AHF Podcast
AHF Podcast
Part III: Examining Anterior Approach from Down Under
In Part III of our series, Joe Schwab continues his discussion with Australian hip surgeons Patrick Weinrauch, Ilan Freedman, and Jit Balakumar, along with orthopedic sales rep Joe Scerri. They discuss the biggest disruptors in their practices, the importance of the surgical team, the role of technology, and their personal experiences with the anterior approach in hip surgeries.
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 three of examining the anterior approach from down under. Let's get back to the last portion of our conversation with Australian hip surgeons, Patrick Weinrauch, Ilan Freedman, and Jit Balakumar, as well as orthopedic sales rep, Joe Scerri. Speaking of things that have changed how you look at or how you think or how you learn in your surgical approaches, what would you, if we can go around to each of you, but what would you say have been the single sort of biggest disruptors in your practice, whether it's an actual practical technique that you've learned around the anterior approach, an implant, or a new piece of technology that's really changed or improved the way that you've done anterior total hips.
Ilan Freedman:Yeah, no single, Technology, I think, just, I think using fluoro, and then I think there's a whole lot of fluoro based systems, whether it's verifier or Velys or whatever. I think, I've changed incision from longitudinal to bikini, this little, but these things are chasing the 2 percent improvements. I don't think there's been a single element of anterior that's, that's changed. I looked briefly at off table, went back to what I knew, but little things that make marginal differences. I use special, I use a special skin sealant. So just, we're chasing, the one percenters now. There's no single thing that's really revolutionized, my anterior approach specifically.
Patrick Weinrauch:Mine's, mine's not surgical. so I'd say, the, incorporation of low dose spinal, right? So low dose spinal has made, has really made a big difference to my patient's first 24 hours and, their experience of the surgery. a spinal where they're able to still walk straight away and, to be able to, they haven't lost motor function. Yet they don't need big doses of opiates and yeah, they're really comfy and they've got no nausea and they don't get, they get less constipation and all that sort of stuff. So I think for me, if I look at the one thing that's really made my patients most happy, because listen, I do lots of posterior approaches to you see, And, and they both go really well, right? And I suppose that leads into the second thing. If I'm allowed a second disruptive technology,
Joseph M. Schwab:of
Patrick Weinrauch:the second disruptive technology is just the change in mindset of, of our teams, right? Where we've got teams of therapists and nurses who are, willing to be able to get people mobilized, early and they've got, they're quite used to dealing with all of that. any of the problems that people might see in the peri surgical period, yet still push on with good rehabilitation. And, so that mindset that you don't have to lie a patient in 24 hours and that's so if I've got two, it'd be the spinal and it'd be the team, right? It's actually for me, it's probably not the approach.
Ilan Freedman:Yeah, no, I'd say having a, having a regular team. I was working in a hospital where. Every theater list would be a different team. And I think, anterior approach is, it's, intense for the surgeon, but, also pretty hard for the scrub nurse if they're a newbie. So I think hospitals which have recognized, Just giving you a, consistent scrub team, who know your instruments, having a company rep, which, doesn't change every week, just giving, I agree with Pat that the team is beyond just, the surgeon. There's so many sub teams within that, within the anterior approach, which are very important.
Jit Balakumar:Look, I think the table I've been using the HANA table, since Dr Matta convinced me to his probably to his benefit. We've got about three of those tables in our hospital. and I love it. I've tried to, for J and J. I was like the K. O. L. For off table for the whole of Asia Pacific, and it was just the most unpleasant experience with, 140 kilo, 160 kilo patients. It's not fun, but look, it's, each of them have its own benefits and disadvantages. But I think the table for me is big disruptor. And, I think, planning to me is a big change only to, I would say, we all know, total hip in the century, 95 percent improved patient outcomes, 60 percent forgotten hip, but I'm confident that either through experience, through impeccable planning, 3D planning, my bandwidth of forgotten hip is increasing. And particularly in the anterior approach, I'm learning, actually, you know what, I'll probably put people, change their anterior offset, reamed a bit more anteriorly. Now I'm focusing on reaming into the right pillar. obsessed about getting rid of the psoas impingement by tucking the cup in deep, but you can get extra articular impingement, which I wasn't appreciating as much with just Dynamic examination. So I think that 3D planning really gives you that, bit of information. and to me, that's a big disruptor.
Joseph M. Schwab:How were you guys incorporating your team in the learning portion of the, approach? How were you bringing a team up to speed?
Ilan Freedman:I think, first of all, the company which I've had referenced, which was sending surgeons education was also sending the reps. So they put a lot of investment into trying to educate not just their team, but their sales team. And then it's up to the surgeon to, we run what we call in services where you'd be running a little mini workshop for your team and the company would bring the gear and the stuff and you have to just give the time to go through the trays and to workshop those cases and to, Also, you'd be a bit pushy initially that you wanted a consistent team. The hospitals didn't necessarily give it to you the first time you asked for it. Ironically, the more senior the surgeon, the better the team. So you had this situation where when you were a very junior surgeon without much experience, you'd get the least experienced nursing team, which makes no sense. it should be flipped the other way. But, having enough, having enough, say in the hospital to, to get the team that you want and to spend the time educating them.
Joseph M. Schwab:Elon, as you become the more experienced surgeon, are you willing to give up the experienced team for the less experienced one?
Ilan Freedman:I should be, but no, you hang on to what you hang on to what you've earned. But, but it is a bit ironic that the, new surgeon in the hospital gets the least experienced nurse,
Patrick Weinrauch:That does bring up an important point, though, is that, say, for instance, when I do have someone come and visit and they want to learn anterior approach and they, see it and they've maybe they've done a couple of visitations, they're at that point of getting ready to pull the trigger and they ask me, how do I incorporate this seamlessly into my, into my practice, or, with the minimum amount of turbulence and I think that the, you've got to think of the surgery as a team sport, right? And so you've got a mental model of what you. Wanted to look like because you've seen it and you've trained it and you've, thought about it. You read about it and you've been on visitations and you've done, certain about training, but the rest of the team, none of them have seen it. All right, so they got no, they got, you haven't got a shared mental model there. And so to be able to achieve that, you've got to. achieve. You've got to deliver some form of education to them. And I think the best way in which you, you can achieve that is to bring that your key people with you when you're learning, right? So if you go into a cadaver lab, if whoever's running the cadaver lab will allow them to be able to bring, for instance, your first assistant or your scrub sister, right? you scrub stuff, then they can see that, right? and we've had visitations where they've brought in the lead scrub nurse, right? And they, and because when they come and see the procedure, the surgeon is focused on do this, release that, do this, do that. But the scrub sister's looking at the flow and they're seeing how they drape and, which, bits of equipment they need and the sort of, and so when it comes to time of actually needing to do the surgery in their new place. The thing that's going to be the hardest is the surgeon works and walks in and he goes, Oh, let's whack some drapes on. But I wasn't really thinking, I wasn't really taking much attention to all of those little things that, that the other members of the team, that's their world, right? And they see that stuff, right? And they grab it and then they transplant it in. And yeah, because we're so focused on what we do, right? So I think, I think, the key point out of that is that if you can, get some form of education for your staff around you, and that's, how I introduced it into my practice. I had my lead, surgical assistant who happens also to be a nurse, Come with me. And then she was able to not only, assist me. so there was a buddy system there, but also she was able to very easily translate that over to the other staff to be able to say, this is what you need to do right in a way in which I wouldn't have been able to articulate myself.
Jit Balakumar:The issue is for me, this is a, Ideal situation, teamwork is dream work. You've heard, I'm sure you've all heard Christophe Corden talking about the efficient anterior reproach. And he did this great talk about how many minutes is saved in a day translated to how many years it's saved in his life, right? And, it made me very depressed,
Patrick Weinrauch:least you're not waiting for, At least you're not waiting for cement to set.
Jit Balakumar:I realized is that every three years my table technician moves on to, becomes a rep there. They joined some company, right? Oh, my nurses get pregnant or if they can't get pregnant, they move on. And, I always say, look, in our hospital, we, I refer to the surgeons as the big five, like in the game parks. And, I'm just a hyena, jokingly knowing that secretly I'm in the big five, but you want to, I think you have to be open to the idea that it's not like it used to be. Everyone's moving. People have ambitions, the really good stuff that we have actually some time want to move on, To something else. it's a very hard, hard thing to be able to do that. And I think what I've actually got a lot more of is patience. I've just realized I'm no longer getting frustrated. And, I want to be more like Roger Federer, when all those unforced errors happen and not like Nick Kyrgios, because when I see that new member of nursing staff in my theater, I don't want to be smashing that racket on the floor. And so I would say, look, I agree with everything that Pat and Alana are saying. I have a different experience. I'm getting to the stage where I'm like, Oh my God, how did this happen all of a sudden? And there's some completely new member of staff in my theater or on the wall. There's a physio who says, let's start using the walking frame and don't sit and bend over more than 90 degrees. That's what's happened. how did that happen? And, I don't, are you, guys seeing that at all or not really? Maybe I'm the only one who's just getting all this change and stuff.
Patrick Weinrauch:No, I think, I think that having, I think the benefit of having a, a high volume practice though is that, people can learn things pretty quickly because they, just get repetition really fast, right? and if they're, if you're doing enough volume, there's a critical mass where, or, Yeah, even if they're not your regular staff, even your irregular staff have now had the opportunity to be able to do lots of them. So there's like depth in the team. so if you have a complete stranger come in, you know that you've you're surrounded by lots of people who aren't complete strangers. So there's enough you can accommodate there. So we can have two new staff come in. And that's not that's fine. We, we do that all the time. and pretty quickly, they learn the ropes because there's enough resilience in the system to be able to compensate for that. Yeah. I think that's probably one of the, one of the, one of the, tagline, benefits of having a reasonable volume practice too. Yeah.
Joe Scerri:I was gonna say, the big thing that I've noticed is if you go back maybe 15 years, a surgeon would change an implant and nothing else would change around him or her. whereas, whereas now, if you go to, your question, Joe, direct anterior, suddenly you've got to change the draping, to Ilan's point. You might need to use plural or you may not. you might want to use the table. You may not. you're going to need a bunch of different retractors. You may or may not. you might do the figure four. and so all of those things have now changed. As distinct from just changing from a, I don't know, porous coated stem with HA or one without, or a polished stem and maybe using cement. Whereas now, suddenly, all these people that are involved in you having a successful outcome, there's a lot of moving parts and what I've noticed, in the last few years is just the amount of laptops that are in theatre now looking at screens and, what, what degree is that and what, angle is that? Whereas back in the old days, you were lucky sometimes if someone did a pre op plan with a template. so it's, what are you planning? What's the strategy today, doc? And it's I don't know. I haven't seen the x ray yet. and we've come a long way and that's a credit to the industry and people are getting that great attention. And also it was like back in the day it was, what clinical history do you have? And now it's more about how you put it in rather than what you're putting in.
Joseph M. Schwab:Gentlemen, I want to thank you for taking time to talk with me today and, and thank you for helping educate our listeners. And of course, thank you for everything you do for your patients. If you're interested in learning more about today's guests, you can check out our show notes for their practice links. Join us every Friday for a new episode of the AHF podcast. You can find us an audio form in your favorite podcast app, or watch our video podcast on YouTube. Don't forget to like and subscribe and leave us a five star review to help us reach a wider audience, and to keep this content coming. Until next week, this is Joe Schwab reminding you to keep those hips happy and healthy.
