 22:11
  Jeff Barry: Like we didn't take that long.
• 22:12
  Jeff Barry: Like this, this kind of salvage stuff didn't take that long, but you know, just with, with an O2 requirement and, and a baseline and kind of wanting to watch her, they sent her to ICU for short term.
• 22:23
  Jeff Barry: But you know, she, she is, she's a nurse.
• 22:26
  Jeff Barry: She knows what, what happened.
• 22:27
  Jeff Barry: She knows this isn't kind of like plan A, but still like the nicest and happiest patient.
• 22:32
  Jeff Barry: So, you know, I'm, I'm seeing her again, I think in a couple of weeks for her seven month or eight months, something like that.
• 22:39
  Jeff Barry: But hopefully she's, seems like she's doing well.
• 22:42
  Jeff Barry: I can see PT notes and she's still walking around and doing everything.
• 22:45
  Jeff Barry: So hopefully no satellite crashes.
• 22:48
  Joseph M. Schwab: for hip pain at the clinic.
• 22:49
  Joseph M. Schwab: Um, can you go back to that previous one?
• 22:51
  Joseph M. Schwab: And maybe it's the quality of this, uh-- Yeah, that one right there.
• 22:55
  Joseph M. Schwab: Maybe it's the quality of this X-ray, but, you know, you had remarked earlier, at least on the right-hand side about, you know, there was that intraoperative film where her diaphyseal, uh, cortical, um, you know, thickness appeared pretty reasonable.
• 23:11
  Joseph M. Schwab: It, it seems to be much less reasonable looking on, on this X-ray, and maybe it's a projection or it's a, uh, a, a, uh, you know, something about how they took the image issue.
• 23:24
  Joseph M. Schwab: But at least on the right side, the, the diaphyseal cortical bone is now starting to look kind of a little moth-eaten.
• 23:32
  Joseph M. Schwab: I mean, it looks pretty irregular,
• 23:33
  Jeff Barry: like that on bo- it kind of looks like that on both sides, actually.
• 23:37
  Jeff Barry: And, and I, I think it really is just the, it is technique or, or, or films.
• 23:41
  Jeff Barry: This was done at one of our satellite clinics, so the, the films there are a little funky.
• 23:45
  Jeff Barry: But yeah, I, I think that, you know, clinic to clinic, like you get used to what your clinical films look like and, and kind of that often gives you a better sense of like what the bone quality is, because you're used to seeing your, your gating, your exposure.
• 23:59
  Jeff Barry: And so I think when we get these films from outside hospitals that have been gated funky or, or changed, it, it definitely will, will throw you off.
• 24:05
  Jeff Barry: And that's where I think like in this situation, the DEXA is the objective like density test.
• 24:11
  Jeff Barry: Like I think I have a good eye for like Dorsi and kind of I try to plan ahead when I'm gonna cement, but, but this was a little bit of an eye-opening, one of like,"Hey, this actually looks okay, but I'm pushing on it and it's, and it's bending." Like maybe there's some pathologic metabolic process going on here.
• 24:25
  Jeff Barry: You know, I, I don't know what it is, but, but this is, this is, this is different.
• 24:29
  Jeff Barry: And the DEXA seem more in line with what we're seeing than the, than the plain films for sure.
• 24:35
  Joseph M. Schwab: Well, I think we're gonna have to call that the Berry test from now on, right?
• 24:38
  Joseph M. Schwab: If a cortical-- femoral cortical bone flexes with pressing,
• 24:42
  Jeff Barry: Yeah, exactly.
• 24:43
  Jeff Barry: Exactly I, I thought it was interesting to, to bring up, and this in my mind was, was a very similar case, but I had a different role in this one.
• 24:51
  Jeff Barry: And, and I, I thought I'd bring this up just because, like, when we're in the heat of the moment and we are the primary surgeon, it's often very hard to distance yourself from, from what just happened and, and get some clarity in thinking.
• 25:04
  Jeff Barry: And, and this was one that, um, I, I was not the primary surgeon.
• 25:09
  Jeff Barry: I, I had a different role in this one.
• 25:11
  Jeff Barry: And I, I think it just-- it, it speaks to, or hopefully I can speak to kind of the, the, the process-y differences that, that at least went through my head.
• 25:19
  Jeff Barry: So this is one that had a femoral neck fracture.
• 25:21
  Jeff Barry: Um, one of the fellows was on call, and this was their case, um, to take care of.
• 25:26
  Jeff Barry: They also had a distal femoral nonunion below it with a nail.
• 25:29
  Jeff Barry: Um, and so, you know, to treat the femoral neck fracture, that, that retrograde nail had to be switched to a short nail.
• 25:36
  Jeff Barry: The trauma team also put a plate on, and then they were gonna do this, this total femoral neck fracture.
• 25:41
  Jeff Barry: And, and so the fellows, by the time they got to the part of doing the hip, you know, they're the only surgeon in the hospital from the arthroplasty perspective.
• 25:48
  Jeff Barry: They go to put a cup in and, you know, they didn't, they didn't get good serum shots.
• 25:52
  Jeff Barry: But they actually created a discontinuity putting the cup in.
• 25:55
  Jeff Barry: So the whole pelvis discontinuous, like fracture all the way across.
• 25:59
  Jeff Barry: Um, and, uh, again, this is a renal patient.
• 26:04
  Jeff Barry: You can tell this is a little more, you know, apparent on the X-ray how bad the bone is.
• 26:08
  Jeff Barry: Um, but this is one where, you know, at nine thirty at night, I had a call from the, the fellow and was like,"Hey, uh, can you come help us?" Right?
• 26:17
  Jeff Barry: And so this is a little different.
• 26:18
  Jeff Barry: Like, this is, I get to come in on my white horse.
• 26:20
  Jeff Barry: I have time to think about things like, you know, I'm kinda game planning.
• 26:24
  Jeff Barry: It's like, okay, just cement the femur.
• 26:26
  Jeff Barry: I'll be there.
• 26:27
  Jeff Barry: We'll, we'll help you fix the socket.
• 26:29
  Jeff Barry: Um, and so I, I think that this-- these, these types of situations where you have a second to step back and really think about, like, okay, what's my plan?
• 26:37
  Jeff Barry: Like, I'm gonna ask for this, this, this, and this.
• 26:40
  Jeff Barry: Like, I'm gonna be the quarterback as soon as I walk in.
• 26:42
  Jeff Barry: Like, tell circular, get this.
• 26:44
  Jeff Barry: Rep, get this.
• 26:45
  Jeff Barry: You know, uh, scrub, get this ready.
• 26:47
  Jeff Barry: Um, I think things, things go a lot smoother than when you're doing the Chris Farley and like,"Okay, give me this.
• 26:53
  Jeff Barry: Actually, I want this," and like, call for that, and like, things are just scatterbrained.
• 26:57
  Jeff Barry: Um, and, and if you have that second to really just plan ahead, direct traffic, let everyone know what's going on and, and kinda what you need to be successful, the thing goes a lot smoother.
• 27:08
  Jeff Barry: And so in this situation, we actually were able to do a cup cage really quick.
• 27:12
  Jeff Barry: So I think this took, like, thirty-five minutes from the time I scrubbed in to the time I was finished with the cup.
• 27:16
  Jeff Barry: And, and everything was ready'cause I had called in and asked for it and said,"Have this there.
• 27:21
  Jeff Barry: I'm gonna do this, this, and this.
• 27:22
  Jeff Barry: Have the cement ready for the inner cup." And we were able to just kinda slam this thing in really quickly.
• 27:27
  Jeff Barry: You know, a different, different scenario than the last one.
• 27:29
  Jeff Barry: Both columns are out.
• 27:31
  Jeff Barry: It's not something I'm gonna just rely on a few locking screws inferiorly.
• 27:34
  Jeff Barry: But, you know, this is, this is a, a very similar problem intraop, um, but with a, a very different workflow in terms of how we got to, got to the same outcome.
• 27:44
  Jeff Barry: Um, but yeah, just, uh, just thought that was interesting.
• 27:47
  Jeff Barry: So, you know, my takeaways from this case are bad bone can get really bad, and, and a minus five standard deviation is really rare.
• 27:54
  Jeff Barry: Um, and then beware of the trap side, right?
• 27:57
  Jeff Barry: So you, you know, think of sports.
• 27:59
  Jeff Barry: There's like the trap game where you got the big game you're thinking about and some, some nothing ahead of it.
• 28:04
  Jeff Barry: You know, it's the f- it's the cup and a femoral neck fracture.
• 28:06
  Jeff Barry: It's the femur and a DDH case with a, with a Crow four or three.
• 28:10
  Jeff Barry: It's, it's that other side that you get, you get blindsided by.
• 28:14
  Jeff Barry: Um, and then the less is more or less can be more thing is a, a predominant theme.
• 28:18
  Jeff Barry: And, you know, this is a patient who y- you always hear run towards your complications.
• 28:22
  Jeff Barry: Like, I was rounding on this person every day.
• 28:24
  Jeff Barry: You send them more messages.
• 28:25
  Jeff Barry: You see them more frequently post-op.
• 28:27
  Jeff Barry: You give them more time every, every time, and, um, you know, that- that's how you take care of these patients.
• 28:32
  Jeff Barry: But, you know, uh, uh, just, just tongue in cheek, like, nice disposition risk factor, healthcare provider risk factor, follow-up risk factor, right?
• 28:41
  Jeff Barry: All these things are, are, are, are troublesome.
• 28:45
  Joseph M. Schwab: Um, well, uh, Jeff, that, that's a, that's a great case.
• 28:49
  Joseph M. Schwab: Um, and, and, and I have a question for you.
• 28:52
  Joseph M. Schwab: You know, based on your-- the, that second case that you showed where you get to be, you know, riding on the white horse, right?
• 28:58
  Joseph M. Schwab: You get to be the hero.
• 29:00
  Joseph M. Schwab: Is your-- If you envision your role in that scenario, where it wasn't your case to begin with and, and you didn't have to be sitting at home thinking about it, planning it, um, you got to come in and got your head straight.
• 29:13
  Joseph M. Schwab: When you find yourself in the next version of this nurse's case, right?
• 29:20
  Joseph M. Schwab: Are you going to be thinking to yourself,"How can I be my own hero on a white horse?" Or are you gonna be thinking,"Who do I need to call to be my hero on a white horse?" Meaning, is this something you wanna grow within yourself, or is one of the messages, um, to learn to rely on others and what they can bring, um, to a, a challenging situation?
• 29:46
  Jeff Barry: Yeah, I think that's a really good question.
• 29:47
  Jeff Barry: I mean, I, I think that, you know, the skill set for, for, for, you know, surgeons that do a lot of revisions like myself is, is definitely there to take care of any of these problems.
• 29:57
  Jeff Barry: But sometimes the, the mental clarity aspect is not there when you're, when you're in the moment.
• 30:03
  Jeff Barry: Um, and you know, I do ton of customs, ton of cup cages, ton of all these like big things.
• 30:09
  Jeff Barry: Um, but definitely there have been instances, um, where, you know, y- it might not even be an arthroplasty surgeon, it may be a trauma surgeon in the room next door that you're just like,"Hey, can you come over here and can I just bounce something off of you?" Or,"Can you just look at this and like tell me whatever you-- comes to your mind?
• 30:28
  Jeff Barry: Like, just give me another reasonable person to, to talk to here." If you're with an R2 like that, that's not a great sounding board, right?
• 30:37
  Jeff Barry: Like a, like a second-year resident's not a great person to be like,"Hey, what do you think?
• 30:39
  Jeff Barry: What, what, what should we do here?" Uh, you know, sometimes the fellows are actually very helpful and, and especially early in my practice, like I actually loved bouncing stuff off the fellows'cause they're very close to you and it's like in, in terms of your training and experience-wise and it's like,"Hey, what, what, what should we do?
• 30:55
  Jeff Barry: Like, you know, what, what do we come up with?
• 30:56
  Jeff Barry: How do, how do we MacGyver this thing back together?" Um, now I, I, you know, hopefully eight years into practice, I, I am a little bit better at kinda stepping back and kinda thinking and, and be like, okay.
• 31:08
  Jeff Barry: Luckily, you know, the, these primaries, these are, these are few and far between where, where these issues happen.
• 31:13
  Jeff Barry: But, you know, on revisions you get, you get used to being caught off guard by, hey, that's not what I was expecting, or hey, this, you know, femur just cracked or whatever.
• 31:23
  Jeff Barry: Um, so I, I think the more revisions you do, the more used to it you get for the, the troubles in primaries.
• 31:28
  Jeff Barry: But the most humbling are the straightforward cases, right?
• 31:32
  Jeff Barry: That have trouble.
• 31:33
  Jeff Barry: I don't, I don't expect a primary hip to have trouble, and so when it does, tho- those hit the hardest and those are like, okay, you, you definitely play back that one in your head a few times that, that evening
• 31:46
  Joseph M. Schwab: Well, a- and that was gonna be one of my questions is, you know, you, you're used to these revisions.
• 31:50
  Joseph M. Schwab: You've got a revision mindset certainly when you're going into revision cases.
• 31:54
  Joseph M. Schwab: And is this an issue of bringing that revision mindset to primaries so you don't ever get caught off guard?
• 32:00
  Joseph M. Schwab: That's also gotta be kind of exhausting, right?
• 32:02
  Joseph M. Schwab: Because, you know, revisions, while they can be exhilarating, putting that amount of time and energy and effort and thought and, and worry to a certain extent into every primary has gotta be, uh...
• 32:13
  Joseph M. Schwab: That's gotta be just as exhausting, if not more so
• 32:16
  Jeff Barry: Yeah, I don't think that's necessarily a sustainable practice, but I, I think that the-- You know, all of us are, are creatures of habit, and we have our workflows, right?
• 32:25
  Jeff Barry: And if you have a workflow that is complication avoidant, right?
• 32:30
  Jeff Barry: So like certain steps you know are maybe a little more dangerous, and you're kind of verbalizing that and, uh, at least in my setting, I'm teaching, and so teaching fellows and residents, and you're, you're looking for the problems before they happen.
• 32:44
  Jeff Barry: Um, I think that is the-- You know, uh, avoidance is better than trying to fix it later.
• 32:50
  Jeff Barry: And so, you know, for, for these situations, you know, this ca- you know, we, we learn from our last whatever number of cases, right?
• 32:57
  Jeff Barry: Those are the ones that stick in our minds.
• 32:58
  Jeff Barry: So-- But, but certain things will stick with you, and they will become new, uh, stepwise things you take forward.
• 33:05
  Jeff Barry: So, for example, in this now, I, I do the femoral releases of the, of the conjoin and the piriformis now for a lot of the femoral necks and for the really bad fractures, so that I don't pull that troche off, um, or, or this doesn't happen again on the troche, which, which didn't used to be my normal workflow.
• 33:23
  Jeff Barry: It's a little harder to do it when the femur's not down and under, but, but if it takes a-another 30 seconds and, and then those bad bone, bone patients, that, that might be what's needed.
• 33:33
  Joseph M. Schwab: So the one other question I was gonna ask you is, um, obviously you do have learners.
• 33:37
  Joseph M. Schwab: You have, uh, you have fellows with you, you have residents with you, and clearly you took something educationally away from this case.
• 33:45
  Joseph M. Schwab: Do you think the learners who were there with you took those same lessons?
• 33:50
  Joseph M. Schwab: Did they take different lessons?
• 33:52
  Joseph M. Schwab: What do you think they took away?
• 33:55
  Jeff Barry: Yeah, I mean, I-- you'd have to ask them, obviously.
• 33:57
  Jeff Barry: I mean, we, we kind of, uh, we, we discuss kind of what's going on, and I'm sure they see the, uh, you know, the, the stress in the, in the sur- in the attending surgeon when things are going wrong.
• 34:08
  Jeff Barry: Um, so, you know, I, I think that when I was a trainee anyway, and I was seeing, seeing troub- tough problems, like, I always took away kind of what their thought process was, or what are they thinking?
• 34:19
  Jeff Barry: Or I would-- You know, you don't ask them in the moment.
• 34:21
  Jeff Barry: That's a very dangerous move as a, as a trainee.
• 34:24
  Jeff Barry: But, you know, you, you kinda see, like, what is their workflow?
• 34:27
  Jeff Barry: Did they step to the back table and kinda think about stuff?
• 34:30
  Jeff Barry: Did they suddenly start to find the need to irrigate for another mir- minute or two?
• 34:35
  Jeff Barry: Did they kinda just go somewhere else?
• 34:39
  Jeff Barry: You know, go to the femur and come back to the socket, or, like, what was their workflow?
• 34:43
  Jeff Barry: Um, and I've kinda tried all those through the course of practice, and, and I th- I think I've come to my own response, uh, strategy, which is, you know, I, I kind of am more of the put the thing in the wound, turn around for a second, like, just game plan.
• 34:59
  Jeff Barry: What do we have open?
• 35:01
  Jeff Barry: What are my options?
• 35:03
  Jeff Barry: Pick one, and then what do I need?
• 35:04
  Jeff Barry: Communicate with the scrub, communicate with the circulator, like,"Hey, shit just hit the fan.
• 35:10
  Jeff Barry: Like, let's turn down the, the EDM music for just a little bit and kind of we're, we're gonna focus a little bit more for a second.
• 35:16
  Jeff Barry: Like, this is not a typical primary anymore.
• 35:19
  Jeff Barry: I need your, need your help." Um, and then go back to, to fixing the problem.
• 35:23
  Jeff Barry: And, and I think that's been the best way for me to kind of just recenter, get the blood pressure back down, and, and go at, go at the problem at hand.
• 35:30
  Jeff Barry: And then, and then you get into revision mode.
• 35:32
  Jeff Barry: You get into normal, like, fix-the-problem mode, and it's just another case.
• 35:36
  Joseph M. Schwab: And was this a communication issue with the anesthesiologist as well?
• 35:40
  Joseph M. Schwab: Obviously, given the, given the frailty of the patient, was that, uh, also part of your communication strategy?
• 35:46
  Jeff Barry: Yeah, for sure.
• 35:47
  Jeff Barry: I, I think that, um, you know, you gotta be, gotta be communicative with the other side of a drape for these sick patients and, um, uh, yeah, it's like,"Hey, I just..." You know, for the cup one, for example, it's like,"Hey, I just added probably another, you know, 20, 30 minutes to this case.
• 36:05
  Jeff Barry: Just letting you know, like, it's gonna bleed a little bit until I get a, get a liner back into this socket, and, you know, you might wanna have-- If we didn't have the platelets in the room already, like, maybe call for that stuff.
• 36:16
  Jeff Barry: If we didn't cross for some blood, make sure you got that." Um, and then, you know, for the, for the femurs on these patients, I am, I am super cautious about cementing femurs.
• 36:26
  Jeff Barry: Um, I will, I will tell them at the timeout, like, that's part of the timeout when we're gonna cement.
• 36:30
  Jeff Barry: Like,"Hey, we're gonna cement," you know, whatever anesthesia intern is on the other side of the thing.
• 36:36
  Jeff Barry: Like,"Please keep the oxygen at 100.
• 36:38
  Jeff Barry: Like, run fluids a little higher.
• 36:40
  Jeff Barry: Like, I know they might have to pee or get CAFFed afterwards, but, but let's not kill them from cement syndrome." Um, so, you know, that, that's something that's already in my workflow.
• 36:50
  Jeff Barry: Luckily, that hasn't been something I've experienced, but if I cement enough, I'm sure it will.
• 36:54
  Jeff Barry: Um, but, but yeah.
• 36:57
  Joseph M. Schwab: Um, o-one last question because at least the first side you indicated was on a normal primary total hip day.
• 37:04
  Joseph M. Schwab: And I don't know if it was first case, I don't know if it was last case or somewhere in the middle, but assuming it wasn't the last case of the day, and maybe it was, how does that affect w- you know, not just your workflow, right, your timing, because you're used to setting aside a certain amount of time for a primary and if you're going back and forth between two rooms.
• 37:24
  Joseph M. Schwab: But how do you take that into the next room, or how do you not take that into the next room?
• 37:32
  Jeff Barry: Yeah, that's a, that's a really good point.
• 37:34
  Jeff Barry: Yeah, I do-- That was, that was kinda middle of the day, you know, maybe second or third case of the day.
• 37:39
  Jeff Barry: You know, we run two rooms and have multiple cases after that.
• 37:43
  Jeff Barry: I, I am not an overlapper, so I don't let other people start a case while I'm in a different room.
• 37:48
  Jeff Barry: So, so that aspect of the stress is not there.
• 37:51
  Jeff Barry: Um, like I didn't have another patient under anesthesia yet, you know, it's not something where I have to worry about that, and that's part of the reason I don't overlap ever.
• 38:00
  Jeff Barry: Um, it's allowed in our hospital with, with a fellow who's helping you or another attending on backup, but I just-- That should not come into it where I'm gonna rush something because another patient's already under anesthesia or already gotten their spinal and that's kinda ticking.
• 38:15
  Jeff Barry: Um, so luckily that, that's a decision I made a long time ago that I'm just like,"I don't wanna deal with that added, added aspect of things." Uh, I don't know how surgeons who do do that, and they're in one room and kind of another room's going, like I'm way too much of a control freak to, to, to give away that to, to, to a trainee.
• 38:32
  Jeff Barry: Um, but the, the, like bringing it to the next case is like, is, is totally a, a hard, a hard thing to do.
• 38:40
  Jeff Barry: I-I-It's impossible not to have it somewhere in the back of your mind, right?
• 38:45
  Jeff Barry: Like it-- you, you definitely have to take a second to take a deep breath though, and like in between the cases, like do whatever you gotta do.
• 38:55
  Jeff Barry: Like go get a glass of water, like take a second to go get a snack downstairs.
• 39:00
  Jeff Barry: Like for me, it's just like I kinda will just, just sit down and kind of look at the what happened, and I like to debrief myself and kinda go through like,"What could I have changed?
• 39:12
  Jeff Barry: Um, was it an avoidable thing that I made a mistake or was this kind of a, hey, this is, this is just a bad situation that, that something was gonna happen?" And I think a lot of times we're-- our, our ego's able to be like,"Okay, that was something that was probably, you know, not 100% your fault.
• 39:32
  Jeff Barry: Like there, there's some other stuff there." Like y-you know, you do these, you do these things like you do, um, like a Crow-4 or something, right?
• 39:41
  Jeff Barry: Like that's like a 25% major complication risk.
• 39:44
  Jeff Barry: If that, if that has a complication, you can't beat yourself up over that.
• 39:48
  Jeff Barry: Like certain things are gonna happen.
• 39:49
  Jeff Barry: You do your best, you try to learn from them, but, but there's a certain risk that, that is, that is just inherent to the procedure, so you have to kinda keep that, that ego to your advantage sometimes.
• 40:00
  Jeff Barry: It, it some-- Usually it's bad, but sometimes it can be to your advantage, and in between those complication, I think that's where it's good to just take a second, think about what should you have done differently, avoid it the next time, and then, and then move forward.
• 40:12
  Joseph M. Schwab: A- and, and to be honest about it, how much of that type of debrief when you do it in a situation like this, how much of it is truly constructive and how much of it is a little bit of just beating yourself up for something that maybe you could control, maybe you couldn't?
• 40:26
  Joseph M. Schwab: What, what's it like for you?
• 40:29
  Jeff Barry: Yeah, and I mean, you definitely beat yourself up.
• 40:31
  Jeff Barry: I, I think I don't-- I'm, I'm decent about beating myself up later in the day, um, you know, not, not in during the middle of the day.
• 40:40
  Jeff Barry: But like I, for example, have a, a, a text thread still with all of my co-fellows from eight years ago.
• 40:47
  Jeff Barry: Uh, and we, we-- It's kind of like our confessional.
• 40:51
  Jeff Barry: Like anytime we have a problem, we go and we, we have, have confession where we're like:"Hey, look at this shit I just did.
• 40:57
  Jeff Barry: Like, I'm an idiot.
• 41:00
  Jeff Barry: Like, would you guys have done anything differently?" And, and it's a nice way to just be like,"Okay, wipe your hands clean.
• 41:06
  Jeff Barry: Like, I told someone about this.
• 41:07
  Jeff Barry: Like, it's, it's gonna be okay now." So I think having that support network wherever you get it is, is good.
• 41:13
  Jeff Barry: Like I have good partners as well that I, I can do that with.
• 41:16
  Jeff Barry: But if you're by yourself and you have no one to kinda share this with or, or kinda talk it through like afterwards, I, I think that's where you can get into trouble
• 41:26
  Joseph M. Schwab: Uh, that's, that's interesting.
• 41:27
  Joseph M. Schwab: I've heard the, the confessional story from a few other people.
• 41:31
  Joseph M. Schwab: I think this is a, uh, I think this is a rich area to explore at some point.
• 41:36
  Joseph M. Schwab: Uh, um, well, Jeff, thank you so much for, for sharing this case.
• 41:41
  Joseph M. Schwab: Um, thank you, you know, quite honestly for what you did for the patient.
• 41:44
  Joseph M. Schwab: I, I'm-- You know, she, uh, a- as miserable as it might have been during the case itself, it, it looks like things have, have gone okay for the moment.
• 41:52
  Joseph M. Schwab: I hope when she shows up for her next visit, there's nothing about pain listed on the, uh, on the reason for the day's visit.
• 41:59
  Joseph M. Schwab: Um, but
• 42:00
  Jeff Barry: she
• 42:00
  Joseph M. Schwab: thank you for being, being honest and, and sharing this case with our listeners.
• 42:04
  Joseph M. Schwab: I really appreciate it
• 42:06
  Jeff Barry: Yeah, of course.
• 42:07
  Jeff Barry: Thanks for having me.
• 42:07
  Jeff Barry: This is, uh, uh, y- as we mentioned before we came on, a little bit cathartic to go through it again.
• 42:12
  Jeff Barry: But, um, yeah, these are, these are good.
• 42:14
  Jeff Barry: I, I think it's good to share these, these bad outcomes.
• 42:17
  Jeff Barry: Like, we do thousands of these that work really well.
• 42:20
  Jeff Barry: Hip surgery's amazing.
• 42:21
  Jeff Barry: But, um, but yeah, y- you're always gonna get these if you do enough of them, I think.
• 42:26
  Joseph M. Schwab: And thank you for joining me for this episode of"The AHF Podcast." As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this.
• 42:38
  Joseph M. Schwab: Please also drop any topic ideas or feedback in the comments below.
• 42:42
  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.
• 42:57
  Joseph M. Schwab: Episodes of"The AHF Podcast" come out on Fridays.
• 43:01
  Joseph M. Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy and fracture-free