AHF Podcast
AHF Podcast
2024 ePoster 2nd Place Dr. Brian Gladnick
In this episode of the AHF podcast, host Joe Schwab interviews Dr. Brian Gladnick from the Carrell Memorial Clinic in Dallas, Texas. Dr. Gladnick discusses his background, the history, and the growth of the Carrell Clinic, along with his research on automated impaction in total hip arthroplasty. His study discovered that selective use of automated impaction significantly reduces fracture rates during surgery. Dr. Gladnick highlights the benefits and offers advice for both current users and potential adopters of automated impaction technology.
Hello and welcome to the AHF podcast. I'm your host, Joe Schwab. Our guest today is Dr. Brian Gladnick of the Carrell Memorial Clinic in Dallas, Texas. Dr. Gladnick's study,"Mitigating Calcar Fracture Risk with Automated Impaction During Total Hip Arthroplasty", took second place at the most recent AHF meeting. Dr. Gladnick, welcome to the AHF podcast.
Brian Gladnick:Joe, thanks for having me. Honored to be here.
Joseph M. Schwab:So first of all, tell me a little bit about yourself, a little bit about your background and your practice.
Brian Gladnick:I'm here at the Carrell Clinic in Dallas, Texas. We are one of the oldest clinics really in the south and really even in the country. We're 100 years old. We were, our clinic was actually started in 1921, by a guy, W. B. Carrell, who started out as a, proponent of, pediatric deformity and fracture care. He was actually one of the founders of the Scottish Rite Hospital, orthopedic hospital here in Dallas as well. And so, over the last hundred years, um, what started out as a very small, uh, children's orthopedic clinic has, uh, grown into a specialty orthopedic hospital. We have all service lines, spine, sports, total joints, foot and ankle, hand, all that stuff, of course. Um, and, uh, we have a very, very busy total joints department here. I joined the faculty, uh, about almost six years ago. Um, and, uh, we do about, gosh, 22, 2400 joints a year in this hospital between, we have, uh, five fellowship trained, um, total joints doctors, um, that do that. And, um, so we, uh, got a very busy revision service. We started a fellowship, um, at, uh, kind of that whole process began a couple years ago. We're just actually graduating our first fellow this year. In recent years, we got we have a 501 c3 Charitable foundation, so we got approved for REDCap and we were able to start our institutional registries about five years ago based on That so it's really improved our ability to put out good quality research.
Joseph M. Schwab:Where did you do your residency and your fellowship
Brian Gladnick:Yeah, I trained at HSS for residency, graduated from there in 2015, uh, did my, uh, my fellowship at OrthoCarolina in Charlotte, uh, graduated from there in 2016, um, and, uh, spent some time traveling around a little bit, went to Switzerland at the Schulthess Klinik and saw Michael Leunig and those guys for a little bit, went down to, uh, Austin saw Tyler Goldberg operate and I've been trying something I've been trying to do now every year is take a couple days off and just sort of travel around the country and watch other people operate. I think it's a really valuable thing to do.
Joseph M. Schwab:Is, uh, ortho Carolina where you were exposed to anterior approach, or was that with Michael Leunig?
Brian Gladnick:Well, even when I was so I when I graduated HSS 2015, it was it was HSS at that point was still very dogmatically posterior approach, but there was starting to be some some, uh, people dipping their toes in the water. Mike Alexiades had been doing it for decades, really, at that point. So, but there was some other people kind of starting to get into it. So there's still some experience. I did see some anti approach there. Um, but yes, going to Switzerland and see Michael Leunig, operate was just an eye opening experience for me and, watching him do what he does. He's one of the most outstanding surgeons, technically I've ever seen operate. And, um, so then kind of coming back, I really wanted to be at a, a anterior specific, uh, fellowship, which is why I went to OrthoCarolina, which is an incredible experience. And probably the, the, one of the few years of my training, uh, that I ever said, gosh, I would, if I would do that again in a heartbeat, if I could.
Joseph M. Schwab:What prompted you to want to study this automated impaction concept in total hip arthroplasty?
Brian Gladnick:This started at the study that we had at the AHF, Was really started out as kind of an observation that we had seen over years. And so, um, when I first started using the device, like I said, I had some brief exposure to it when I was in Virginia back in, like, 2016. But then I started using it in earnest when I came to Dallas in 2019. And so, um, when I first started using it, um, I was just kind of blindly just on power everything. So broaching on power. Stem goes down on power, impact the head on power. And the thing is, it's calibrated for the same amount of newtons of force that you want to engage the trunnion. I remember when they first came out with this thing, it was a lot of the messaging from the companies was, um, this is a, uh, a panacea for fractures. You know, you'll never break anybody with this thing. It's calibrated, it's safe, you're in line. And my experience was that that was clearly not the case that every once in a while we were, we were having a fracture. just as you would if you're broaching by hand every once in a while, you're gonna have a fracture if you're doing enough hips. Um, and so we went back and looked. And in fact, when we looked at that study, you know, if you ever look at our overall rate, I think it was something like almost 1600 hips. We had like 17 fractures as rate of like 1.1%. was clear to me that there was, it's not a, it's not a panacea, but it's not, it's didn't seem much different than, than mechanical or handheld broaching. And it's just that it's, you know, there's certain patients are going to have, have, have fractures. Um, but one thing that did become clear to me, you know, as we use this thing more and more was that there were certain situations in which I was just naturally saying, uh, that's a case. I'm not going to put the final stem down. By hand. And I know. And so we know it's very early on. It seems like all of our fractures were occurring, not with the broach itself, but with the final stem. Um, so I would be, you know, and I was ruthlessly aggressive with this thing, just like full auto, just Wedging these stems in super tight on then say, okay, it looks great. I'd take the end, take the broach out and then when we, and then you put the stem down, but every once in a while you'd have a fracture you go geez, gee whiz, we were, you know, like I said, ruthlessly aggressive with these broaches, but then all of a sudden we put the stem down, we have a crack. Why did that happen? Um, and one thing we started to notice was that. In situations in which you imagine when you have that final broach in there and we just look at it, and if there was a rim, like a sort of a cushion of cancellous bone surrounding the outside of the broach, that was situation, I was pretty comfortable saying, okay, it's almost like a cushion, right? We're going to, it's going to, you know, uh, be a safe situation to impact that stem by power.
Joseph M. Schwab:So what did your study actually find? What were the results?
Brian Gladnick:it brought our fracture rate down from like 1.2 to 0.6 by going, by being, going that selective. And I will say. It was certainly clinically significant to me to see a, basically a, a 50% reduction in fractures.
Joseph M. Schwab:Were you using a consistent stem throughout the entire time? Were you using a mixture of stems? Tell me a little bit about that.
Brian Gladnick:Yeah. I mean, I use, I'm pretty consistent with my stem. I mean, I use a triple tapered collared HA-coated stem in virtually almost everybody. Um, I excluded patients that we cemented or certainly any kind of conversions, revisions, things like those were all excluded. So the only people that were allowed to be included in the study were primary triple tapered stems.
Joseph M. Schwab:Based on what you found, what advice would you give to surgeons who are using automated impaction?
Brian Gladnick:First thing I would tell him is to go for it. It's a, I think it's a real, um, benefit to the surgeon themselves. And we actually, we have an ongoing, a couple of manuscripts in publication right now, but a, um, ongoing, uh, multi centered RCT, uh, prospective RCT looking at a variety of different things, not just, you know, accuracy of, of, of component placement, but also things like operative time, um, broaching time, uh, fracture rate. Um, and also biometric data looking at the, the burden of effort on the surgeon themselves. So they had all the surgeons in the study wearing a biometric vest with real, real time EMG data. So looking at your muscle activation, your deltoids, your biceps, your pecs, things like that. It's a lot less wear and tear on your body. And so I think, you know, we'll be operating longer and more comfortably with these devices as we go forward. Um, Number two, I think we're doing a better job putting these, these stems in, you know, I think if anyone who uses the device and it's hard to quantify in the study, but there's something very palpable about when you broach with automation that the consistency of your broach envelope is just much more pleasing to the eye and pleasing to the feel of your hands than when you're doing it by hand. Um, I think ergonomically it's easier to control the broach. Think about a really tight muscular patient or you know how these, you know, think about a patient who, you know, as you go, you know, As you grow larger and larger in your broach size, how sometimes the anatomy will force you into that and increase an inversion. You're trying so hard to resist that, but you're fighting a belly or fighting their their their musculature, and it's kind of forcing your hand out. It's much easier in my mind to resist that using automation. It's not a panacea for fractures. You can definitely still crack somebody with these things. Um, but there's, if you, uh, if you pay very close attention to the relationship between the broach and the calcar, if there is a full circumferential cushion of cancellous bone between your final broach and the calcar, go ahead and put it down by power. But if there's any part of your broach that's directly contacting that calcar, just be safe, tap out the stem and put it down gently by hand.
Joseph M. Schwab:Any advice that you would give surgeons who aren't using automated impaction, would this be a, an indication to consider using it or what's your advice there?
Brian Gladnick:You know, I think if you've been broaching by hand for 20 years, you're very used to the pitch changes and the, the, the feel of a stem as it engages, um, you know, the proximal bone or distal bone, you know what that feels like. Um, it feels different when you use automated impaction. And, uh, and there's some just things where you have to just use it to get used to those things. Um, but the learning curve for it is very, is very easy. I mean, we, we train our fellows on it. They have it within like a week or two. They, they got it, you know, it's not, it's not terribly difficult.
Joseph M. Schwab:So is it going to give you an extra 10 years on your practice? Do you think?
Brian Gladnick:I hope so. I'm going to, my, plan is to work until I drop dead. So that's the,
Joseph M. Schwab:Hopefully not anytime soon.
Brian Gladnick:that's right.
Joseph M. Schwab:Um, well, you know, we really appreciate you submitting your poster to the AHF this year. We congratulate you on your victory. It was, uh, uh, an excellent poster. It had great scores from the scientific committee and we look forward to you submitting, uh, further research in the future.
Brian Gladnick:Well, thank you, Joe. Yeah, we were, we were honored to have that, um, to have that recognition and, um, yeah, hopefully, uh, much more coming forward.
Joseph M. Schwab:Thank you for meeting with me today, Brian.
Brian Gladnick:Thank you. Thank you for your time.
Joe Schwab:thank you for joining me for another episode of the AHF podcast. If you want more information, you can check us out on Facebook, LinkedIn, or X, or you can visit us at our website, anteriorhipfoundation. com.
