AHF Podcast
AHF Podcast
Cut For Time: Anterior Total Hip Replacement in the (Super) Morbidly Obese with Dr. Bob Sershon
Welcome to another insightful episode of the AHF Podcast! Join host Joe Schwab and special guest Dr. Bob Sershon from the Anderson Orthopedic Clinic as they dive into the challenges and solutions for performing anterior approach total hip replacements in super morbidly obese patients. Dr. Sershon shares his journey, training, and experience, providing invaluable tips on managing these complex cases. Learn about the importance of preoperative planning, patient selection, implant choices, and innovative techniques to ensure the best outcomes. 🦴💡 🎥 Highlights: - Dr. Sershon's background and practice - Impact of COVID on practice development - Challenges in performing anterior approach total hip replacements in super morbidly obese patients - Importance of preoperative planning and shared decision making 🗝 - Tips for handling large pannus and fat distribution - Implant choices, including stems, cups, and automated impactors - Detailed case studies and step-by-step surgical techniques 🛠 - Tips on post-operative care and follow-ups Don't miss this episode packed with practical insights and expert knowledge from the Anterior Hip Foundation (AHF). Perfect for orthopedic surgeons, residents, and anyone interested in complex joint replacement surgeries. 💼👨⚕️👩⚕️ 📅 Subscribe for more episodes every Friday! 🔗 Connect with us on Apple Podcasts, Spotify, YouTube, and your favorite podcast apps. Keep your hips happy, healthy, and not too obese! 💪🩺
This episode is sponsored by ZimmerBiomet. Visit https://www.zimmerbiomet.com for more information.
Hello, and welcome to another episode of the A HF podcast. I'm your host, Joe Schwab. My guest today is Dr. Robert Shan at the Anderson Orthopedic Clinic, and he's here to give us another cut for time episode. Dr. Shan, welcome to the A HF podcast. Why don't you tell our listeners a little bit about your practice, your training, and what you're gonna talk about today?
Bob Sershon:Yeah, I appreciate it. Thanks for having me on. Um, yeah, so Bob Shan Anderson Clinic, uh, Anderson Clinic trained actually, um, fellowship back in 20 18, 20 19, joined the practice right after that. COVID hit, which was, uh, interesting being first year in practice having that stuff happen. But, uh, it actually was ended up being great for me because a lot of the other places shut down and a bunch of revision volume and all the complex stuff that couldn't wait started to come in right away. So, um. Things, they couldn't wait. They had to go. That was still medically necessary. So it built a pretty quick practice through that. And, uh, over time, you know, when you do enough complex stuff, you kind of get known as the guy in the area that's doing that. So, um, a lot of the, uh, more difficult cases, more complex revisions, seeing things like that started to stroll through. So, um, now, you know, we're, we're. Out in Alexandria, Virginia, uh, really over the, uh, entire Northern Virginia area right outside of DC And, uh, my practice is only hip and knee replacements. Uh, we're very subspecialized at the Anderson Clinic. Basically, all of our partners are fellowship trained one way or the other, and just stick to their subspecialty. So you won't see me doing any ankles or wrists or anything like that. Uh, never did, never will. So, uh, probably terrible of those now. Um, but, uh, yeah. Yeah, that's it. We got great fellowship, do some research, um, you know, real proud of everything the institution's done so far and, you know, good talking about some, uh, big people on big cases.
Joseph M. Schwab:Well, and we had you invited, you came and, and were part of the a HF uh, uh, annual meeting this past year in Nashville, and you are part of the revision session. And we're intending to give this talk, uh, as a part of that session that, uh, session was so, uh, popular and had so much, uh, involvement from, uh, our audience and so much discussion back and forth that we literally lost time for your talk. And so, uh, for better or for worse, you get to be the second in our, uh, cut for time series, uh, here on the a HF podcast, and you're gonna be talking to us about. Uh, doing anterior approach in the super morbidly obese patient. Is that correct?
Bob Sershon:Uh, that's, that's right. And then we got, uh, one more case that just to add on, um, if we have time revision, uh, morbidly obese patient.
Joseph M. Schwab:Let's, uh, let's get to it. The floor is yours.
Bob Sershon:Great. Great. So, um, here we go. These are my disclosures, you know, um, involved with Zimmer Biome and day care, so. High BMI, total hips, we know higher wound complications. It's not just from the front, from the back as well. Higher rates of PJI, higher revision rates. Really just any complication essentially. You name it. We found that it's, it's higher with higher BMI. Um, and then, you know, unfortunately on the flip side, a lot of these patients are doing it to, to lose weight and, you know, they, they really don't afterwards. And, uh, you know. Reasons why, who knows? Lifestyle life choices. It's just been too long for them. Uh, that's something I used to talk to people in clinic about, and Joe, I don't know if, if, if you talk to people in clinic about that afterwards, but, uh, I, I've stopped discouraging, um, them saying, Hey, you're probably not gonna lose weight after this. I give'em a chance. Uh, in my opinion, I Do. You do the same or.
Joseph M. Schwab:Yeah, I, you know, it's, I, the weight discussion's always interesting, but it's, it's not likely that unless they gained a whole bunch of weight in the, you know, two years or so before they, uh, got their hip replacement because their hip was bothering them. It's unlikely they're gonna lose it afterwards, but I, I don't usually mention it. I encourage'em to be as active as they want to be.
Bob Sershon:Yeah. Yeah. And I, and that's the route to go of it. You know, in the back of my mind I just say, all right, we're doing this for pain relief and hopefully better function if the weight comes. That's a huge plus. So. Uh, you know, where that goes, you know, in, in our world unfortunately is, you know, harder surgery, arguably worse outcomes and not necessarily patient reported outcomes, right?'cause they get, they get substantial relief from that aspect, but we're talking complications. Um, and then is it worth the risk? I mean, you have a lot of institutions on bundled programs. Um. Yeah, some people get dinged for having complications at their institutions, readmissions, reoperations. And so some people just won't even take these patients on and they've drawn these hard cutoffs that makes access for them pretty hard. So, uh, we don't have that, uh, at our institution and we, we take all comers and we try to individualize it because the risk is really gonna be shared right between the patient and the surgeon. So, um, it's not our hip that's getting infected, it's, it's their hip and they have to live with that. And that's, that's a tough thing to live with. So. Um, we, we just do shared decision making and, and if we feel like their pain and function are significantly, uh, impacting their life, then we go ahead with the replacement knowing that hey, they, they might have a complication that somewhat of normal weight didn't have. Um, we're just very straightforward about that. So, you know, dealing with this population and preoperative planning is so important. So, um, you have, you know, the exam mobility, I'm not just talking about their mobility walking in the room, I'm talking about the mobility of their panis, right? So you have some people that have a very mobile panis. Um, it, it moves, it gets out of the way easy. Uh, you know, some people you looked underneath. I got a little bit of what we'll call some funky stuff, and that's something that you, you really wanna, you know, uh, pay attention to because you don't want fungal infections and things like that. Those are notoriously hard to treat. So that's someone where you may say, oh man, I actually have to go through the back on this one. Uh, just to avoid any type of local, um, contamination, uh, booty check, right? I, I teller fellows do booty check where, where do they store their fat?'cause some people actually from the front. All their fat is stored posteriorly and, and actually, you know, they may be morbidly obese and have large bellies, but maybe it's mobile. You tape it outta the way. Um, they don't really have much in the way of soft tissue in the front, and it's really not that much more difficult of a case to do so where they store their fat. Really, um, uh, important for, for DA and then leg lengths. You know, I, I tell the, you know, the fellows, Hey, we wanna be close. Like we, we wanna, leg lengths are one of the biggest things for litigation and patient satisfaction. Um, but you know, if you have to give them a few more millimeters of offset or length in order to give yourself a, a stable hip in this population, feel free to plan to do that. Um, in terms of implants. You know, you could use whatever you want. It's dealer's choice. I think all the data at this point though, um, from both anterior posterior is pointing towards these triple tapered stems with a collar, uh, the cup. I like to use a cup that you can get a large head and a smaller cup. So, um, almost every company at this point now, you can get a 36 head or larger to size 50, uh, which is, which is great. Um, some companies are already at a 52, you're starting to get a 40 head in there. Um, that's, that's definitely positive. If you can't, uh, consider dual mobility, maybe this is a population at increased risk or dislocation. Um, whether or not that's also true from the front, that's probably debatable, but, uh, it is something that you want to keep in mind. Uh, constrained line. I mean, I think that's just overkill on a first timer. Um, automated impact or, I, I love using these things, you know, whether you're using. You know, we could do branded by, by company, you know, concise or hammer one of these things. Uh, I think it saves a ton of time. It gives you consistent impacting all the way through for me, it really helps me control the version, uh, of the STEM as it's getting sent on the way down. Um, which is, which is great. Then also your other technology. These are larger people. So you know, if you're doing this off table with no fluoro, I would say that that's a hard task. Um, it's hard to feel their malleoli, everything's draped out. Uh, I, I prefer in, in my practice to use some sort of navigation, um, ai, robotic platform, mixed reality, whatever people want to use. Then have offset ready. And by offset I'm talking offset reamers, offset insertion handles, offset broaches, offset insertion. Anything that you can do to have offset, even the hand table, if you're using a table, uh, you know, they have the standard hook and the high offset hooks. So these are all things that you're gonna wanna have ready, maybe not necessarily used, but at least have ready, um, when you're, when you're planning for the surgery.
Joseph M. Schwab:Do. Any challenges with the, do you see any challenges with the automated impactor in, in these large individuals? I know, uh, or is it, is that just taken care of by the offset, um, you know, broach handles and things like that?
Bob Sershon:I, I only use the, the straight impact, or I, I haven't used the offset. I, I've had it ready in preparation of, Hey, they're just too big. I can't get this out of the way. But I, I've personally not run into the issue. Um, I, I don't know, have, have you.
Joseph M. Schwab:No, I, I mean, I, it's, it's interesting that you mention that, right? Because, um, you know, originally when I first started, uh, well over a decade ago. I, I think I was using offset on everybody just'cause I thought that was, would be easier. And I've gotten to the point where I just, I rarely use offset even in the more obese, uh, patients. And, uh, with something as big as a, as some of these automated impactors are, it seems to be far enough away from the patient, even in obese situations that it hasn't, I haven't noticed it being problematic.
Bob Sershon:Yeah, I'm, I'm right with you on that. I think they do have offset. Articulations or handles that you could pop in there if you need. Um, but I do wonder how much power is, is lost through that. Um, but, uh, may, maybe I'll give it a whirl one day, but, but for now, I just haven't needed it. So, um, so here we go. You know, 55-year-old female coming in, BMI 55. Uh, she traveled two hours for surgery because nobody locally was able to take care of her, whether or not it was from cutoffs or they just couldn't handle the case. It, you know, that's debatable problem's been going on for years. Um, you know, really these, this pa this population usually comes to you trying extensive non-operative treatment. Um, most of these patients, at least that I've seen it. Has some type of intraarticular steroid injection, which, which for me is really just diagnostic is, is it really coming from their hip? Um, especially when they don't have, you know, severe erosive bone, bone arthritis, like I'll show you on the next case. Um, so, and we do all that planning and here we go. So here's, here's the, uh. Intraoperative views. I'm trying to give you all of the same patient here so that we can see. But you know, even with her on the table, she has such a large panis that it is completely over the operative site, even with Lang supine. Um, the uh. The center, you know, leg holder there if you will, um, between the legs you could barely see. It's kind of poking its way out. But she's one of these people that has a large mobile panis. Um, and so you would say, Hey, this actually isn't that terribly difficult of a case once you take the outta the way and you let the fat fall posteriorly as well as you could see. I mean, it's hanging down there pretty low. Um. Pre-op fluoro views are, you know, you just wanna match exactly what you got. Pre-op uh, there's, there's been debate back and forth about standing versus supine views and, you know, functional range of motion and all of these, all, all of these other factors. What, what we found at our institution. We tried doing standing views for a while. Um. With patients like, like this, they're morbidly obese. You, the pan is hanging so low that you have a really hard time, at least we did getting quality x-rays and then reproducing their standing film supine. You were doing all these crazy things with fluoro. Um, so we actually. After trying standing, went back to supine films on everyone. All of our surgeons, uh, at the clinic, for the most part, they're, uh, are doing da and that's how we positioned during surgery. Um, so, so we've continued getting, getting supine and just matching supine. And, uh, you know, fortunately on our dislocation side, I mean our rate at the institution for anterior is, you know, like 0.3 some something below a half percent. Are you doing anything different? Are you getting standing films or?
Joseph M. Schwab:No, in my practice it's supine. Um, I, you know, I'm, uh, a bit of a, a Joel Matta disciple on this. You know, he always teaches the frontal plane of the body is what's most important. You know, the, the position. Uh, supine versus standing is less important than the position of the frontal plane of the body with the pelvis in the position that you're operating in, so usually supine. Um,
Bob Sershon:so we're on the
Joseph M. Schwab:yeah, I mean it's, we're, we're, we're talking probably like you described, you know, less than hundredths of tenths of a percent difference probably in our dislocation rates based on that. So, who knows?
Bob Sershon:Yeah. So, um, but it's important to get, you know, to, to really match these shots and, and, um, if you're not using, uh, navigation or something like that, it's hard to get the C-arm unless you have one of those large, you know, 12 inch or or larger square, uh, c-arm that I've seen. Um, it's hard to get the entire pelvis in there, and then there's a lot of parallax. So, uh, that's, that's a challenge if you're not using something where you can do an overlay. Um. So now you got everything draped out. We do that normally. And then, you know, from the bikini standpoint, the way that I like to do it, and, and there's not too many variations of this'cause it, it's not a very forgiving incision if you're not in the right spot. Um, so I'll, I'll put my, my pinky finger right on the a SIS and then go three finger breaths distal. Uh, and that's been the most reproducible way for me. I mean, some people just, you know, put their ring finger, um, right below a SIS, but, uh, that that's how I do it. And. Most patients, I mean, the incisions a little bit smaller probably than 10 centimeters. But on these larger patients, I give a larger incision. Uh, it's you, you just have to, for visualization purposes, in my opinion. Um, I tend to not travel medially to the A SIS, although I would tell you in a large patient where you have a really thick subcutaneous fat layer, you're probably safe to do that. Without, you know, being at risk of getting into any of the vessels or anything like that. So let me get to the next one. So the approach is pretty standard. Once you get through the skin, right, you get down to the fascia, you find your A SIS, that's gonna be your lighthouse. It's gonna tell you, Hey, this is where I know I'm at. It's a reproducible landmark. And so for anyone taking these cases on for the first time, I would say, Hey, make your incision. Feel a SIS know where you are in terms of space and then get into your capsule, or sorry, into your fashion work your way down to capsule from there, uh, once you get down into the hip, I, I like to use an inferior tag stitch on the inferior LA image. It just helps get the capsule out of the way. Uh, some people don't do that. Some people do a complete capsulotomy or a capsulectomy, I should say. That's probably dealer's choice. Are, are you doing anything different on that in terms of the, the, uh, capsule.
Joseph M. Schwab:No caps. Capsular management for me is, is a, a stitch on, on both flaps and I, I do a capsulotomy and I, I use those as retractors basically.
Bob Sershon:Exactly. Yep. I mean, it's, it's really nice to use his retractors and it, it really helps stay outta the way, especially with a bikini, you're not mastering the middle of the incision. Um.
Joseph M. Schwab:Right. I.
Bob Sershon:Uh, on these large patients, I, I almost never use fluoro to identify the saddle or what I wanna make my neck cut. Uh, but on these, if I'm not sure, bring in fluoro, um, it, it is such a useful tool for anterior, especially in, in a learning curve or your, your fresh out of fellowship or something like that. Um, and if it's a big stiff hip, like this lady was very mobile, um, but if it's a big stiff hip, uh, make a napkin ring. Like make it easy on yourself to get that head out. Uh, and early on, I, I did that on every case. And then as I got more comfortable and just more confident with doing things, I, I, I moved away from it. But I don't think you're ever really wrong to do that.
Joseph M. Schwab:Are you normally just doing a single cut on your, on your standard primaries?
Bob Sershon:Normally, yes. Um, and that's stem. Yeah. We can go back to that. I mean, that's, uh, STEM dependent as well, right? So. Some of, some of these implants have a little bit of a longer neck built in, uh, naturally. Uh, like if we're gonna compare vendors, like I, I would say that, you know, I feel that, you know, the Z one has a little bit of a longer neck than Actis. If you're looking at triple taper stems, those are the two that I used here. So, you know, I might cheat a little lower if I use Zimmer or if I, you know, I have to use the pew, I might go a little bit higher with a net cut. Um, but it, that's, that's again, deal dealer's choice. No right or wrong there. So with reaming, I, I still, even in these large patients, ream with a straight reamer, um, I haven't used, uh, at least that I can remember. Maybe I have, but I, I don't recall using the offset reamer, even though I have it available all the time.'cause you just don't wanna get in a situation where they have such large anterior subcutaneous fat on their thigh that it's. Pushing you completely inverted and vertical, um, which is the tendency, uh, on these patients when you're reaming. So, uh, do, do you switch over in the larger patients to offset, or do you use offset all the time, or you said you
Joseph M. Schwab:No, generally. Generally straight reamer. Yeah, generally straight reamer. Mm-hmm.
Bob Sershon:Yeah, it's, it's amazing. I mean, just'cause it's hemispherical, I mean, you, you get a great ream. Um, I think you just on these patients especially need to be careful about not reaming out the anterior wall because that fat is gonna wanna push you anterior. Um, it'll also want to have, you have a tendency to raise the, uh, the center of the cup as well. So, um, I'm, when I'm reaming I'm kind of pushing down in posterior to, uh, to keep the hip center lower as or as low as we reasonably can and to not ream out the anterior wall.'cause I do it under direct visualization. So this picture here is with the lights off the wound, no headlight on, and you could still see in the wounds. Then you could imagine, turn your headlight on, put the, or the operative field lights pointing back in the wound. Um, and you get actually a, a very reasonable view here. Uh, I like to, when I'm reaming, uh, under visualization take out, uh, so if we're gonna say that towards the head is 12 o'clock, I'll usually have, uh, like a pointed cobra. I call it the medium, um, right down near the TAL. And I'll take that out because that tends to get in the way of the reamer for me. And I'll just have that shorty that pointed shorty retractor that you could see, um, right over the anterior brim there. And then something posteriorly to help me from catching all the fat and tissue as I'm getting in and out of the wound. Um, so you know, then when you send your, you know, your reamer down, you could use fluoros. I'm bringing Fluor up here to show you. Just the AP pelvis that I always get to make sure that I have symmetric obterator and that I'm not in a inlet or outlet view. I'm matching their, their ap, that we got supine beforehand in these larger patients. But if you're not sure how medial you've reamed or you want to get more medial, you're not sure of your cup size. Bring in fluoro ream under fluoro if you don't usually do that, I mean, a lot of guys, you know, especially, you know, really high volume guys can ream under fluoro really well, um, without reaming out the walls. Um, do you ream under fluoro or are you a direct visualization guy?
Joseph M. Schwab:No, I'm a, I'm a ream under fluoro guy, uh, with a, with a direct visualization double check. I would say less than half the time, but, but yeah. Uh, um, it's, uh, the, it's one of the benefits that you mentioned, and I, I think this is true even in, in straightforward patients. But in difficult patients, if you're ever not sure what's going on. Uh, or you want to double check, bring fluoro in. It's just super easy. Right? And, and it's, whether it's with your cup or with your stem, or with your approach, uh, with your, your cuts. Yeah. Just bring fluoro in.
Bob Sershon:Yeah. And the, and the feel on these patients is admittedly not as good in terms of how you feel the reamer catching and engaging. Uh, so what, what I'll do is I'll, you know, on all the cases we just measure the head we go up. It's just like, let's say we measured a 51 millimeter head. I'd start at a 51, uh, reamer and, and probably get up to a 53. Um. On these patients. Some people they like to ream very small to medial eyes and then get bigger and bigger and bigger. I think that's probably a little bit more dangerous under direct visualization'cause you can't really see that you're, you're centered and not ec eccentrically reaming. Um, so I, I would say if you normally start small and go up, my preference for this case specifically would be, Hey, change it up a little bit. Start with a reamer that really fills the acetabulum early on. And media lies from there. Um, and then you have your offset, and again, navigation or, you know, mixed reality. What whatever you want to use is great for there. So you get your cup in. I always have my templates up. I am crippled if I don't have templates. I, I mean, I. I rely on it for everything. Um, just as a double check and, you know, how medial should I go, how many yield do I wanna go? And these larger patients, um, I will personally have, you know, less of a, uh, hesitation to leave their cup of hair more lateral just to help with a little bit of offset. Um, if I don't wanna lengthen them and maybe I want to add a couple millimeters of offset for. Attention purposes. Um, but, but here, you know, we, we matched it, you know, fairly close, uh, to our clan. The cups probably the sides are too bigger than what we templated, but in these larger patients, depending on where they put the calibration marker, uh, you could, you could be way off. Um, so, so just be aware of that as well. This is where I think the, other than the wound healing being. Being better. Um, this is where I think Bikini really helps with large patients and very muscular patients. Uh, you know, to cook convinced me to switch over to this, uh, maybe a year or two ago, I can't remember. But, um, he said, Bob, one of the craziest things is that the femoral prep is easier and I, it, it just, it never made sense to me. I said, I have a horizontal incision that's limiting how proximal I get. How can the femur. Easier. And it is, and I, I think a lot of it is because of that medial Mueller that I have there, the white handle, uh, on the, on the image, it allows you to, to pull a little bit more medial and present the femur laterally, which is probably the more limiting factor with getting femoral exposure to these large patients. Um, so I, I find the femur on these patients to actually not be very challenging at all. Um. Not, I shouldn't say at all to not be as, as, as challenging, uh, than, than with a standard incision. Um, I use all my standard retractors, uh, standard sequential releases, you know, capsule and a still type, you know, piriform ish or external rotators, kind of the normal trajectory. All of us. Uh, follow. Um. And then one of the, you know, the big helps here is I, I usually just do these cases. Um, like if the fellow's not in the room, just with my pa she's on the other side of the table. And, um, if you're alone in doing these cases, like the fellow's not there, in my case, just have your tech come and give a little hip check to add up to the hip a little bit. Um, you know, right at the distal thigh that goes. That is just so helpful for, for bringing the femur, um, into a more, you know, I guess distally, abduct, a deducted and approximately abducted, uh, space. So, um, then you, you know, you get everything in and you go to closure and what's amazing. That I noticed early on is once you take the retractors out, that the picture to the left here, maybe, hopefully my mouse is working. That's nothing. We haven't put anything in there yet. It, it just, it closes on itself.
Joseph M. Schwab:Yeah.
Bob Sershon:Yeah. And it's just amazing in these larger patients, it's a long, you know, it's along the lines of tension. It just closes on itself. So then, you know, here's, you know, our running four oh closure. Um, and then we'll put on usually either a, you know, silver impregnate dressing or a just a tepa tegaderm. Uh, if we're not really worried in patients with a really large panis, I like to put something on that's just gonna be. Super watertight and I could leave on for two weeks at a time. Um, I'll give them another one of these dressings here and tell'em, Hey, in two weeks when you, or 10 days when you take that off, slap another one on, um, just to keep any of the, the, the bacterial burden underneath the panis, away from that wound. Um, what are you doing for your, for your dressings in these patients?
Joseph M. Schwab:So exactly the same. Um, you know, the question that I was gonna ask is some people talk about doing things like vacuum assisted, uh, dressings, you know, vac dressings over the top ones that people can go home with. Uh, some people, um, some surgeons that I've talked to will put, um. Essentially a, a, a large, almost kind of diaper in the area over the, uh, over the dressing itself to just act as a barrier and, and act as, you know, to prevent, um, any friction maybe from, uh, moving the dressing or curling up the dressing or anything like that. What I was gonna ask is, do you let them shower with this? Yep.
Bob Sershon:Yeah, right off the bat. Um, are you keeping them from doing that or
Joseph M. Schwab:Not at all. I, I encourage him to shower.
Bob Sershon:Yeah, the, the VAC dressings, um, you know, there's reasonable data that is showing that, that it helps in these higher risk wounds. So, I, I, I can't argue too much against it. I just, in my population, for whatever reason, um, it almost promoted drainage. And I, I, I don't, I don't, I can't explain it. That's just my experience. I'm not gonna poo the wound vax. So, um, so that's, that's one. The other thing is, you know, the VAX would malfunction and they'd be beeping and we'd get a bunch of calls from patients. So we, we kind of moved away from that. What I used to do on these patients, which is kind of cruel, is I'd put'em in a pelvic girdle
Joseph M. Schwab:Oh
Bob Sershon:uh. Yeah. Yeah. I, I like a, almost a corset.
Joseph M. Schwab:Yeah.
Bob Sershon:it, I, that's when I was doing a standard incision. I'll tell you what, it, it worked, but they, they didn't like me for it.
Joseph M. Schwab:to, to minimize swelling, basically. Minimize any sort
Bob Sershon:well, to hold the panis up
Joseph M. Schwab:oh. Okay.
Bob Sershon:to like, to, you know, like you, you see those cartoons where, you know, you got this spat guy and you know, this like good looking woman walks by and he puts the girdle on her and he makes his chest bluff up. It's like, that's. That's kind of what we were doing. And, uh, I, I just, it was, I found it. I, I don't know. Patients didn't love it. We'll put it that way.
Joseph M. Schwab:you're, you're not using any skin glue on this. It doesn't look like Right. It's just the Monocryl and then dressing.
Bob Sershon:Uh, no. We, we did, um, use derma bond.
Joseph M. Schwab:Okay.
Bob Sershon:We put derma bond on all of it. Yeah.
Joseph M. Schwab:Okay. All right.
Bob Sershon:Fortunately, haven't had any. On the bikinis, uh, and the large patients. I haven't had any of those adhesive reactions. I, I do worry about that. Um. So if people just wanna do the silver impregnated, they're, they're fine to do that. Um, but this is, this is her four week follow up, right? So, um, incisions healing. Well, you know, she's, she's doing well. She was really deconditioned before this, so, um, you know, she's, she's still getting around with a cane and things like that. But just'cause she's gassed and, uh, no hip pain, right? I mean, doing really well. Super thankful. Um, and that's, you know. That's how you get through it. Then you get, you know, cases like this. Um, and this, this poor woman, I mean, you know, she's 50, you know, 52, um, horrific hip. That clearly has been a problem for a long time. And, uh, I, I said, when did you first. Try to get a hip replacement. Like, how long have you been living like this?'cause she, she came in in a wheelchair and, uh, oh. For a decade. You know, no one would touch me for a decade. Yeah. Um. Just'cause she, they kept telling her, you're too young, or You're too heavy, you're too young, you're too heavy. And, uh, and just a total shame and lost like prime decade of her life to this. Uh, but these are really tough cases because the joint, you could see, I, I should have taken the templates off here, but, uh, the, the joints almost auto fused. Um. Really no range of motion. When she tries to stand up to walk, she's leaning forward like 30, 40 degrees.'cause she's got such a terrible flexion contracture and now her back's affected. And, um, you know, and then she had one of these not super mobile panes to go on top of it. Um, which, you know, just, just that makes it so, so much more difficult, um, in, in any situation. So for her. You know, we just did much of the same. So, so this is just showing here. Okay. You get him on your back, you, you try to reproduce as best he can. The, the AP view. Um, and she started, which I wanna show you, and I'm curious of your thoughts on this. You know, she started over an inch short and, uh, I mean, what, what's your threshold here for, for lengthening when it's been about a decade with a hip? Probably not this bad, but definitely shortening.
Joseph M. Schwab:Yeah, boy, it, it depends on a number of factors, but if this was a a true, if this was a pediatric situation, I, I would probably aim to make up only about a half to two thirds of it. But if it's been over the last 10 years and she had, or you feel confident she had sort of a demonstrably normal hip before that, I, I think this is one that you could probably get all the way back. Um. And obviously, I mean, it looks to me like she's in fixed external rotation too, right? So, yes. So that can. I, I have found that that can, um, affect a little bit the measurement of, uh, of leg length, at least with the, the line, uh, you know, using lines, um, just because you're, you're catching a different, uh, profile of the lesser tro canner, um, you know, depending on what, uh, what landmarks you're using. So this is one I would say I'm prepared to make her even. I'm prepared to not make her exactly even, but to give her back at least two thirds. Um, but I'm prepared to use a lot of fluoroscopy and any tools that I can get, um, to, to help me understand exactly how much length I've given her back.
Bob Sershon:Yeah. Yeah. And that's, and this also, you know, the, the external rotation, uh, really screws up any ability to measure offset. Um, which, so you, you. You go, okay, let's get her close to the other side. At least you got a fairly normal, uh, left side hip here. So, um, yeah, so that was our goal was to make up as, as much of it as we could, so long as soft tissue tension, um, allows, because what I don't like doing, uh, having, having done it once or twice is the hip's hard to reduce, and you pull manual traction and then you lock it and you do one or two clicks of fine traction. You push the hip in. That's just that, that's too tight. Like, like I, I, I probably in my mind, shouldn't have done that, uh, trying to chase leg lanes on people. Um, so now I just, I go until it's a little bit difficult to reduce and I, I leave it there. Um, but whatever they get is what I get. So. So here you go on those, this is one of those, you know, fluoroscopy showing you getting down there, um, you know, trying to Alize and, and this was a patient where, and maybe these are a little bit different fluoroscopic views from bringing the fluoro in and out. But I, I brought this up because I specifically remember on this patient just wailing as hard as I could to get that cup seated. And taking it out reaming, taking it out, reaming, and it just kept sticking. Um, so I probably, I feel like you can't see the airball here, you know, but I feel like that cup should have been, you know, two, three millimeters. Even more medial based on the fluoro shot. And maybe it's some optics playing into here with different fluoro shots, but, um, that's something that you gotta pay attention to as well. There's nothing behind the cup, there's nothing stuck. But I felt that I was just getting such a good press fit here, um, that I, I was comfortable leaving it not, not putting any screws. Is that
Joseph M. Schwab:line to line or do you ream? Uh, one under two under.
Bob Sershon:one, one under every, every time. Yeah. Yeah.
Joseph M. Schwab:as far as the, the, the surface of your, uh, acetabular component, high friction acetabular component. Like a, a grip or a a, a TM or something like that. Something high friction.
Bob Sershon:PPS.
Joseph M. Schwab:PPS.
Bob Sershon:Yeah. Yeah. So, um, and again, I could have one line to line on this and, uh, you know, really. Uh, you know, went to town, hitting it down. But once you get the bite, and I feel you're shaking the whole pelvis on this large patient and the cup's not moving, all right. Like, you, you, you're done. Stop, stop wasting time. Like, get out of there. Um, so, you know, and then these are her.
Joseph M. Schwab:is better, right?
Bob Sershon:exactly. Um, and then you could see here, like I, I still, I bring this up'cause I still don't see. A big radiolucent line around the cup here. I mean, I see one in zone two. Um, but, but you know, not down here. So I don't know, maybe it was floral playing tricks on me, but, uh, uh, but, but, but the point, the point is here is, you know, she, this lady crippled, I mean, totally crippled for, uh, better part of a decade. No one will touch her. You come, you do all the steps I showed you on the prior one, um, and then, you know, four weeks out you get a completely different looking x-ray and they're so thankful and grateful for it. Um. But to your point earlier, I made up about two thirds of this. Um, she's still got a little bit more external rotation, as you could see compared to her, her other side, uh, and clinically was a little bit short still, so she might need a lift, but I could not, that's the longest ball I could get on there. Um, I I, I probably could have done the trick where you pull the manual, lock it, do a couple clicks of fine and gotten one more ball. Uh, but at that point. Not, not worth it. Not worth it in my opinion, so,
Joseph M. Schwab:Interesting. Yeah. This, this is one where rather than doing more, um, a lift is probably gonna be. Uh, reasonable for you and she might not even notice the difference. I don't know. How far out has she noticed?
Bob Sershon:she didn't notice at all.
Joseph M. Schwab:Yeah,
Bob Sershon:Like by we, we saw her back at four weeks. I asked my pa, um, who sees all my four weeks, I said, and I said, Annie, did she noticed that? She goes, oh my God, no. She's just happy she could walk,
Joseph M. Schwab:I was about to say, especially if she was in a wheelchair for that long. It's, those are, those are folks who don't notice leg length discrepancies that much.
Bob Sershon:Yeah. And I don't know if she came in on a walker or cane. I can't, I, I, I should have looked at that. Um, but it was like a substantial over four weeks already, um, increase in, in quality of life there. So,
Joseph M. Schwab:That's, that's amazing. That's great.
Bob Sershon:yep. Yeah. So, uh, so that's, that's the bikini there. And we didn't do anything special. Just, you know, a, well, a ael and. Dermabond seen his last case. So, um, if we got time, this is the, you
Joseph M. Schwab:We got time for this for sure.
Bob Sershon:yeah.
Joseph M. Schwab:Another standard primary.
Bob Sershon:Yeah. Yeah. This is one of the cases that, uh, I was gonna present there, um, at, at a HF, um, which, you know, the, the time thing, I totally understood that. I mean, you've got, you know, Aldo and your acid medias up there given like a. Unbelievable, you know, chorus, and I'm sitting there going, I, these guys are, are just animals. Totally unreal at what they're doing. Um, so I just, you know, I, I could tackle this stuff, but they're just total wizards. It, it, it's just incredible. So, um, but uh, yeah, so, so this lady, uh, she had DDH, uh, had a primary hip done in Puerto Rico. 20 ish years earlier was sub Yeah. Subsequently revised, uh, about a decade before this. To a, um, uh, for, for acetabular loosening. Uh, it was one of the implants where the, the back coating had come apart and, uh, clearly had a loose cup and then, you know, had a, a revision and then that came loose and was repeat revision. Um, which in those settings, I'm always worried about some subclinical infection, uh, versus. Metabolic disease, like do they have p acnes or, um, pseudomonas? Do they have some like slow growing indolent bug in there? Uh, so anyway. She had a revision. Um, that, that actually I did. Okay. So I brought this up. This was my, my public shaming for myself. Um, and, uh, so we, we did this. I got. Great fixation, like one of those hips where you're going, I don't even really need to put screws in here, but I'm going to'cause it's a revision. So, you know, I don't follow the principles that, you know, I, you know, kind of always tell my fellows of, you know, you want inferior fixation, superior fixation. So she, she, you know, goes and has one of, not a fall, but what I think is worse than a fall, which is one of these like hard stumbles where they plant really hard, um. And felt like immediate pain. Uh, went to the er, got x-ray, ct, um, you know, didn't, didn't show anything, and then literally walks into the four week visit like this on a cane.
Joseph M. Schwab:Wow.
Bob Sershon:and we're going, what happened? Like how, how did we go from like very robust, great fixation to this hard stumble? And then so, you know, really she had no pain. She was probably doing a little bit too much and, you know, fell, stumbled, caused, you know, what I thought was an acute discontinuity, but it was really just a fracture through the anterior column. And, um, and, and here we are now, right? So. You've got, uh, you know this lady. BMI 40, multiple prior surgeries, complete absence of the anterior column, cups in the pelvis, tenting the vessels, um, and, and that, and this has all been done anterior, by the way, the most recent surgery. So, so now here you are four weeks out. I mean. Your decision is go back in through that, which of course we did. Um, or, you know, if you're not comfortable with it, go through the back, through her prior incisions. So, you know, the, the planning on this one. Um, and these, these are all the, you know, the pearls. And this is from her case actually. I, I said let's, let's, you know, take some pictures and show people this, this complex reconstruction. So. Um, so, you know, the pearls, I, you just do your normal incision. I, I usually go two finger breaths, ladder lateral to the a SIS, even even in the obese. Um, and then you want to just extend that. So if the A SIS is right here labeled, you know, you could see I came pretty far proximal right along the crest right there. Uh, and right off the bat on these cases, I'll, I'll go ahead and, and find TFL. You know, small cuff, you could probably see about a centimeter of a cup of tissue there. Um, that, that, I'll leave, I'll peel it off, off the outer column right away. Um, I don't know if, if, if you go to it right away or if you wait, I mean, what's your preference on these?
Joseph M. Schwab:So, um, definitely right away if I'm planning on doing significant, uh, femoral work, I feel like the TFL uh, peeling that off gives you a better, uh, femoral mobility. Um, but, uh, for a large up and in like this, I would say I might wait and, um, but chances are pretty good that you're gonna do some sort of. Ensile, uh, maneuver in order to to, to get good access for what you want to do.
Bob Sershon:Yep. Yeah. Um, and I knew I was gonna do a cage on it. So for me, just right off the bat, I mean, to enhance femoral. Mobilization, um, as well, just to get it outta the way. Let that femur fall. Posteriorly, uh, that really helped. I mean, I didn't even need a posterior retractor for the case. The femur was just floating out of the way. It was, it was beautiful. Um, and then, you know, so, so you elevate, you know, indirect erectus, do all your capsular releases. I mean, she had already had all this done. Um. Posterior pocket for the ion if you need it. So let's say you're going in the first time, you can peel off some of that posterior scar tissue, posterior capsule to allow the ion to kind of tuck back behind the posterior, um, acetabulum. Um, what I'll normally do then, so I do all this before I even. Dislocate the hip. Uh, I like to knock the head off into the cup. I mean, there's a million different ways to skin the cat, but, you know, two, three clicks of fine traction normally is enough, and you could just hit that thing off into the cup, pull it out, you know, right away. Um, what I don't do until after I've done that the majority of the time is in, uh, is released the inferior capsule, um, you know, pubic, femoral, whatever you wanna call it. It, it just, because I, I don't know how mobile the femurs gonna be till I try to tuck it back behind the posterior acetabulum. And, uh, I've had some cases where I haven't had to release any of it and I've had others where I can't even get the trion, um, outta the socket because it's so tight inferiorly. And that is just such a great trick, um, that you know. Nobody showed me, right? I mean, I just started doing these on my own. Um, these like bigger anterior revisions. So, uh, you know, that, that's one thing that I tell everyone. If you're gonna do that, maybe wait until you knock the head off and you're trying to get the truing outta the way just to see what kind of room do you need. Um. And, uh, you know, of course, uh, you know, fluoro is your, is is your tool, uh, throughout all of this. If you're lost, you need to know your landmarks. Where, where am I in a revision setting? Not a common question you get from the fellows. Um, and, uh, you know, one of the actually great articles that I found, um, this is probably just from a couple years ago. It was, you know, from the guys outta Utah, you know, Lucas, uh, Jeremy, those guys out there just goes over. This exact technique. Uh, they've got pictures like this, uh, in the article. It, it is super helpful. I, I gave this to our fellows. Um, I think I found this be like right before the case. Uh, and even I got a couple pearls out of it. So it was, it was super helpful. It was this half cup cage construct from the front. Um. So anyway, we, we get in there, we do that, you know, we do that exposure that I showed you. Um, getting that cup out of the pelvis can be a challenge. Um, this is one where, you know, you could have vascular on standby, uh, and maybe that's not a bad idea. Uh, you could get a CT Angio two if you, you know, you really think that that's acutely up and in there. Maybe you got the vessels. Um, and you know, for your reconstruction, even though it's a bigger patient, I think the principles all were remain the same. You know, again, anile exposure so that you could really see the inferior part of the acetabulum come all the way up over your, over your anterior acetabulum. I mean, she had nothing there, so there was really nothing to release. Um, and, and do your reconstruction that way. And you know, this time, you know, we got a couple screws. You know, in inferiorly, whether or not that would've saved her the first time. I don't, I don't know. I mean, it, it seemed like she just had a, basically a pelvic fracture that knocked the whole construct loose. But, um, and then after you get this in, I actually really like using fluoro, uh, for like a, even a trial cage to see where the trial's gonna sit. Um, and the other nice part about a cage, at least for me in this situation, is it can distalize. Your joint line. Right. So, um, that allowed me to actually put a full cup in here, distalize it. I think I got a 40 head in her. Um, and, and it, it ended up working out, you know, pretty well. I think this is her x-ray, uh, over a year out at this point.
Joseph M. Schwab:Very nice.
Bob Sershon:Right. Yeah. And, and this is, she actually lost a ton of weight. I, I saw her, it was like, I know you, but, uh, like, you know, I, I know you, but if, if, if I, if I hadn't, you know, she, she lost like, she's like BMI of 30 or like close to 30. So she's one of these patients that actually. You know, it became way more active and, and made healthier and, and lost weight. You know, it was just kind of a, a, you know, kind of an inspirational story for, for others that are in her situation. Um, and yeah, I mean,
Joseph M. Schwab:nothing to do with the stem on that one, right? You, you were able to maintain the original stem.
Bob Sershon:Yeah. Well, thank God, you know, that that adds,
Joseph M. Schwab:Um, did you have to go up and into the inner table of the pelvis at all? Were you up and into the inner table or were you not?
Bob Sershon:I didn't need to. Um, I mean, this is a, this is a good case though. If you don't wanna use a cup cage, uh, you, you can go in the inner table, put an augment there. Uh, I mean, that's probably what, I don't wanna speak for him, but I mean, that's probably what Aldo would've done, um, you know, running this, run this by him. What, what, what would you have done with, uh, you know, this big old defect?
Joseph M. Schwab:I mean, I, I think it's, uh, I, I, so I think a cup cage, you know, potentially, uh, if you're, if you have the opportunity to plan for it, like a custom tri flange would also be a possibility. But since this kind of happened acutely, you want to get in there as quickly as possible. And, and maybe you don't have the time to have something custom made. But I, I think this is a great application, um, of a cup cage, uh, and clearly. You know, at being a year out and seeing her post-op films, that's what she needed. Right. Uh, I mean, that worked out really, really well.
Bob Sershon:Yeah. Yep. Um, so, you know, she's, she's doing fine now. No worse for the wear and, and hopefully this construct, you know, I always worry about, you know, Mayo's got good data on cementing cups. Um. Uh, in, into revision constructs. Uh, but I, I worry long term. I mean, she's, I think I said she's in her fifties. You know, how, how long does that cemented cup really, uh, really last? Um, I don't know. I, I, I'm assuming at some point she'll, she'll knock it loose. Uh, but that's hopefully not a horrific revision because now you've got ingrowth of your, you know, your, um, porous metal shell and your, your cage isn't going anywhere. So.
Joseph M. Schwab:I mean, if she just needs another cup cemented in, that's not the end of the world. Um,
Bob Sershon:That's a win. That's a win.
Joseph M. Schwab:that is a win. And this, so her original, um, I'm gonna come back to just us, but her original, um, revision surgery done by you, that was an anterior approach, but that was a traditional. Incision that you used, right? For that, uh, for that revision. And you chose to do that for her revision specifically.
Bob Sershon:yes. I tried to do all of my, um, revision acetabular work from the front. Uh, I just, I, I feel at this point it's easier for me. Um, the, the femur falls out of the way. You get a great view of everything. Um, you can use fluoro, which is a huge, huge plus compared from the back where you're taking plain films. Um. Uh, yeah, I mean, I, I, I, I pretty much do it. All the exceptions are. Like, let's say it's a headliner exchange on someone that's had a prior posterior, they've got a ton of aversion built into their cup, their STEM's a little bit verted. I start going, Hmm, I mean, our data, you know, bill Hamilton and our institution published saying that, that the dislocation rate's about the same regardless of approach after a headliner. So those are ones where I'll still go through the back, but anything where I'm swapping out parts at this point, I, I really try to go through the front for everything.
Joseph M. Schwab:And as far as using the traditional incision for that original, um, uh, revision as opposed to a bikini incision, do you ever use the bikini incision for revision? If you're just focusing on acetabular work, does that dissuade you from that? Wh where, what are your thoughts there?
Bob Sershon:I, this specific case basically made me say I'm probably not doing bikinis from the front for on a revision. Right. I, I don't. I don't foresee a scenario where I would've been happy with myself. Uh, haven't done that through the front, even though I thought her first case was a pretty straightforward revision. It's just, you know, things, things happen. Um, so
Joseph M. Schwab:She's definitely made it a lot farther on this second revision than she did on the first revision, it sounds like. So the, the proof is in the pudding. That's great. Um, well Bob, hey. Thank you so much. So first of all, uh, uh, thanks for being a good sport and, uh, coming and joining us at the a HF annual meeting. And thanks for being an even better sport and coming and giving your talk. Hopefully we gave it the, the time and attention to do it justice. And, and I think what I would impart to our listeners is that if they've got, um, super obese, morbidly obese patients, they should be sending'em to you at the Anderson clinic. Isn't that, that's that.
Bob Sershon:Yeah. Yeah.
Joseph M. Schwab:No. But hopeful. Yeah, hopefully they walk away from this with, uh, uh, an understanding of what's possible and, um, and, you know, hopefully, um, if they have any questions about, uh, your thoughts on a patient and what might be reasonable, uh, that they could reach out to you and. And that's one of the things we encourage as part of the Anterior Hip Foundation is sort of that, uh, collegiality in, in answering questions. I'm sure, uh, I'm sure pa uh, uh, providers out there watching or, or listening to this would appreciate that
Bob Sershon:Oh yeah. I mean that, that's one of the awesome things that I found at the meeting. I've already abused that privilege on multiple guys, Laura, at the meeting. So, um, it's, it's great.
Joseph M. Schwab:It was great to have you as part of the meeting. It's great to have you as, uh, a guest on the A HF podcast and, uh, thank you very much for your presentation today. Super impressive stuff and I look forward to seeing more from you in the future.
Bob Sershon:Thank you. Appreciate it.
Joseph M. Schwab:Well, thank you for joining me for this episode of the A HF podcast. As always, please take a moment to like and subscribe so we can keep the lights on. And keep sharing great content just like this. Please also drop any topic ideas or feedback 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. episodes of the A HF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and not too obese.
