AHF Podcast
AHF Podcast
Interview: Leandro Ejnisman, MD
Advancing Orthopedic Surgery in Brazil with Dr. Leandro Ejnisman
Join host Joe Schwab on the AHF Podcast as he explores the advancements in orthopedic surgery in Sao Paulo, Brazil, with Dr. Leandro Ejnisman. Dr. Ejnisman shares his decade-long journey of introducing the anterior approach to hip replacement in his community, the role of technology and innovation in modern surgery, and his vision for a future where robots play a crucial role. Dr. Ejnisman's insights also cover the challenges and successes in adopting new techniques and the importance of mentorship and ongoing education. Tune in to hear about his experiences and the growing trend of anterior approach surgeries in Brazil.
Hello again and welcome back to the AHF Podcast. I'm your host, Joe Schwab. This week we head to Sao Paulo, Brazil. Where Dr. Leandro Ejnisman has been working hard to introduce anterior approach to his community for the past 10 years. He shares his insights on technology, surgeon entrepreneurship, and what the future of orthopedic surgery just might look like. And here's a hint. He's betting it'll involve robots. Let's join in on the conversation. Leandro, welcome to the AHF Podcast.
Leandro Ejnisman:Thank you very much Joe. It's an honor for me to be here. Thank you very much. And especially being the first one, I believe, from Latin America.
Joseph M Schwab:That's right. So which, tell our listeners a little bit about you and a little bit about
Leandro Ejnisman:I. Sure. So I'm from Sa Paulo Brazil, as you mentioned. I was born here and I did all my training here. I went to medical school at University of Sao Paulo, and for those who don't know, it's a very prestigious university here in, in South America. It's considered, definitely one of the best here in Brazil, Latin America, but, but also it ranks really well, in world rankings. a little thing that's different here in Brazil is that. Usually if you are in a good way, in a good place where you did your medical school, people tend to stay in the same place for residency and fellowship. So it's a little bit different than us. What I see that most people go around in different places. so I did my, medical school at University of Sao Paulo, my, my residency and my fellowship, which was in hip surgery. also our practice here is like joint centered, so. Most people like my practice as, as you asked, is basically hip surgery. I do both hip replacements and hip preservation surgery. So after my, my fellowship here in Brazil, I went to the west to do another fellowship. I. And in my, in my hospital, we didn't have much hip arthroscopy. So I spent one year after my fellowship at, in Il, Colorado with Dr. Philippon at the Stateman Clinic. I went there as a, we have like a institution here that gives scholarships to Brazilians that want to go abroad. It's called Institu technology, the S, so I went there and I have a wonderful year of Dr. Philippon. I learned a lot of laproscopy. I did some research, which was really interesting, and then I came back, When I started my practice, I divided myself between public system here in Brazil and my private practice, the public system was at the University of Sao Paulo where I trained. I also did my PhD there in, in hip surgery, especially studying, the relationship between labor affairs and, and, Angle measurements in CT scans, which was a very interesting study. And after seven years, I decided that I wanted to study a little bit more and, and actually hone, yeah, even more my, my research skills. So I spent one year, in 2018, I. California with Dr. Mark Saffron at Stanford, which was a really interesting year. I was able to do more research. Again, I studied basically a lot of hip micro instability. but it was also very interesting to get in, in like the mindset of the Silicon Valley. Did a lot of courses on innovation and a lot of stuff on design thinking. So it kind of changed my, my practice a little bit when I came back. So I decided a lot to go. I started to do a lot of stuff with innovation. I actually found that I started up, I started doing some angel investments in, in health tech, related, companies. I also did, started doing a lot of stuff with, technology in, in. In medicine now we practice in orthopedics. So I've been doing a lot of stuff with robotics, navigation, also some stuff with, augmented reality and virtual reality. So definitely my experience in California changed me a a lot.
Joseph M Schwab:So were most of in the area of orthopedics or more specifically in hip surgery or were the, was it a kind of across the gamut of medicine
Leandro Ejnisman:I, I have a, I have vested in an engine investment in a company that does a lot of stuff with digital health in orthopedics. So they have like a software that's nap, especially like for, for like a company that has like thousands of employees and have a lots of. Problems with people getting absent because of back pain, this kind of stuff. So it helps monitor their health. And Oslo has some, like tele physiotherapy and Teleconsultation helped by ai, so that's a very interesting company. I also helped a company that had stuff with 3D printing, but especially with Sprint, like for, ortho Posis and this kind of stuff. And I also have, in a, I also have some investment in a company that does stuff of. Medical education, they do like, especially for medical students, they do like clinical cases with actors. So you have like a situation that, like you have an actor that presents himself with a symptom, let's say his coughing. And then you have like, you have to ask, what's the exam that you want? They show the exam. Then you, you see the, you wanna see, tell what you're gonna do. And it's a very interesting company actually going abroad as well. So it's very popular. Yeah.
Joseph M Schwab:I mean, you really have your hands in a lot of different, areas of medicine it sounds like, as well as in technology and innovation. focusing a little bit on anterior approach, hip replacement, tell me about how common it is, either in Sao Paulo or, or in, you know, Brazil overall.
Leandro Ejnisman:It is definitely growing. So I don't have official numbers, but I would guess around 5% of doctors here would do anterior approaches, definitely less than US or Europe. But I would say like until like five years ago, it would be. Probably less than 1%. So it's definitely growing really fast. My, my first contact with the interior approach was when I still, when I was in, in Vail with Dr. Philippon. I've seen talks of Dr. Matta and doing the interior approach of the HA table, but that was something that looked a little bit far from me'cause. Brazil. It's an interesting country'cause it's a land of disparities. I would say, you know, because you have like lots of wealth here. So the, the hospital that I do that, that I work now, it's called Albert Einstein Hospital. It's a Jewish hospital. I'm very proud of that here in Sao Paulo. And it's considered, the, definitely the best hospital in Latin America, but it also ranks in as 22nd in the wards, a really prime institution. But they have lots of other hospitals here that are not, so there's not. The infrastructure that Einstein has has, and even like being in such a good place, like for me as a ledge surgeon, asking for like a special table that costs so much, it looks like a far thing, you know, for me. So I decided to do the interior approach. I, I saw Dr. Christoph Carin from Belgium doing the interior approach off table in a meeting. And I went to him and I said that that's when something clicked to me, you know, saying that's something that I can do in my practice, you know? So I went to visit him in 2016, and that's when my journey began. So almost 10 years now I have the opportunity to visit him again. I think 2000. 2000 and. In 22, I think he, I was the first visitor after the pandemic with him'cause he had to, to block his visitors for a while because of the pandemic. So since 2016 I started doing interior approach off table and it's been amazing. You know, it's, I decided to,'cause I was listening to other, other, other, orthopedic surgeons here at the podcast telling that some people decided to go like, full, full. Food directly to the anterior approach and do a hundred percent of their cases. Interior. I took another, approach. I started like changing gradually. So at the beginning I was very picky, like doing the easy cases, like thin patients, very vgo snacks. And then I started slowly growing, like doing more difficult cases. And last year, 2024, I did, I think like 92% of my cases were interior approach. You know, so I'm, I'm basically converted now. I still don't feel like confident. I don't, I don't say confident, but I, I still rather not do a hundred percent of them.'cause especially like the. What I feel is that like as I'm in an environment where, where anterior approach is not the norm yet, I feel like if I do a patient that it's like more complicated. Like if you do a really obese patient that has a higher rate of infection, independent of the approach, if I do an anterior approach and he gets infected, it's because of the approach. If I do a posterior approach and gets infected, was was a tough case. You know? So I think, I feel I have to protect myself and the approach, you know.
Joseph M Schwab:So do you find that's one of the biggest challenges you have in sort of performing or growing anterior approach in your area? Or what, what are the biggest challenges you see of greater adoption in Brazil? I,
Leandro Ejnisman:It is changing. You know, like I, I would say the, the first meeting I, I, I, I think I heard of in Brazil of interior approach was in 2017. It was, organized by mad. So a, a lot of pe, a lot of people that do interior approach here in Brazil, they use the med system with their table.'cause the HANA table, we are getting some here in Brazil. I know in Sao Paulo of two places they have it, but not many. So. I went there and like people were telling about the interior approach and, and me, so one thing that's a problem here in Brazil is because our health system is a little bit different and dependent, depending on the insurance of the patient and the hospital that are doing surgery, sometimes it's not easy for the surgeon to choose the implant that he wants. So one thing that I, when I decided to do an interior approach, the, the thing that convinced me of doing it off table was because I didn't want to get, stuck. To, to a table, because I thought in, in Brazil, our practice, even though I'm most of the time at Albert Einstein Hospital, I still do surgeries in other places. So I felt like if I'm, if I'm, I'm attached to the table and I can only do the surgery with the HANA table, if I go to another place that doesn't have it, I won't be able to do the approach that I want. And the same thing happened with, it was my, my, my mindset with mea. I felt like, well, if I can do like most of my cases with mea, that's good. I can do the interior approach. But if some insurance or some hospital. Doesn't allow me to use their implant, that I'm gonna be not able to do the approach. You know? And I feel like as some, a lot of surgeons here in Brazil still linked the anterior approach, or to the MEA system or to the the H table. They're kind of like, whoa, I cannot do this because I wanna be able to do in every case. But I feel like, Now, especially the past three or four years, I feel like the mindset is changing and I've here, I feel like two, five years ago, I knew every surgeon here in Brazil that do the interior approach. And now I don't, like every once in a while I get patients, patients know. I get surgeons that come talk to me in meetings. Oh, I've been doing interior approach, I've been doing off table. I've been doing on table. So it's spreading and I feel like the, the grow, it's been, the growth, it's been leading by the patients themselves, you know? So I was talking to you that, yeah, I, I feel like my practice, when I began my practice in 2011, that's when it began. It was like in the public system, was mainly, hip replacements. I didn't do many. Hip preservation there. But in my private practice, I would say probably 70% was hip preservation. But since I started doing, the interior approach, it's been changing a lot. So I would say probably now 20 to 30% of my practice is, is, hip preservation and the rest is interior approach, because I've been getting referrals. by, by another, by patients themselves, by physiotherapists to see a lot of difference. The TER approach. It's funny, you know, like a couple of years ago I operated on, the mom of a physiotherapist here. She's really known here. She has a great practice. Like she, she, she treated one of my patients like she was. Pled by like the, the, the recovery and the speed recover. So like two months after she sent me her mom to operate on and she like, she knows a lot of guys here and like I was very honored. But it shows to me how the physiotherapist see the difference. Like when during your approach, you know.
Joseph M Schwab:the growth has really been word of mouth through the patients, it sounds
Leandro Ejnisman:Word of mouth. Yeah. One other thing that's that's big in Brazil is social media. So the, the, like many doctors have like social media pages and Instagram, YouTube, LinkedIn, in all the, you know, the, the places. And also I have one myself, and there's lots of patient education and it's something like then when the patient starts. Studying, quote unquote, about the, the procedure. And they hear there's a procedure that's muscle, more muscle sparing, there's less invasive, they're, they're really convinced, you know, so lots of patients come to me, they, they come to me and the first thing they, they ask is like, you, you do inter approach. Right? Because that's what I want. You know? So that's something interesting.
Joseph M Schwab:So, so you've been doing it for about 10 years, plus or minus. And if, if you could go back to the beginning, really, there one thing that you wish you would've known, or you wish you would've approached differently when you were starting to learning anterior approach?
Leandro Ejnisman:I wish I had more, more structure than I had in the beginning. So like the companies, the, the medical companies wasn't, weren't like too, too red, weren't ready for the interior approach. So when I started I didn't have like offset handles. I. For doing the interior approach I had, to by myself, the retractors that I used, you know, so it was very, like, sometimes when I think of the beginning, I would think, I feel like I was very brave doing it, you know?'cause I was doing, like, I wouldn't recommend people to do it the way I did.'cause like, I didn't have like the, the right instrumentation. I was in the public system doing, with residents, like junior people to not help me very much, you know? So it was the, the beginning was. Tough, but I'm, I'm, I'm really happy that I did it, you know?'cause now I'm really happy with the interior approach. One thing that I did that some people do not recommend, but I still think like it was a good call. I did in the beginning many hip fractures.'cause I do a lot of femoral neck fractures and I've seen some people telling people like to stay off of femoral femoral fractures in the beginning. And that's not my feeling because people are worried about the femoral fracture, like getting, doing like a, a calco fracture or something. That's something that I, I didn't have. In the beginning, and I feel like usually there are older patients, like very, with very soft tissues. I very lax, so getting like the proper releases and getting the femoral exposure, I feel like it's very easy in, in femoral fractures. And I still do a lot of those. And it's interesting, some people say, oh, but it's e femoral fracture is an elderly patient. You don't need like to be less invasive. But that's something that I totally disagree. I feel like they, they do really well. They recover faster, they bleed less and they're really happy, you know, so that's something that I kind of disagree with many people that I've heard of.
Joseph M Schwab:No, I, I completely agree with you. I think hip fractures are a great place to learn anterior approach, for the reasons that you mentioned and the fact that you want to do everything you can to get those patients functional and minimize their amount of. Pain, so that they avoid things like dementia or delirium and things like that. So in your journey, I mean, you mentioned, for instance, Kristoff Corten as a, as, as a mentor. What was it that you felt you got from those sort of mentorship relationships? Was it really specific ways to do things or was it introduction to different technologies, or was it just sort of a, a, a whole picture of efficiency? What do you felt like you learned from your mentors? I.
Leandro Ejnisman:I feel from him, I learned like the most important thing definitely is the, the technique itself. You know?'cause, like doing the proper releases, like being, when I spent the first time I went there, I think like three days with him in the, or the second time, two days. He has a great volume. So like being the, the first time I think I saw. 30 plus surgeries and I was able to scrub in of him. It's a big difference, like from when we visit the us you know,'cause I've did lots of visitation with surgeons, which it's just a great way to, to learn from people. And usually when you go to the US you cannot scrub in. And especially if you're like, learning, the interior approach is kind of deep, you know, it's really hard to see from the outside, you know. So being able to scrub in with him was great. He was also a mentor for me. Like I, I remember like I had. In the be beginning of my learning curve, I had one case of femoral nerve palsy, which I, I got really, really scared. So I was able to, to send an email to him like, did this ever happen? It's gonna get better. And he's like, calm me down. Say it gets better. Just the pulse. And actually it did get better really fast, so it was really great. And the technology also. So like I have access to the gripper, the technology that he developed. It's great. I still struggle in Brazil because of the cost, so I'm not able to use it in every surgery. It's a pity, I would love to use it, but I feel like he's a guy that's kind of pushing like our technology and everything, and I really look up to him for that and appreciate that, you know.
Joseph M Schwab:based on your experience, based on your time with mentors, your time studying, have you made any adjustments to your instrumentation, to your positioning or to your team coordination, to work on essentially efficiency in your ORs or how, how are things working for you currently?
Leandro Ejnisman:Unfortunately, efficiency is not the best thing here. You know, like our, I would say like I've, I've visited some places like in Belgium, in the us like the turn, the turnover of the, the rooms, the time, like the amount of surgeries that guys can do like in a day, something that, unfortunately it's not my reality. So most of the days I'll do like. Two cases, three at most, you know, and, and I kind of mix like in the morning or the surgeries in the afternoon, or the clinic or, or the other way, you know, so efficiency, unfortunately it's not that great here. so like, I'm like, especially like, let's say I'm doing also a lot of robotics now, and I talk to some people that say, oh, doing robotics, like. Gives you an extra time in surgery and it's, I don't wanna do that because if I add like five or 10 minutes to my case, in the end of the day, I'm doing one less case. And actually it's not my reality, you know, if I'm doing like two cases and even I, I feel like the, the more in the advanced learning curve you are, the less. It, it take, it adds time to the surgeon actually starts, lessen the time. But even if it does, for me doing two cases that in 10, 10 minutes not be like a great difference, I think the biggest difference, inefficient that's happening in my or now that people are getting more used to interior approach, you know, because at the beginning I would get to the OR and every time people would say, okay, so let's turn the patient to the side. And I'm like, no, I don't, I'm not turning the patient to the side. I'll be asking for Flora and like, why do you need flora for, for a, for a hip replacement? You know, so. That's something that has changed and I think that's a bigger, efficiency that I added. You know, like having a team and also the people that scrubbing with me. It's not every time the same people, but most of the time, most of the people you know. So now I feel like you're getting like a proper protocol that you're doing like the things basically the same, same way every time. You know? So having the numbered retractor is something that, it's so simple, but it adds, you know, like giving the refactor number one, number two, number three, and people start getting used to it. Definitely add adds efficiency to the surgery.
Joseph M Schwab:are there other surgeons in your practice who are doing anterior approach, or is it just you?
Leandro Ejnisman:no, there's not, there's there, there are more people there. One, more senior guy that actually he's doing interior approach, but it's a Watson Jones, not a direct interior. and as I said, like in in, in, in Sao Paulo people we are not like, I think it's different like from Europe and US or patients, but people, surgeons mainly go like to one hospital. So like people go around in different hospitals. So I say that, that the doctors that like operate mainly at my hospital, I would say this, me and this other guy that does Watson Jones are the only two. But like people that will come from time to time there, there are more people that do anterior approach as well.
Joseph M Schwab:So I, I mean, you have this perspective of the, you know, the possibility of growth of anterior approach specifically in Brazil. If you were to give advice, to some surgeons who are considering switching to anterior approach, but are hesitant, what advice would you give them?
Leandro Ejnisman:look for proper education. Definitely. So that's something that's growing in Brazil. So one thing that I think really changed in the past year is that we're starting to get more, more, more support from the industry. You know, so like our, our Brazilian hip meeting from our society happens every two years. So the last one was in 2023, and it was amazing'cause I saw like most of the symposiums of the, the companies were. About interior approach. So they brought a lot of, foreigners that do interior approach. I participated in one. I work a lot of the, I work a lot with the Pew Johnson, so I, we had a symposium about interior approach. So I always tell, don't be like, I think I was probably a little bit too brave. I tell patients, like, I tell another surgeons, like, go to a lab, you're gonna, I know you're gonna have a great lab in, in Nashville this year. visit a surgeon if possible. Ask to have like a reverse. Visitation when you can, you know, really pick your cases in the beginning. You know, like something that happened with me that I don't hear very often from people, as I told you that I, I had like a, I was very picky in the beginning of my patients. I almost feel like I have a doubled curved learning curve. What I mean is that like, I was like, I think I did like a hundred cases, like really picking the, the easy ones. Then I decided, okay, let's move to the harder ones. And then almost felt like I was learning again, you know? So I started to have like a little bit more complications. The cases were difficult again. So I really understood the difference between doing an easy case and a tough case. So I usually tell tell people like start easy cases and don't be in a rush to turn your practice to a hundred percent interior approach. You know, take your time. That's something that I did and I'm really thinking, I'm glad I did that.
Joseph M Schwab:I almost feel like publishing about the double learning curve is something worthwhile. That that's such a,
Leandro Ejnisman:That'd be interesting.
Joseph M Schwab:That is such an interesting observation that I've never heard anyone say before. But you're absolutely right. If you start out with that sort of, narrowed set of patients, you get really comfortable with it, and then you expand your indications. Yeah, absolutely. You can hit a whole nother learning curve. Right. I mean, you, you have this tremendous perspective. you've seen the growth where you're at. You're, you're clearly you're interested in innovation and technology. What do you see for the future of, of hip surgery, hip replacement surgery? You mentioned robotics. Where do you see this going?
Leandro Ejnisman:I feel like if it, I don't know the number, it's gonna be 10 years, 20 years, or 50 years, but I feel like we're gonna move to a hundred percent robotics and technology. That's something that I'm really, really be believing.
Joseph M Schwab:Mo
Leandro Ejnisman:not sure it's gonna be some.
Joseph M Schwab:out of the operating room and everything's or what?
Leandro Ejnisman:If you go like farther far, yeah, I think if you go further away, probably at some point I think like it's gonna be like in a Star Wars where the robots like the rain plant, like the looks hand. But I think that's definitely farther away. But I would say like in. Not so long, not in so long time, like 10 to 20 years we're gonna move. Like every case is gonna have technology with it, you know, which the thing that I'm not sure is which technology will quote unquote win. You know, if it's gonna be 3D printed guides, if it's gonna be help with, augmented reality, if it's gonna be a robot itself. Navigation, that's something I think it's open for, for discussion. You know, at this point I've been using mainly the valve system from the pew, which I really like. And the Mako from, from Stryker. I've been using both and I feel like both has have their adv advantages and disadvantages. But like as I told you, like I'm, I'm, I'm not able every time to pick the implant that I'm using. So I still do a lot of surgeries with other implants without the help of technology. And definitely like when I'm doing without technology now I'm kind of, I'm not sure if I'm doing like the best treatment that I can do to this patient. You know, that's something that, that's a feeling that I have at this point.
Joseph M Schwab:I mean, I, I feel, I, I, I absolutely hear what you're saying and I feel like, I mean, that's almost the goal of every surgeon, right? Is to feel like what do we need to be doing better? it's that, that, desire to be content with what you've done, but also to be, even more content with what you can do in the future. boy, I, I Leandro, I, I really appreciate the opportunity of talking with you. I, I really love hearing your perspective on this, and I, and I love that you are, bringing this approach and this enthusiasm for innovation, to Brazil and, you know, bringing it all around the world At this point, you know, we've been to, to Belgium, you're coming to, to Nashville, and, you're gonna be, giving us some of your perspective there. So. I really appreciate you being with me today on the podcast.
Leandro Ejnisman:Thank you very much and, thank you for the opportunity to be here and I look forward to seeing you in Nashville and every other surgeon that, really, eager to talk to everyone and learn from people from all over the world.
Joseph M Schwab:Thank you for listening to this episode of the AHF podcast. Remember to like and subscribe so we can reach a wider audience. If you have an idea for a topic, leave it in the comments. Remember. You can find us in audio podcast form in your favorite podcast app, as well as in video form on YouTube slash at anterior hip foundation, all one word. New episodes of the AHF podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.
