AHF Podcast
AHF Podcast
Part II: Examining Anterior Approach from Down Under
In part two of our series, we continue our discussion with Australian hip surgeons Dr. Patrick Weinrauch, Dr. Ilan Freedman, Dr. Jit Balakumar, and orthopedic sales rep Joe Scerri. We delve into the challenges and controversies of Direct Anterior Approach (DAA) hip surgeries in Australia, discuss the impact of patient education via the internet, and explore the role of industry in advancing surgical techniques.
Meet our guests:
Mr. Patrick Weinrauch - https://brisbanehipclinic.com.au/about-us/a-prof-weinrauch-orthopaedic-surgeon.html
Mr. Jit Balakumar - https://jitbalakumar.com.au/
Mr. Ilan Freedman - https://melbournehipsurgeon.com.au/
Joe Scerri - https://au.linkedin.com/in/joe-scerri-45a003254
Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/
Welcome to part two of examining the anterior approach from down under. Let's get back to our conversation with Australian hip surgeons, Patrick Weinrauch, Ilan Freedman and Jit Balakumar, as well as orthopedic sales rep Joe Scerri. Which, which just raises my next question, and you started this conversation here a bit, Jit, so what do you guys see as the biggest challenges or controversies about DAA, within the landscape of Australia?
Jit Balakumar:The biggest controversy, it's what you've said already. I think the, creme de la creme in orthopedics for most, hip surgeons is arthroplasty. you have a winning surgery. very predictable outcome. Patients are usually low maintenance. So that's what most people want to do. And so I think you have to be careful. There's the private practice aspect and we've all seen LinkedIn videos, YouTube videos of patients walking day one post op 20 steps of stairs. And, is the marketing, right? And. I think this it's no, it's not dissimilar to what my senior colleagues did with yellow pages. So we shouldn't criticize people for that. with it comes some risks because we all get complications and we all have problems. So when you put yourself out there, it can also be the sword you die by. let's look at the data. The data shows anterior and posterior approach is. It's exactly the same in outcomes at six months, and there's double the rate of dislocations with posterior approach, almost three times the increased rate of infection, twice the rate of fracture and loosening, early loosening in the anterior approach. so there's, trade offs and I think we have to be cognizant when you do it. But I agree with Dr Matta completely. I think the market is the current market is very astute. They know what they want they are all on social media. Pat does a lot of resurfacings. I have so many patients coming in saying, look, I want a resurfacing. And I said, where did you hear about this? I go, I'm on a Facebook website. I'm a runner. I'm a marathon runner. I've heard that you've got to be loading your proximal metaphyseal bone if you want to run long distances. And, I said, look, you're, absolutely right. look, I'm going to send you to one of my partners. But the market is way more well equipped to actually know and have the knowledge Then we give them credit for I think gone is the paternalistic era But you've got to play a role in this and say look I think Um in my hands, this is what the best approach is. So I think it's Dr Matta's absolutely right the market's driving it and that's what's going to organically grow it.
Joseph M. Schwab:Do you think we're moving the paternalism out of the clinic room and onto the internet when we're engaging with patients, that way? is that, we're ceding that information a little bit, to our patients, ahead of time.
Ilan Freedman:Yeah, it can be a bit difficult. Patients come in now, asking for specific bearing surfaces or asking you about what particular polyethylenes or which, which exact metal have you used. So it's, I guess it's the, the side effect of having all this information on hand. patients can access all of that very easily, and many of them do. So come in with good questions, but sometimes come with questions which, They don't really know what to do with the answers, they come in asking, what metal is it? And you tell them and they look stunned. yeah, but people are coming in, very informed and they read your bio, they read your results. In some cases, they've read your papers. So I guess that's the reality now.
Patrick Weinrauch:I don't, mind, patients being well informed, I think that, I think it's, I think that it's good that they've we instinctively, I think sometimes they may be a little over informed, but, there's a, good balance there. And, and I think, I think it's nice to be able to have a really robust sort of education of a patient prior to their surgery. so I I don't, shy away from, a patient comes in and my heart doesn't sink when they come in with their, with their ream of papers, it's like, Yeah, sometimes it can be a bit tricky, our role is, as a responsible professional is to guide them, right? And we're there to be able to educate them and to be able to put, what they've read into context and balance because we're the subject matter experts and, if they're relatively well read, then it's actually quite easy to direct them there and to be able to, give them a framework to be able to understand what they're reading. And I suppose my, comment, bringing it back to anterior approach is, that, historically, I think when, anterior approach first came into Australia in any numbers. There was very much a, it was really marketed hard. That wasn't necessarily just, in fact, that probably wasn't so much surgeons who are driving that. That was industry. So industry was driving anterior really hard because there was one company in particular that was linking, anterior approach and, this is the implant and this is the table. And so it was like a package and this, and from a surgeon's perspective, that was the easiest conduit to be able to get education in the space as well. So it was a very successful marketing strategy, to be able to, educate surgeons, educate the community and build awareness around it all simultaneously. And so that particular company, which was really a minnow in Australia at the time has really boomed, right? So it's a very successful company now in Australia for that reason. I think we've seen a bit of a correction now over the last sort of eight years where pretty much all of the companies have got an anterior offering now. So instrumentation platforms and things like that. And so, we're now starting to see a bit of diversity, amongst the ways in which we are doing surgery. For instance, whether it's being put on a traction table or not on a traction table, there's quite a, I'm not sure what the, we can't capture that on the Australian registry. My instinct is it's probably still dominated by table use, but then there's a quite a big component which are doing it off traction tables as well now, which is pretty much, and, very much being implant agnostic now as well.
Joseph M. Schwab:Would you say that the industry based education, that you're talking about, was that a primary driver towards adoption of, of anterior approach or were people getting their surgical, education on this technique, it mostly in other ways.
Patrick Weinrauch:So in Australia, like when I went through My residency, we call it registrar, but residency, the, there was really no exposure to anterior approaches. So this is a technique that I've taken up post, qualification fellowship. and We're very reliant on industry support to be able to get that education, right? and this of course you do us nowadays if you can find a place to go and do fellowship, right? Where you can learn those techniques in your fellowship, but you know a post fellowship orthopedic surgeon requires Industry support. The industry is still very involved here in Australia in, surgeon education, not just an anterior approach, but in all aspects,
Jit Balakumar:I run two fellowships, and my, all my fellows, they start their practice. I have a local fellow and international fellow their practice almost instantly explodes because of anterior approach. Um, look, obviously, I learned slightly differently, but I remember that actually the first anterior approach I saw was with a guy in Box Hill Hospital, public hospital, and, there was two of them actually there. One guy who did it on the table. Supine and another guy who did it in the lateral position anteriorly and I was blown away by it. No one talked about it. There was no marketing, but their recovery was very different to the rest of the, unit. And then when I went to my, equivalent rural rotation, I convinced my boss there to do it anteriorly. We had a ASR head, with an ASR cup with a Zweimuller stem, and, it was, a disaster, and I should never have convinced my boss to do that, But I would say, look, I echo Pat's points. It's, changed very much in the industry has really been, people are very quick to criticize industry. They have improved patient outcomes dramatically by championing high quality education, right? And, they, the smaller startup companies use it as a point of difference. The larger companies try to get ahead with it. And now, fellowships that are attached to an anterior, because they can see the, the return on investment and how they can monetize it. On the flip side, think every hospital, I'm sure it's the same in Queensland and in Australia, in Victoria to be credentialed. So they classify anterior hips, robotic surgery as a tier B credentialing. So not the standard that you finish in your training program. And to be credentialed, they expect you to have done either a fellowship. Or have done at least 30 cases with someone who's an experienced anterior hip surgeon and then be supervised by their local, whoever the hospital representative is. there's some very robust credentialing process and I again tell trainees, look, you've got to be careful. When you first start, you don't want to be, you've got to slay a few dragons to get your princess and we don't want to go through that process, right? don't want to be slaying dragons. That's not the process with this. And, I think that's industry has done that amazingly here.
Joseph M. Schwab:Joe, as the representative of industry in this conversation, what do you, what have you seen in the landscape of anterior approach in Australia? What has been most striking to you?
Joe Scerri:I think I'd like to answer that question a little bit historically, and that is in a lot of the points that the guys are making, certainly fellowships are really important. and I've done a number at, Wrightington and various places like that over the years. in France and, so forth and they have been, as has been mentioned in terms of the return on investment, excellent because quite often they're with a high volume surgeon who happens to be using obviously, the implant that is manufactured by the company that sponsors it. And then they come back as a devotee and, it becomes a nice circular return. Everybody wins. And, and that's been a worthwhile investment. And as far as I know. continue to do that. then you've got the existing fellowships. the one that, that you've mentioned Jit when Jit does the anterior approach, the people that become, proficient at that, have to learn somewhere. So if they decide that's for them in their private practice, then they'll continue to do that. So that goes on. And then you've got. people like Pat who, do visitations from various companies. and I think that there are selected people around the country who, perform direct anterior where there are medical companies that will send, surgeons to those, to those surgeons because it enables them to be trained on the anterior approach, but at the same time, presumably. If they like the implant at the time, then they go back and that becomes part of their private practice. And I think that's where, one hand, rubs the other and everybody wins as well. And, then there are other things that, I'd like to get involved in. And that is, we're not big enough to be able to sponsor those things, but certainly things like, cadaver workshops, where, you know, that can be learned on that approach. think, those go on as well, but I think the combination of fellowships, visitations, And certain workshops are probably the collection of things that surgeons are getting exposed to when registrars and senior fellows.
Joseph M. Schwab:has the landscape for visitations in Australia, has it begun to include things like reverse site visits where a mentor will come and spend time with a surgeon as they're starting to do their cases? And has there been any introduction of, virtual visitations, using, augmented reality, virtual reality, those sorts of things?
Jit Balakumar:I've got to say something about that, though. Look, I do have a problem with visitations. And I think Pat and I were with J and J at this stage where they were trying to develop this mini fellowship and and reverse visitations. I do think, the. One of our all of our pet, interest is adult education, right? And adults are very differently educated based on who you are. There are some who can just do that and they'll come back and I'm sure Pat, you probably taught a lot of people how to do resurfacings, but there are some you would never let do a resurfacing afterwards just by watching you. And some of these things require a lot more. So you want the expert novice right at the end of that And that's not what you're getting. I don't think with anterior who've never had it before. So it's probably different for the next group of trainees, but I think that was one of the downfalls of the anterior early on was was high fidelity training on cadavers. Then you came and saw someone, but they weren't the expert novice. They weren't the airline pilot has done 10, 000 hours on the simulator, right? They were essentially still going through their learning curve. And hopefully that, so I do have a problem with visitations and reverse visitations for certain surgeries. And I think anterior approach is one of them. it has its place at a certain stage, not early on in their learning curve. But it looked at everyone's different. There are some people who are exceptionally talented. And they'll be able to do that very easily, right?
Patrick Weinrauch:I see, I see people at various points in their learning journey, and they might come up and visit to be able to, see a bunch of cases being done just to be able to know, actually, is this a, is this really a thing, is this something that's, that I would even contemplate bringing into my practice or is this something that, it doesn't stack up for me and then they see it and they can make their decision, right? And and then they might go off and they might start learning a bit more and they might go and see another guy. And the, what, I tended to, observe. in that space, though, is that, they would sit in a, like a pre learning space or a learning space, but they would never actually start. It would be like the conversion on that, that, that conversion into starting doing their own cases was a bit of a rocky, a bit of a rocky, road. a transition and that's where, having a high quality long fellowship, I think, has the benefit because there's a lot more, there's a lot more sort of guidance in that transition zone and to try to bridge that with a reverse visitation is sometimes difficult because it's so it's one day, we've only got a couple of cases. Yes, it is. You have got an expert surgeon with you, but it's not like doing it for over a period of months, right? And, reverse visitations for, us are, they're difficult because, you've got to get licensure, and accreditation in the receiving facility. and and it's very, very time consuming as well. if it's just something, If it's just a guy down the road, that's pretty easy. But if it's like we're a big country, right? So to fly, three or four hours to go into a reverse visitation is like a two day process, right? Could we use technology to be able to help that? I think, absolutely. There's a space for that, right? So having the remote. expert with, like we've talked about, like Google Glass or, equivalent sort of devices where the remote expert can see what the, surgeon is doing. is that a bridging tool? The answer is yes. is it? I suppose if we rated things on the scale of minimum better best, is it the best? The answer is no. I think a fellowship with Jit would be the, that would be the gold standard. but is there a person in their learning journey in whom you don't necessarily need to go expend that much? do you need to have best every time? The answer is there are people in their learning journey at all different stages. And for some, that might be enough. And we're seeing, for instance, like new surgeons coming out now who have done some anterior through their primary training. So they've actually had experience in this, but they're, junior consultants and they just need that little bit of a high handholding or and then so maybe a visitation and a reverse visitation is all that, right? So that's, a different person.
Joseph M. Schwab:So Patrick, you, raised this question in my mind and you had mentioned this before. is there a role in this type of education, especially anterior approach or other more complex procedures, For a no fly list. are there people that we should just be able to say you should move on me Just do something else Or is this a situation where you enough time enough dedication enough resources? And we're gonna get you to where you need to be
Jit Balakumar:Oh, look, 100%. I think I'm going to step in there and say it. I, I have one of my mentors used to say to me, can't fly like an eagle when you're a duck, right? And it's a horrible expression, but it's, but look, it's a very, I think we all know our abilities and, watch some of my senior surgeons who are master surgeons are beautiful. And I just sit there thinking, Oh, am I ever going to be like that? And I think we're all pushing ourselves to be better and better. we know some of us have awareness, some of us don't, but I definitely think there is. There is a higher level of manual dexterity and manual, intensity and awareness that you need to do to be able to do that, right? It's a more technically demanding operation and makes it fun for us. We need. a new level of challenge. but the flip side, it's got lots of, I guess benefits. I am going to speak to with technology and training. I went through a lot of things to try to enable this to be better. So I went on augmented reality, virtual reality with, as a group called Fundamental Surgery in the UK, who've got, haptic feedback. So you can feel the incision, feel the osteotomes, feel the broaching. And, I'm one of those people was happy to accept that my initial belief about Covid was completely wrong. I'm always very happy to accept and go back and say what I did was wrong. And I can say that all of those enabling technologies, which I thought was going to be great, wasn't so good. And I think it comes down to something very simple. I think what Patrick said, hopefully it seeps into training enough that it may be that these visitations and reverse visitations is all that's required hopefully in the future, nothing at all. that they've done enough training that they don't need to do it.
Patrick Weinrauch:The real question though is who is the, who was the gatekeeper on that, right? So if, interesting um, a trainee or so if they're a trainee, that's easy, right? Because there's a, there's a standard that you need to achieve, for you to be able to pass that unit. And, if you haven't achieved it, then you require, Retraining, right? So that's easy. What? What happens when you've got the ticket? got your ticket, haven't you? and so the real question is, who is the arbitrator of, of the gate as you who is the gatekeeper? And, is that the educator? because, if someone comes to visit me, I can't tell them not to. It's like I can give them some really sage like advice saying watch out and maybe you might consider a little bit of additional training. but then, I think the other thing is that most. Companies now are quite invested in trying to make sure that their implants are, in Australia anyway, because of our National Joint Replacement Registry, picking up the trends of revisions and failures, industry has a, a stake in ensuring that their implants are being maintained. Placed in by, surgeons who have got a low revision rate and so it's in their interest to make sure that we're up to scratch. and so sometimes I might have a industry come to me and say, listen, we've got the surgeon who's struggling a little bit and these are the, parts that he's finding hard. He or she is finding hard. do you mind if we can bring them along so you can like specifically nail there and how to deliver the femur for instance, right? and so that's, where they come back to be able to learn that one particular step.
Joseph M. Schwab:Join me next week for the final part of our round table discussion, examining the anterior approach from down under. We finish our conversation with guests Patrick Weinrauch, Jit Balakumar, Ilan Freedman and Joe Scerri. Don't forget to check our show notes for information about each of their practices. Make sure to like and subscribe so we can keep this type of content coming. And until next week, this is Joe Schwab reminding you to keep those hips happy and healthy.
