AHF Podcast
AHF Podcast
Reconstruction, Revision, and Rural America (Interview with John Horberg, MD)
In this episode of the AHF Podcast, host Joe Schwab interviews Dr. John Horberg. They first met in the fall of 2024 during the Revision Round Table series, where John's complex cases from rural Wyoming impressed Joe. John discusses his journey from Southern Illinois to building a successful total joint practice with Premier Bone & Joint Centers in Laramie, Wyoming. They talk about the logistics of running a practice with twelve locations and a fleet of planes to reach patients across the state, the value of preparation, and the complexity of handling revisions from an anterior approach. John also shares insights on building a supportive team, succession planning, and the challenges and rewards of practicing in a rural setting.
Hi everyone and welcome. Welcome back to the AHF Podcast. I'm your host, Joe Schwab. I first met John Horberg in the fall of 2024 while recording a series of episodes that we ended up calling the Revision round Table. I'll put a link to those episodes in the description and I encourage everyone to go back and watch them. John submitted cases and videos that we could review and discuss as part of the broadcast, and I was really impressed by the complexity of cases that he was dealing with. Little did I realize the complex and challenging environment he was doing those cases in. As I got talking to him more, I realized one thing about John: he's a problem solver. And he's put his problem solving skills to building a complex total joint practice in a challenging environment. John joins me today to talk about his journey to building a practice of complex hips in rural Wyoming. John, welcome back to the AHF Podcast.
John Horberg:Good to be here.
Joseph M. Schwab:So tell me a little bit, how did you, my recollection from our initial discussion is that you're from Southern Illinois, right?
John Horberg:Yeah, I grew up in, farm country in central Illinois and trained in that area. after my fellowship, I went back and I practiced, where I trained for a few a period of a few years at a level one trauma center. I. All the resources you could hope for from a surgical standpoint. but my wife and I are both, in love with the mountains. She grew up in rural Wyoming, and we decided after a couple years of practice in, an academic setting that it was time to move out west. And now I'm practicing in Laramie, Wyoming, with the Premier Bona Joint Centers.
Joseph M. Schwab:And it, was it your, was it your wife really who got you interested in Wyoming or was that something you had been independently interested in?
John Horberg:I had always been in love with the mountains. I'd grown up skiing and rock climbing, mountain biking, hiking, hunting, all the classic outdoor stuff. but my wife, being from Wyoming is what made us settle on the rural state as opposed to any of the other states in the mountain west. I.
Joseph M. Schwab:And so when you started looking at practice opportunities in Wyoming, was there something you found immediately or was it a difficult, a difficult search for you?
John Horberg:In some ways it was a difficult search. when I came to Wyoming, I was the only fellowship trained joint surgeon in the state. no other practices were looking for one. I. So I put my feelers out and I cold called a couple of practices and I was fortunate that the group that I'm with now was, had the foresight to say that yeah, we can make this work. It's a good opportunity and it works for both of us. I.
Joseph M. Schwab:And tell me a little bit about your practice setup at the moment.
John Horberg:Yeah, we have a fairly unique model. We're a, single specialty private practice physician owned. we work on a spoken wheel model. We have, our headquarters in Laramie, Wyoming, which is, where the University of Wyoming's located. we have our surgery center there and our main office, but I. Wyoming being such a large geographically, but small from a population standpoint state. we travel to outlying clinics around the state. We have 12 locations, and then we see patients as close as we can to where they're from and then bring them back to our central locations to operate. And to do that, we have, a fleet of four twin engine turboprop airplanes, and three full-time pilots, that help us get around. a lot of folks aren't. familiar, but a lot of roads in Wyoming get closed sometimes as many as 60 or 80 days outta the year for Interstate 80. So we have to fly over the weather if we're gonna get to these outreach clinics. I.
Joseph M. Schwab:Yeah, so I think of, there being geographic, issues with a lot of different types of, practices, but a practice that has four planes and three pilots, that's gotta be an additional. Headache on your, the management of your practice? what sort of, what sort of difficulties has that created for you and your partners or what sort of opportunities
John Horberg:it's, both, obvious. the obvious, biggest concern is the cost. it's not cheap to own your own airplanes. It's not cheap to maintain an aviation operation. But, my, my partners have been flying, for 50 years now, starting off in small single engine airplanes, up to the, fleet of planes we have now. And what we've found is from an economic standpoint, we can make it work just by staying busy. We, go all across the state, we see as many folks as we can, and a lot of these patients, their only other opportunity was to drive to Montana or to Utah or to Colorado, which sometimes is a six or seven or eight hour drive for them to get musculoskeletal care. So for us, we o overcome the cost of the aviation with volume. And then from an administrative standpoint, we've just. Been fortunate and, relied on excellent administrators who can not only run clinical practice, a surgical center, our ancillary, revenue streams, but also manage an aviation business, coordinate with the state, coordinate with local airports. it's a big complex machine with a lot of moving parts for a practice of nine physicians. But, it allows us to do what we do and we're passionate about taking care of people in rural environments without having them feel like they need to leave the state.
Joseph M. Schwab:So you mentioned you were the first, total joint fellowship trained, surgeon that came and joined that practice. Were your partners before doing any complex revisions? Were they handling complex cases or what was happening in those circumstances?
John Horberg:for the majority of cases, the, complex primaries and the revisions, were being referred down to the university depending on where the patient in the state came from, whether it be the University of Colorado, the University of, Utah, or some other larger centers in surrounding states. my partners who were doing primary toll, joint arthroplasty would take on basic revisions, bearing changes and things like that. But for the most part, we were, Relying on the surrounding states to take care of the complex cases. I was a bit nervous coming in just from a volume standpoint, being the only joints guy, and not having a prerequisite, model, to see if I could do these things. But the volume was certainly there. It was just more getting my system set up so I could actually do those cases in hospitals and centers that weren't used to doing them.
Joseph M. Schwab:Yeah, and it had to have been more than just travel logistics too, right? what sort of things did you need? To do, to prep your practice for being able to do some of the complex cases that you're, doing now. It's not just like flipping on a light switch, I imagine.
John Horberg:Yeah, exactly. the, things that I anticipated coming in and I had come from a place where I had every resource under the sun. We were the referral center. I. I could start a uni and end up doing a distal femoral replacement if I wanted to,'cause everything lived in house and was sterile. So I, had anticipated needing to coordinate with vendors for implants, inventory instrumentation, especially less common instruments. burrs and, saws and cement removal equipment, extraction equipment. There's little things that I hadn't anticipated. Just simple stuff like, multiple suture options, arrogance for the complex cases. so those were the things that I had focused on. Initially. We bought ha beds for all my facilities, for my anterior approach. I'm, an on table surgeon. but there's a lot of other things that go into. Doing complex cases that are above and beyond the, what happens in the actual or the availability of, ICU care, the availability of blood, which we, had to coordinate, the availability of infectious disease and other consultants, plastic surgeons, people to help you with complex wound closure to help you with infection and an antibiotic management. and then also getting buy-in from. Staff at the facilities that yes, we can do these complex cases from, central sterilization that yes, we can turn trays for big revisions in a small facility from anesthesia that yeah, these folks that we're not used to taking care of this complex of surgery and this sick of a patient. it, took a lot more logistics and a lot of the problems were problems that I discovered along the way. But, the one thing that's wonderful about Wyoming is it's a blue collar state of hardworking people who love to rise to a challenge. I,
Joseph M. Schwab:I can imagine. And it sounds like you've risen to that challenge too. I think back when I was a resident, we, were, able to do, A rotation in Nicaragua for a month and do some surgery, excuse me, for a week, I apologize. and do some surgery down there. And we used to talk about, the changes that you make to your practice or the things you learn about what you can do during surgery, from environments that aren't fully resourced, full environments. Is there anything you've learned about how to approach a revision or how to approach the care of patients following or leading up to a revision? just by practicing in the environment that you're in.
John Horberg:I think the thing that I learned the most is the value of preparation. just like you mentioned, when you're in training at a big academic center or you're in practice in a, large tertiary referral center, you take for granted all the resources that are there and all the stuff that can be done on the fly. So for me, I look at, I. Even, cases that I wouldn't necessarily consider terribly complicated, but that could have unexpected problems, but especially the revisions. What's my plan A, what's my plan B? What's my plan C? What instruments am I gonna need for that? And which ones do we have and which ones do we not have? What, implants and systems do I need to have available? And make sure that we can get them there logistically in certain times of year. That can also be a challenge just with the weather problems that we have getting to our clinics. the vendors have those same problems, getting those implants from their larger distributor distribution centers to, to our facility. and then all the preoperative and perioperative care needs. for infections, I try to make sure that I get consultations with infectious disease prior to surgery. I try to anticipate whether or not I'm gonna need a plastic surgery consult because I might not have a plastic surgeon, in the hospital for. Weeks at a time, unless I arrange it in advance. anticipating the needs of, higher blood loss, potential need for blood after surgery, potential need for, intensive care. even simple things from a critical access facility, needing to know if there's gonna be a bed available for my patient after surgery in a step down or an intensive care unit. Most of the problems that I anticipate in advance my team and my vendors and my consultants and everyone else likes to give me a hard time that, you brought in 40 trays and you had three doctors available and you had a bunch of blood in the building and you didn't use any of it. but then there's those cases where you get into something that you weren't expecting and you always wanna make sure it's there. The worst thing you can do is get into a surgery, be in the, or have the patient open and say, oh shit, I can't do what I want to do.
Joseph M. Schwab:you mentioned your team, the team can be as small as, you and your ma, your pa, the team can be as large as anyone who's gonna see and touch the patient, at the time, through their, through their time in the hospital. Was there pushback from a certain groups, or certain, people who played certain roles or, administration or anything like that, that you had to negotiate? how did you navigate that?
John Horberg:Yeah, it, for me, it started small and then grew. I was fortunate that right off the bat, the ma that they hired for me before I even got there, is the best MA I've ever worked with. she works her ass off. She coordinates with all these people and she's even gone out of her way to find a. Things that have helped us take care of our patients. She found a home health organization and coordinated with them. So we had some step down care for people who were 500 miles away from me in a rural market on a ranch in the snow, who might not get into PT as frequently. but then every step of the way, there's little things. the anesthesiologist initially box saying, we can't do these big complex cases here for cardiac issues or pulmonary issues. But then, I talked with them and figured out what are their concerns, what can we do prior to surgery to optimize them. Sometimes that means we have to do more in-depth screening for pulmonary issues, for cardiac issues, and do a little bit more to optimize'em prior to surgery to facilitate them feeling comfortable doing the big surgeries. at our surgery center, the most joints they'd ever done in a day, between multiple surgeons was six before I got here, and now I do 12 in a day. it. Wasn't so much pushback. It was more skepticism. Can we really do this? Can we really turn these trays over? and then I had to figure out what are the issues there. And some of them were, it's gonna take us forever to turn these trays over, but we found out that I can eliminate 70% of the trays'cause it's a bunch of superfluous instruments and facilitate faster turnaround to those trays, working with the vendors to get more sets of sterile. Implant and, system specific trays available at our facility, getting a larger stock of implants, in-house. and then I think one of the other challenges was getting care for my patients all over the state. getting, I. doing an ACL and a 25-year-old, you don't necessarily need pre-op clearance and COPD screening and sleep apnea screening and cardiac clearance. So we had to figure out ways that we could get labs, EKGs testing, and a physician to clear these patients prior to surgery. And a lot of this stuff just. Took being a nice guy and, trying to go out to these environments and talk to people. I met with primary care doctors in their communities. I met with local therapy groups around the state. We have a physical therapy group in Laramie, but we cover the entire state, and we don't have a therapy office in every single town. So meeting with the private therapists in their own communities, meeting with the infectious disease teams, meeting with the plastic surgeons. and another thing in private practice that was. Surprising, but refreshing to me is meeting with my competitors. a lot of groups around the state, they're local, they're hospital employed. They're a small private group that covers a small community, and they didn't want to be doing some of these bigger cases. They were happy that I would take care of their patients and they were also happy to take care of my patients when the need arose. As long as, I'd be willing to do the same for them.
Joseph M. Schwab:So there was somewhat of a handoff agreement between, the, competing physicians, right? If you're taking care of their patients. And, that's interesting. so all that travel around the state, are you going on those planes as well or is the planes for patient and, goods transport? What, tell me how that works.
John Horberg:Yeah, so we all live in Laramie and then, our philosophy is that, we'll go and see the patients in their communities. So we have 12 outlying offices and we'll fly, to go see the patients. but that takes a five hour drive and turns it into a 35 minute flight. We all get to sleep in our own beds at night. We all get to put our own kids to bed. but. We get to go see the patients. They don't have to travel through the perioperative period. They only come to see us once for surgery, and then they get to stay in their own communities and we take care of them where they are.
Joseph M. Schwab:So I had a group of surgeons recently, that I interviewed for the podcast who, started in practice doing posterior approach and had transitioned to doing anterior approach. I. There was a discussion that came up in there about the, utility of revisions from an anterior approach, which it sounds like you do the vast majority through an anterior approach. Is that correct?
John Horberg:Yeah. since I've been in practice, I've only ever done an anterior approach. I still haven't found an indication for going in from the back.
Joseph M. Schwab:So I'd be interested to hear your perspective on this.'cause the, discussion which I thought was a reasonable one was, there, there should be, a hip surgeon should have, many quivers in their, many arrows in their quiver, right? So to speak, should be able to do things from all different approaches and that there's a value in considering different approaches in revision scenarios. But it sounds like you who do quite a number of revisions. In a very challenging setting, continue to do it through an anterior approach. And I'm curious to know, is that, is there something with the way you've set up your, your system to facilitate that? Is it the types of cases that you see? Is it just the type of training that you have? What, can you tell me about that?
John Horberg:I think some of it does come down to training. I'm certainly more comfortable operating from the front than I am from any other approach. if you asked me to, told me I had to get through a posterior approach, I could probably do it, but I certainly wouldn't be nearly as comfortable as I am from the front. from a case selection standpoint, I. I'm non-selective. I've done everything from proximal femoral replacement, periprosthetic fractures, tri flange, cup cage, pretty much anything that's a classic challenging revision hip case. I've done from the front and I think I. A, that comes from the fact that I trained to learn how to do these things from the front. B, it comes from, working with organizations like the Anterior Hip Foundation, doing some of the teaching and consulting. I do, you get to work with experts from across the field. Every time I teach a course, I learn something new. I feel more and more comfortable doing those cases, but it's also easier for my facilities. I have. Aana bit everywhere I went. That was one of the challenges, alluding to your prior question, is getting administration to buy me a table everywhere I went. But then it's the same table for every hip. There's no question mark on how I'm gonna set up. that eliminates the need for as many staff. I, I do my revisions with myself, one pa or a surgical first assistant, and then one tech handing me instruments, my vendors run the table. it decreases the amount of resources needed. In the OR per case for the team. but I, just haven't really found anything that I feel like I need to go from another exposure from. there are certainly cases where that may be of benefit, but one argument people have for doing revisions, from the back or from another approach is. you need to go in the way that the prior surgeon did. I think the benefits of doing an anterior approach revision are one, you have often a virgin plane to work through. if it was a prior anterior approach, it's still a minimally invasive surgery and that you're not cutting muscles, you're not releasing things, you're not cutting tendons, you're just removing soft tissue from around the femur itself as a part of your perioperative releases, but you're keeping all the musculature intact. You diminish the risk of instability. So it's a much more recovery friendly approach in my mind. I've done, large femoral sided revisions on patients that I'm shocked that they're sitting at the side of their bed on post-op day one with their clothes on, wondering why they can't go home. Whereas sometimes you do those same cases from the back and the patients are in the hospital for three or four days, and that a 20 bed critical access facility with limited nursing. a lot of times that's a challenging thing to have patients that want to, or need to be in the hospital for several days.
Joseph M. Schwab:So is there anything you do, with, or for your team members? Make it so that this isn't, something they want to rebel against. it seems like there's, they, you're giving them almost every reason in the world to say, gosh, I don't know. I don't know. But you seem to be successful in doing this. is it personality? Is it, gifts? what, how are you making this happen?
John Horberg:my wife could attest. It's certainly not personality, the, my philosophy is. First and foremost, there's no need to be that surgeon. Everyone knows who that surgeon is. if you're kind and affable throughout the day, you show appreciation to the team when they work hard for you. I say thank you after every case and after every day to the people I work with and just I. Letting the team know that you care goes a long way. I make sure that I personally round on all my patients. I do my complex patients where I anticipate inpatient stays in my home facility. I do some stuff in remote facilities that are gonna be outpatient surgery, where I've got a PA on backup who can round. But in general, I see all my own patients personally. all the nurses on the floors, all the hospitalists, all the consultants all have my cell phone number. They know they can call me directly day or night, they don't have to. I call my hand partner who happens to be on call to answer a question. so I think buy-in comes from people feeling like they're. Doing something valuable. They're taking care of people in their community. And Wyoming is very strongly supportive of and proud of taking care of our own patients, but also being the surgeon who appreciates the work that people do for you. and I do think I. Being efficient is also important. we all know that speed isn't the most important metric of success, but being efficient and not being the guy that everyone looks at the day and says, oh God, we've got 12 primaries at the surgery center. We're not gonna leave until midnight. If they're walking out the door at four o'clock, everyone's happy and bought in. And then on those rare occasions where cases go longer than you expect, or the day goes longer, you haven't had on, people are much more happy to stick around and work with you as long as. They know that you're making an effort to respect their time and showing up early. I'm always there 45 minutes before my cases. All my patients are marked, all my paperwork's done, all my orders are done, and I'm helping the team if I need to.
Joseph M. Schwab:Yeah. So you set up a system like this, super efficient, able to service your community. And obviously you've got, you're a young guy, you've got a significant. Amount of your career left, but at some point you hand over the reins and, keeping something like this going after, hopefully you do it for a long period of time and it gets to be an established portion of your community or an expectation. Have you thought about succession planning or what that looks like? How, when do you start thinking about something like that?
John Horberg:that's a great question. One of the things that I think my practice in general has done phenomenally well at is, strategic planning, succession planning and growth. we celebrated our 50th anniversary. Anniversary last year, as a practice, as a, group that focuses only on fellowship trained specialists to serve our broader community. And they've always done a good job of continuing to bring in new specialists. We just hired a new spine surgeon, who I'm quite proud of'cause she used to be one of my former residents from my academic days. The same thing goes for me. when I came here, I didn't know if there'd be volume enough for me as a recon specialist doing just joints and not having a little bit of a general flare to my practice. And now I'm as busy as I wanna be. I'm probably leaning towards hiring a second recon partner in the next five or so years to help me share the load, grow the joints, practice, and then, allow them to, in stepwise fashion, take over for me as I wind down hopefully in 20 years. but always having somebody there and ready to take over your workload before you're ready to leave, I think is valuable in recruiting to Wyoming. Is in some ways easy and in some ways incredibly hard. we always joke that we don't look at the surgeon, we look at their spouse. if they come into town and they're looking for shopping malls and fancy restaurants and, professional sporting events, it's, it can be a challenge. But if they come in and they, they love the outdoors, they love the things that make Wyoming great. Every outdoor opportunity is available. The University of Wyoming Sports, we're all Josh Allen zealots at this point because of our favorite alumnus. you, recruit the right people who buy into the mission, and we do have a school of medicine in Wyoming as well. So I teach some of the students, I'm a orthopedic proctor for their fourth year rotations. And making those relationships with people from the community who may wanna come back to the community when they finish their training out and about is another way to make sure that we keep bringing people in.
Joseph M. Schwab:And apart from the teaching that you're doing at the university, you're gonna be talking, revisions at the upcoming AHF annual meeting in Nashville in June. We're happy to have you. We're looking forward to that. And it sounds like you give courses, or you teach courses, through industry as well,
John Horberg:I do, yeah, I, I do some consulting work for a couple of different, implant vendors. I teach, primary and revision, hip and knee replacement largely. the hip stuff is largely, anterior approach, whether it's beginner, anterior approach revision, anterior approach, complex primary. I've been fortunate enough to teach with the Anterior Hip Foundation, which I think is one of the best meetings in the country. Plugged to anyone listening to the podcast, come see us in Nashville. and then other academic societies. And I think teaching is another wonderful way to a, grow your network. I'm on, on an island out here, but I've got a network of surgeons around the country that if I have a complicated case and I wanna send it to Jonathan, you and he can send me a profanity, lace, bit of advice, I'm, happy to receive it. But that's been another way to network and it's also another way to find surgeons who might wanna come out and join me.
Joseph M. Schwab:And are surgeons able to come visit you and see what you do in your operating room, or is that a logistically difficult thing given your practice?
John Horberg:both, yeah. I do have surgeons come out and see me. they wanna see either high volume, arthroplasty, which for a rural center we're an extraordinarily efficient facility, not just for my practice, but for all the subspecialties that, that we provide. I. I have surgeons come out and watch me operate. I have surgeons come out, watch me do revisions, but it can be logistically challenging. In the winter, it's hard to get in. sometimes we request that they fly into Denver and rent a car and drive up, which is a bit of a bit of an issue. But it's, one of the more rewarding parts of my practice is teaching and showing other people what I'm doing.
Joseph M. Schwab:those surgeons have got a tremendously benefit from your level of experience and, what you've put together. And I really, appreciate you sharing this with us today, John, it was great to have you. We look forward to seeing you in Nashville. We look forward to hearing more about revision, total, hips from an anterior approach with you in Nashville. And, you're welcome back on the AHF podcast anytime.
John Horberg:I look forward to it. Thanks again for having me on.
Joseph M. Schwab:Thank you for joining me for this episode of the AHF Podcast. We think of the AHF as a family. So if you can remember to take a moment to like and subscribe, you would be helping us find more people just like you to share our thoughts with. And as an AHF family member, you can always drop an idea for a topic or any feedback you like in the comments below. 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 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 like John Horberg to keep all your hips happy and healthy.
