The Anterior Hip Learning Curve Nobody Warns You About

Learning the anterior approach to total hip arthroplasty doesn't follow a straight line. Dr. Joe Schwab shares what happened when improving his femoral technique unexpectedly made his acetabular work feel worse—and why that unsettling experience taught him more than any single complication.

This episode is for orthopedic surgeons and trainees navigating the anterior approach learning curve, especially those who feel like their progress isn't linear. Joe walks through his own journey from posterior-trained resident to anterior-focused surgeon, including the cognitive challenges that don't show up in technique videos or course materials. He explains why the learning curve feels more like riding ocean waves than climbing a ladder, and offers practical guidance for managing the psychological demands of mastering a complex approach.

If you're somewhere in the middle of your anterior journey and wondering whether the struggle is normal, this conversation will help you understand what's happening beneath the surface—and give you permission to keep moving forward thoughtfully.

⏱ Chapters:
00:00 Introduction and disclaimer
01:08 Starting anterior approach out of the gate
04:51 The first plateau: getting good enough
06:10 The femur breakthrough and surprise setback
09:21 Understanding what was really happening
11:19 The waves: changing mindset over technique
13:58 What I wish someone had told me
16:19 Practical takeaways for surgeons on this path

Listen to the AHF Podcast on your preferred platform:
Buzzsprout: https://ahfpodcast.buzzsprout.com
Apple Podcasts: https://podcasts.apple.com/us/podcast/ahf-podcast/id1749521487
Spotify: https://open.spotify.com/show/5CrGJyvRiQFTCU3FFFVvHc

This podcast is intended for educational and informational purposes only.
The content discussed does not constitute medical advice and should not be used as a substitute for professional judgment. Clinicians should rely on their own training, experience, and clinical decision-making when applying information from this discussion.

Transcript

Joseph M. Schwab: 0:01

Quick note before we dive in. This podcast is for education and professional conversation among surgeons and other healthcare providers. We're talking education and general practice patterns, not specific medical. For any one patient. So always use your own clinical judgment and follow your practice policies and local standards of care. The Anterior Hip Foundation, myself and our guests aren't responsible for any decisions made based on these discussions. Hello and welcome to the AHF podcast. I'm your host, Joe Schwab. Today's episode comes from a terrific question I received online about the anterior approach learning curve. And the question goes like this, during the anterior approach learning curve, which complication taught you the most important lesson, and what specific change in your practice helped you reduce risk afterward? Looking back, what do you wish someone had clearly told you before you increased your anterior volume? And I love this question, but I'm gonna answer it a little differently because for me, the most important lesson in my anterior journey didn't come from one dramatic complication, although I had plenty of those. It came from a kind of unsettling stretch of cases where it felt like the more I did. The worst I was getting. So in this episode, I wanna walk you through that experience, talk to you about what I think was happening underneath the surface, and share why I now think of the anterior approach learning curve, less like climbing a ladder and more like being in the ocean. So let me start a little bit with where I came from. I did my residency training in Milwaukee, and like many people's at the time, in the early two thousands, it was primarily posterior approach, total hip replacements, and I was also exposed to some anterolateral, so I was really comfortable with a posterior hip, and that was the lens through which I really understood hip arthroplasty. So I finished training. I did my fellowship, which was in hip uh, surgery, and then I joined my current practice and I actually started doing anterior approach right away, even though we only did a few cases of it in my fellowship. And I had done essentially none of it in my residency. And that's a little different from the typical story of someone converting mid-career. And it's different from the typical story of being involved in it right away in fellowship or in residency. And in my case, there were two big drivers for this decision. First, the practice I was joining was interested in having somebody who could offer anterior hips, and there was a sense that patients would want it, uh, that it fit into where the field was going and that our group should be able to provide that option. Second, when I went to courses and watched Anterior done well, it made a ton of sense to me. Seeing the hip supine, having access to fluoroscopy, watching people reliably restore length and offset, that all clicked. It felt intuitive, at least in theory. I also wasn't doing this alone, so I had a colleague who was also interested in starting anterior hips in his practice, and we began doing the cases together. If it was his case, I would assist, and if it was my case, he would assist. And that companionship, I think, matters more than we often admit to ourselves at least. And it meant that from case one, we were talking through our exposures and our decisions and maybe bringing up little pearls in real time that we had learned rather than each of us struggling in our own sort of silo. That was my starting point. Posterior trained, conceptually sold on anterior, and beginning my practice with basically a new approach that I thought was an important part of my identity as a hip surgeon. So like many people, my early focus was just survival. I just wanted to get through the cases safely with reasonable components without creating problems that I would come to regret later. At least not often. And after about 30 cases, I felt. Really surprisingly comfortable, at least on the acetabular side. My exposure was reliable, my fluoroscopic views made sense, and I had this sort of mental checklist for cup position, and I could work with that checklist without too much stress. And if you'd asked me then, Hey, what's the hardest part of an anterior total hip? I would've said, without hesitation, the femur. Elevating the femur, delivering it safely, controlling version through a relatively constrained window. That felt like a real challenge, uh, to me. So in my mind, the story at that point was, I've got the acetabulum under control, but my approach to the femur needs work. And that led to what I thought was a pretty straightforward solution. Go find somebody who's really good at the femur and learn from them. So I arranged a visit with a surgeon who lives about two hours away, practices about two hours away from where I am specifically to watch how he handled the femoral side through the anterior approach. And I even told him this. That I obviously was gonna watch the entire case, but I really wanted to focus on tips and tricks for better, uh, femoral exposure. So this wasn't some generic, just go see some cases type visit. My intention was very focused and I wanted to come home with a better way to do the femur and. It delivered. It was an incredible day. I watched his sequence of releases. I watched how he used the table. I watched how the leg was positioned at each step. I watched the repetitiveness of what he did, where he stood, how he handled the broaches, and there were a dozen or more tiny details that I had never quite appreciated before. And I came back to my own or super energized, really excited to try these new ideas. And initially it felt fantastic. The femur suddenly felt so much easier. Delivery was getting to be more reproducible, and I was spending so much less time fighting the soft tissues and fighting the bony exposure. And more time actually just implanting the prosthesis. And then I noticed something. To my surprise, the part of the operation I had been most comfortable with, the acetabular preparation started to feel off. The exposure felt awkward in ways it hadn't before. The reamer sometimes didn't quite sit the way I expected my confidence in cup position dipped. I found myself double or triple checking fluoroscopy, not because I was being meticulous, but because I was just not sure anymore, and it was a real unsettling feeling. I had set out in my mind to improve my femoral technique, and on paper I had succeeded, but in the process, it felt like I somehow lost ground on the acetabular side, and the image that came to my mind was sort of a seesaw. One side went up and the other side came down. On some cases, I'd walk out of the, or thinking, man, that femur just went great. I really struggled with the acetabulum, and on other days it felt like the reverse. It was as, as if my brain couldn't hold both halves of the operation at the same level of fluency at the same time. And here's the sort of emotional truth of it. In the middle of that stretch, it was pretty disheartening. I had this nagging worry that the more anterior approach cases I did, the worse I was getting overall. And that's not a fun place to be as a surgeon. Looking back, I don't think this was about a secret technical flaw in my approach, and it wasn't that I suddenly forgot how to expose the Acet tablum or that the pelvis had changed. What changed was where my cognitive bandwidth was going. See, when you're early in an approach, your brain is working at capacity just to run the basic steps. As one part of the operation becomes more familiar, it occupies less foreground space and slips into the background. When you deliberately push yourself on a different part, like I did with the femur, you pull your attention and energy away from what used to feel automatic. And in other words, the seesaw I was feeling wasn't a failure. It was a sign that my brain was actively reorganizing how it handled the operation, but in real time it didn't feel like growth. It felt like regression, and this is where I think the latter metaphor of the learning curve breaks down a ladder, makes you feel like each step is a clean upward move case 31 is better than case 30 and case 40 is better than case 39 and so on. My experience didn't look like that at all. It looked more like. Rock climbing. Sometimes you move sideways. Sometimes you actually climb down a few moves to set yourself up for a better line. Sometimes you're hanging on by your fingertips wondering, is this just a terrible idea? Or to use the metaphor that ultimately helped me the most, it felt like being in the ocean. At that point, the most important change I made wasn't a new release or a different retractor or a clever trick with the table. The change was in how I understood and accepted what I was going through. I started to think of the anterior learning curve as waves going in and out from ashore. There were days when the wave carried me towards solid ground. Everything felt smooth. The cup and stem went in the way I intended, and I could see the whole operation from beginning to end. Those were shore days, and there were days when the wave pulled me back out to sea. I felt adrift. I questioned some of the decisions I thought I had settled in my mind Months earlier, my confidence in one part of the operation came at the expense of another, and what I realized was that the suffering didn't come from the waves. It came from my resistance. My insistence that every case had to feel like linear progress. The more I fought the waves, the more frustrated I became. So I did something that doesn't sound very logical, doesn't sound very surgical. I allowed myself to be part of the waves. Instead of interpreting every backward feeling day as proof that I was failing, I started to see it as part of the natural rhythm of learning a complex approach. When I felt the pull out to sea when the acetabulum suddenly felt hard again, I could say to myself, this is one of those days. Stay present. Trust that when this wave comes back in, you'll be on more solid ground than you were before. And the less I tried to resist that rhythm, the more I felt like I was part of the flow of knowledge in the operating room. Instead of fighting against it, and interestingly, once I stopped panicking about this seesaw, both sides of the operation steadily improved. So going back to the original question, what do I wish someone had told me before I increased my anterior volume? Well, I wish someone had sat me down and said three things pretty clearly. One, expect the waves. As you get better at one part of the operation, another part may temporarily feel worse. That's not a sign to quit. It's a sign that your brain is actively reorganizing how you think about and perform the surgery. Number two, your most important complication. may be psychological, not mechanical. Yes, you wanna avoid fractures and dislocations and malposition components and nerve injuries, but a quieter complication is losing your confidence because your experience doesn't match the tidy story you had in mind about how the learning curve works. If you're not ready for that, it can be just as dangerous because it may push you to bail out early, or it might push you too hard to try and prove something you're not ready for. And the third thing is you're allowed to ride the waves. You don't have to interpret every difficult day as evidence that you're doing the wrong approach or in the wrong job, or that you're not cut out for this. Give yourself permission to have those shore days as well as the sea days and understand that both are part of becoming truly fluent in the approach. Notice, none of those points are about a particular implant or table or incision. Those are important details, but they're not the whole story. The anterior approach can be technically demanding, but it's also cognitively demanding, and your mental model and your expectations matter just as much as your instruments. Let me end with a few practical thoughts for anyone who's somewhere along this journey. My first thought is build some space to focus. There will be seasons where you intentionally push yourself on the femur or the acetabulum or revisions or something else, and during those times accept that something else may feel less automatic. That's okay if you can design your case selection and your schedule with that in mind, don't judge your progress on a single week, but look at your anterior approach. Practice in blocks of cases, 20 or 30 cases at a time. Ask compared to 30 cases ago, am I seeing better radiographs or fewer surprises, or do I feel more in control? That's a much more honest measure than how you feel after one rough Tuesday. Find colleagues that you can ride the waves with. Having a partner who's walking the same path, or someone you can call who's maybe a little further along than you, that changes everything. Sometimes the most helpful thing you can hear is, yeah, that's normal. Keep going. It's actually one of the reasons why I really enjoyed spending time at the Anterior Hip Foundation meetings. Everybody that I talked to was that colleague who's just a little bit ahead or that partner that I can help get past where they're at. It just felt like a big family. And last, protect the patient by protecting your mindset. When you're honest about where you are on the curve, you're more likely to choose the right approach for the right patient on the right day. While hopefully that means growing in your anterior approach. If you're a seasoned posterior approach surgeon, that may mean doing a case posterior. You could do anterior simply because you recognize that your bandwidth is already a little bit taxed. That's not weakness, that's judgment. So to circle back, the complication that taught me the most in my anterior approach journey wasn't a single catastrophic event. It was that unnerving period. Where my improvement in one part of the operation made another part feel worse, and I started to doubt the whole project. The change that ultimately reduced my risk wasn't a new gadget or a clever release. It was accepting that the learning curve comes in waves and choosing to ride them rather than fight them is the best way to go. And if you're in that phase right now, if you feel like your anterior curve looks more like a stormy ocean than a simple ladder, I hope this gives you some language for what you're experiencing and maybe some permission to keep moving forward thoughtfully. I'd love to hear your stories as well. What did your waves look like? What parts of the operation got better as others got worse? If you can send in your questions and your experiences, and maybe we'll build a future episode around that and let me know if you like this. Ask me anything format. I'll put a link at the end of this episode to our previous Ask Me Anything episode so you can check that out. Thank you for joining me for 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. All one word, episodes of the AHF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy and healthy, and maybe to remember to be kind to yourself too.