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2025 Great Debates: Obesity does not need to be optimized prior to Anterior Approach

• Anterior Hip Foundation • Season 2 • Episode 25

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Great Debate: Obesity does not need to be optimized prior to Anterior Approach 🚶‍♂️🦿🩺


Welcome to the AHF podcast! In this episode, host Joe Schwab brings us an engaging and humorous debate on a pivotal question: 'Do we really need to optimize obesity before an anterior hip replacement?' Dr. Nicholas Webber and Dr. Todd Kelley go head-to-head, using props and personal anecdotes to present their cases. Dr. Webber argues against the necessity of optimization, citing his experience with anterior approaches, while Dr. Kelley counters with the merits of patient participation in their own optimization. Tune in for a lively discussion filled with insights, laughter, and a live demonstration. Don't forget to like, subscribe, and share! #AHFPodcast #GreatDebates #AnteriorHipFoundation

Joseph M. Schwab:

Hi, this is Joe Schwab and if you recognize my voice, it's probably because you've heard another episode of the AHF podcast, which means you're listening again, and I can't tell you how much I appreciate that. And because you're listening, again, I want to ask you a favor, if you could share this podcast with a colleague or a friend or somebody you think might be interested in this type of content. Or better yet, leave us a review on your podcast platform or give us five stars, or you could do all of those things. We really appreciate it and it helps us grow. Anyway, thank you so much for being a listener and a subscriber to the AHF podcast. Now let's get on with the show.

Welcome to the AHF podcast. I'm your host, Joe Schwab. I've said it before and I'll say it again. One of the reasons we host these great debates is because surgeons are at their best when they disagree passionately. I. At their funniest when props start coming out during the opening statement. Today's topic is one of those questions every hip surgeon wrestles with, do we really need to optimize obesity? Before an anterior hip replacement, the pro position is Dr. Nicholas Webber, a tumor surgeon, an anterior approach convert, and a self-described quote."immensivist" and apparently proud owner of an alpaca named after me. I didn't know this before the debate, and I'm still kind of processing that. Opposing him is Dr. Todd Kelley, who heard no slides and decided that meant yes, props, including but not limited to pants, coins, a fake pannus, and a demonstration that I think will live in AHF history. If you've ever wondered what happens when serious surgical philosophy meets a kindergarten pep talk about doing hard things. This debate is your answer. Let's get into it.

Joseph M. Schwab:

I'd like to call to the stage Dr. Nicholas Webber and Dr. Todd Kelley, who has come with some props.

Todd Kelley:

You said No slides. No

Joseph M. Schwab:

slides, but I didn't say anything about no props. Alright, position statement:"Obesity..." this is like a double negative kind of thing."Obesity does not need to be optimized prior to anterior approach." The pro position, Dr. Nicholas Webber likes some big right, likes some big, that's that's what you're saying. And Charlie. Okay. And the con position, uh, Dr. Todd Kelley, Dr. Webber,

Nicholas Webber:

you guys don't know me, so I'm gonna tell you about my journey a bit while I'm telling you about that, because you may not care. I want you to think of. Your three most appreciative patients, the one that brought you the most tamales, the one that brought you the most chocolate chip cookies, the one that gave you the biggest fluffiest hug you've ever had in your life. Think of those, and I'm gonna introduce myself. I'm a tumor surgeon. Uh. I started doing joint replacement when I started a tumor program at a, a big hospital. And of course, he imported me from Wisconsin to give this talk just to kind of poke more at Wisconsin. Um, when you start a sarcoma program, everything's a tumor. 160 pound pannus tumor, a butt that's dragging behind in a wheelchair tumor, absolutely perfectly fine. Every older partner I had called me the immensivist. Perfectly fine being the immensivist. So when I got to starting my practice, I said, okay, I'm gonna do everything. That's what everybody says. And I did everything. So part of everything is doing everything that people don't want to do. For 15 years, I became this end of the road type of surgeon, all posterior for 10 years. So I've been there. Uh, Ben Domb came and gave a talk, uh, at Aurora and said. There are all these outliers in the posterior approach. I stood up and said, you don't do anyone with A BMI under 25, or excuse me, over 25. He said, absolutely, yes I do. I made all these excuses for doing the anterior approach three times. I tried to do the anterior approach in my patient population, which is A BMI of who knows, and I'll tell you a little bit about that the first time. Blood bath. I don't know what I'm doing. Why am I a tumor surgeon doing something that's so difficult? Second time, okay, I'll do this. I stayed up all night thinking my of my anterior approach the next day and I said, why did I think about that? And my osteosarcoma resection, I didn't think about, forget it. My one kind of take home to those of you who are posterior surgeons, have someone come and visit you, teach you how to do an anterior approach. Someone did that to me, changed my life and I'm gonna really get into things. I have an alpaca at home named Joe Schwab, not necessarily'cause Joe Schwab helped me do that, but he may have. So to the question, I don't know if you have a kindergartner in kindergarten, they say, can you do hard things? I changed from being a pure orthopedic surgeon to a dad, and I want my kids to know you can do hard things. We have more and more literature saying yes, there are still complications with. Obese patients, however, is their patient satisfaction the same? Yes. Is it better? Maybe not. Do we have problems with incisions? Absolutely. Do we have problems with incisions in little old ladies who have really thin skin? Do we have problems in women who have had C-sections? A hundred percent there are problems. Is that a reason to say obesity needs to be optimized? What does that even mean? Think of A BMI of 37, big strong construction worker. Think of a BMI of 47, someone whose belly you can tape to the side do a perfect approach. I don't have a problem doing any of that. We can change their BMI, we can change all the controllable factors, but in real life, does it need to be optimized? The answer is no. And Dr. Kelley, you and your kids, they can do hard things.

Joseph M. Schwab:

Four minutes.

Todd Kelley:

Alright, sir, we're going South side Chicago on you here. Right here. Right here. Alright. Tell a little story first. Medical College of Wisconsin. I'm on an interview for residency. Interviewer asks me, hands me a sack of coins, says, reach in there, count up, tally up those coins. I say All, all right, start doing it. And uh, the idea is, okay, you gotta figure out what you're doing with your hands. You've gotta communicate, you gotta think all at the same time. So I'm gonna challenge you to, let's do this anterior style. Come on over here. These are my pants. They're, they're relatively clean. I want you to reach in my front pocket there and count up those coins and tally'em up. And let's see what you get. Now all you guys are thinking, where's he going with this? Right? No, no, no. You can't look at it. We're doing hard things here. We're doing hard things. You gotta feel it. You gotta feel it. You gotta feel it. What do you got there? Come on. I only got four minutes here.

Nicholas Webber:

We got, we got a quarter here. 50 cents.

Todd Kelley:

You're too slow.

Nicholas Webber:

60. 65 cents.

Todd Kelley:

60. Brilliant. You can, you can count, you can do math. Alright. Wow. Here we go. Um, now this, this pair of pants here, there's a little extra tissue in here. You can just throw these on the floor. I'll, I'll clean it up. I'm gonna ask you to reach in and do that same task, anterior style. Now, while you're doing that, I'm gonna tell another story here. Um, early in my career, I go to a Matta course and I ask Matta, Hey, I, I need some advice on obese patients. How, how do I, how do I navigate this? And, and Dr. Matta, you know, he's pretty, he's pretty blunt. He says. He says, yeah, just tell'em they're too fat. They'll go away. Right? So that didn't work for me. So here's my discussion with, with, with obese patients. You doing okay? Yeah. Here's my discussion with obese patients. I say, listen, I, I, we're gonna do a good job for you, but I, I, I need you. Help me help you. Right? We, we ask smokers to quit smoking. We ask diabetics to, to work on their blood sugar. I, I tell them, Hey, we're gonna do a good surgery for you, but I ask you, I ask you to lose a little bit of weight. Let's come back in a couple of weeks and and we'll see where we're at. Plenty of research out there that, that looks at. Oh, you know what I, I forgot. I forgot. The pan is here. We're gonna hang this pannus up here too. Alright, now, now you mentioned you can get through this pannus here, right? So CORR, CORR study 2023 looked at how low that pannus hangs on an x-ray. Higher, uh, higher risk of wound complications, higher risk of, uh, infections, higher risk of fractures when there's a pannus in your way there and you here, just tape that here, just tape that up and out of your way. You can just tape that pannus up. You just keep working there. And, um. So plenty of research that looks at higher risk of infection, higher risk of DVT, higher risk of fracture in obese patients. If we don't, and we're just talking about modifying, we're just talking about optimizing'em. And I think it's really important to say here, we optimizing their care is not delaying their care. It's not denying them care. It is just ensuring that they have a good outcome. Alright. My, my second point, the reason I'm doing this is, is to show you that yes, this is hard and yes, we can do hard things, but I don't think we can do our best at it. Right. I mean, he, I don't know that you even found a coin in there. I certainly do. Right, right. So, so, you know, this is hard and I think we can make errors if we're not optimizing our patient. The other thing is, is you know, there's a lot of research out there that looks at you. We know joint replacement surgeons, there's a high physiologic load doing obese anterior approach, um, higher, uh, or, uh, orthopedic load on on us. So I think you have to think about yourself here a little bit too. These are

Joseph M. Schwab:

get through one minute rebuttal.

Nicholas Webber:

So here's what happens when you tell patients to optimize their body mass index. What happens is they diet, they go on wegovy. And what happens is that. Your pannus goes away, right? Everything that you need to get out of your way to do an anterior approach goes away a hundred percent. It does not if their pannus hangs to their knees. My wife is here and I, and I love her, and we drive by this farm every day, and this guy's pannus. He hangs down to his knees. I made him lose weight. I did the 10% thing. And he did, and I think he lost it from his shoulders. So I'm almost positive, almost positive. I wanna optimize body mass index, but it's not necessarily optimizable. You have to treat these patients. I have to treat patients with osteosarcomas. If they're BMI is 70, we're in a similar situation. There are people that are just as debilitated by their arthritis as they are by their osteosarcoma. In one way or another, we gotta do what we gotta do.

Joseph M. Schwab:

One minute rebuttal.

Todd Kelley:

I'm gonna take you through another scenario. You got two patients. One patient comes into your office, their BMI is 40 and they say, doc, you gotta help me. Give me some pain meds, do my surgery. I I, I need to get this done. And I give them that same conversation, come back in two months, lose weight. Their BMI starts at 40. I got another patient whose BMI comes in at 42 and I give them that same instruction. Now this one comes back with a BMI now of 40, so now they're both at 40. Right. Which one do you think is gonna do better with that surgery? Same. Otherwise, I think if you plug that into Christoph's algorithm, you're gonna see that this patient who did lose some weight and optimize their care does a little bit better. And, and the reason is the psychological term for that is called locus of control. One has an external locus of control. They want someone else to do something for them. The other has an internal locus of control. They are able to kind of take control and do some things for themselves to get them in a better position to go that surgery. Thank you.

Joseph M. Schwab:

Thank you, gentlemen. Excellent debate. Excellent.

For all the humor in this debate, and there was a generous amount, including a live demonstration of anterior approach coin retrieval through two layers of pants. Both Dr. Webber and Dr. Kelly were wrestling with the same fundamental question. How do we give high risk patients the safest path forward without judging, delaying or abandoning them? Dr. Webber reminded us that some patients just need someone willing to take on a hard case. Dr. Kelly reminded us that asking patients to participate in their own optimization is part of compassionate care. Both of them reminded us that pannus height apparently matters more than any of us learned in residency. No matter which side you lean toward. It all comes back to the patient, their pain, their goals, their effort, and yes, maybe even their sense of humor. Thank you for listening to this episode of the AHF 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. One word, episodes of the AHF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips and pannuses happy and healthy.

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Joseph M. Schwab

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