Operation FUBAR: One-in-Six-Million Bone

What do you do when the greater trochanter shears off during a routine hip replacement — and the bone is too soft to hold a screw? Dr. Jeff Barry of UCSF walks through two intraoperative disasters in the same patient, and how he salvaged both.

Jeff Barry, who directs the Hip and Knee Arthroplasty Fellowship at UCSF and co-directs the Arthroplasty for the Modern Surgeon course, joins Joe Schwab for an Operation FUBAR case review most surgeons will recognize with a wince: a frail 75-year-old retired nurse with a rapidly collapsing hip, leukemia, low platelets, and osteoporosis so severe her DEXA T-score came back at -5.1 — statistically about one in six million.

On the first side, the trochanter shears off during a femoral exposure Barry has performed thousands of times. On the second side a year later — after a missed femoral neck fracture — a gently tapped multi-hole cup punches straight through the medial wall. Barry talks through the decision-making in both moments: when less is more, how locking-screw revision cups can function as an internal cage, and why the "trap side" of a case is often the one you weren't worried about.

The conversation goes beyond technique into how surgeons process intraoperative complications — stepping back from the wound to game-plan, communicating with anesthesia before cementing in a pulmonary patient, protecting the next case on the schedule, and the value of a "confessional" text thread with trusted colleagues. For arthroplasty surgeons, fellows, and residents, this is an honest look at what severely osteoporotic bone can do to even a well-planned primary.

⏱️ Chapters:
00:00 Introduction and guest background
01:31 Frail elderly patient with a rapidly collapsing hip
03:37 Planning a cemented hip in severe osteoporosis
06:21 Greater trochanter shears off during femoral exposure
08:00 How surgeons react when a case goes wrong
13:27 What a T-score of -5.1 means for hip surgery
14:42 Missed femoral neck fracture in the opposite hip
16:44 Acetabular cup punches through the medial wall
19:21 Salvaging a failed cup with locking screws
24:45 Managing pelvic discontinuity as the rescue surgeon
28:46 Knowing when to call for help in the OR
33:33 Teaching trainees through intraoperative complications
40:12 Debriefing and the surgeon confessional after complications

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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.

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Transcript

Joseph M. Schwab 0:21

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. Joining me today is Dr. Jeff Berry, and I'm really pleased to welcome him to the show. Jeff is an orthopedic surgeon at UCSF, where he directs the Hip and Knee Arthroplasty Fellowship and co-directs the Arthroplasty for the Modern Surgeon course held up in Napa in August of 2026. His practice centers on adult hip and knee reconstruction with particular expertise in anterior approach hip replacement, as well as complex revision surgery, which makes him exactly the right person to have on for an episode like this one. Jeff, thanks so much for coming on the AHF Podcast, and welcome to Operation FUBAR

Jeff Barry 1:09

Thanks so much for having me. Uh, I, I guess it's an honor to be here for this, but, uh, we'll, we'll see if, uh, if you s- you agree af- after we go through these cases.

Joseph M. Schwab 1:19

So, um, you have a case prepared for us, is that right?

Jeff Barry 1:22

Yeah, it's, it's, it's a patient prepared for you. It's actually two cases, so

Joseph M. Schwab 1:26

All right, perfect. Well, let's, let's get right into it. Here we go

Jeff Barry 1:31

Yeah. So I, I called this one, uh, please don't be so nice to me because it, it kinda goes with a theme that I, I think as surgeons, we kinda find that the nicest patients are often the ones that have the, the worst outcomes, and if, if you happen to be an asshole, somehow you're protected against, against the bad things happening. So this is, this is a very nice patient.

Joseph M. Schwab 1:49

I think a lot of surgeons can relate to that for sure

Jeff Barry 1:51

yeah, yeah, a little foreboding. So, you know, this is a 75-year-old, also a retired nurse, which is another bad predictor, uh, being in healthcare. Um, she lives alone. Her daughter accompanies her to visits. Um, she is the nicest woman in the world, um, and was having hip pain for two years, worse over the last four months. So previously gardened, did her own shopping. Now she's limited mostly to a wheelchair, um, a walker for very short distances. But eyeballs very frail, so, so definitely, you know, older than stated age in terms of appearance. She has leukemia, uh, with very low platelets, uh, osteoporosis that's gone through a vanity treatment, um, CHS, u-uses O2 at night and, and has kind of a scattering of, of medical comorbidities. So, you know, just, just right off the bat, kind of a, a less healthy patient, not one that we're not used to here at UCSF. Like, we get a lot of patients like this. But, um, you know, you, you kind of temper your, your expectations right off the beginning, right off the bat. Um, and these were her X-rays. So she came with two sets of X-rays, one that she had had for her referral, and then the ones that we got in our clinic. And you can see just in a couple months how, how this hip has progressed on the right side, that, you know, femoral head has collapsed. Um, you can see some generalized osteopenia, osteoporosis, um, but, you know, a fairly straightforward surgical indication for this one

Joseph M. Schwab 3:16

And this is a six-month timeframe between those two images. Is that right?

Jeff Barry 3:19

Exactly. Exactly. So I, I met her in February, so that's the one on the, the, the right there and, and, um, yeah, this is a very... You know, she started having pain years ago, but, but really acutely started in, in that August-ish period and then came to me in February with a, with a collapsed hip. Um, so this was our plan for her. You know, in these, these kind of collapse cases or, or, you know, sick patients, you know, I kinda treat this like a femoral neck fracture patient. Um, so I'm gonna do it on a HANA table. Uh, I'm-- I almost always do a full femoral release just right off the bat whenever I'm exposing these patients. I, I know that ahead of time. I'm gonna be really aggressive in that to avoid undue tension on, on the troch or, or other, other parts of the femur. Um, we're gonna do a hybrid fixation. We're gonna cement the stem, um, and use a press-fit socket. Um, and I'm gonna talk to anesthesia ahead of time about kinda cement and, and what the risks of that are, make sure that, that they're aware of, you know, keep the O2 all the way up, be a little more aggressive on the fluids. Um, and then for this patient, they got really low platelets. We're gonna make sure we got platelets available if we need to, uh, transfuse and, and just kinda be, be set up for the surgery. But this is going on a regular OR day. You know, I'm usually running two rooms. This is the hip, so it's earlier in the day. Um, just kinda slotting into the schedule like normal, um, but being a little more careful just, just because we know the bone's not gonna be great.

Joseph M. Schwab 4:42

And did you talk with her about time in the hospital as well? Is this something that you would send home the same day? Is this something that you'd plan to keep in the hospital? What, what are your thoughts on that?

Jeff Barry 4:52

Yeah, this is definitely someone we're gonna keep overnight. Um, you know, someone on O2 at night, someone we're, we're gonna cement, low platelets. We're maybe a little worried about bleeding afterwards. We're gonna just keep an eye on her. She also lives by herself. Um, she has family available, but, you know, that, that's not someone that in our, our shop we're sending home the same day. Um, so she- she's, she's aware of that and aware of the risks. You know, you talk about everything with these patients, especially the, the lung risks were actually probably our biggest discussion. Someone on O2 at night, um, gonna go through a, you know, unnecessary cemented hip. Um, th- that, that's the bulk of our risk discussion more than anything. Um, yeah, so we, we do the case. You know, it starts off fine. We do our CUP. No, no issues there. Um, and then this is kind of how I normally will position a femur. So this isn't this case, but just a video I usually-- I made for the residents that has our entire procedure. So I use a hook, I use a femoral hook. I'll rotate out to 120 degrees on the HANA table. Um, make sure that kind of the, the medial calcar is clear of any soft tissue attachments. Um, put a medial retractor and, and kind of use that to lateralize the femur a little bit. Um, and then I'll use the hook to kinda lift up and make sure we're keeping things away from the-- getting stuck behind the pelvis as you go down and under with traction off. So that's kinda my normal workflow. I think that's probably how a lot of people with a, with a HANA table would, would do that initial femoral, uh, exposure or, or leg over and under. Um, and so in this case, you know, we put the hook in, we rotate the leg out, we go down and under. And I don't hear anything. I don't see anything weird happen. But then when I go to look at the femur, all I'm staring at is a tube. Like the entire top half of the femur just shears, sheared right off in the going down and under of the hip. Um, which, yeah, so this is, this is like I was just You know, oh shit, like what, where'd the rest of the femur go, right? Um, and so, you know, this is, uh, you know, it's just stayed right where it was. I'm kind of like feeling around, like I'd done my full capsule release, which I normally do. I keep the capsular flaps. I tag them. I've taken that off the top before I go down and under. I don't usually do the, the conjoins or the piriformis release until it's down and under. And that's how I've done it for thousands of cases. This is the first one where it decided to, to not cooperate here. Um, and so as I'm exposing this and looking at it, I'm like starting to check the bone a little bit better. I knew it was bad when I made the femoral neck cut, but this is where it's like, this is really, really bad bone. Um, when you're pushing on the cortical bone, you can see it flexing on the anterior and the posterior of the, of the proximal femur. You know, you're just staring at this open tube. Um, and I try to show kind of what-- I didn't have a great X-ray obviously, or a picture interop, but you know, this is kind of where that looked like. You'd have a femoral neck cut and the whole top of the troch just kind of comes off. I've definitely had like little tip evulsions, things like that over the years of the trochanter doing DA, but this is like the entire troch below the vastus ridge just, just straight off and down. Um, yeah. And so, so this is kind of like, you know, I, I kind of think of the, the response to, uh, trauma for a surgeon as either the Michael Jordan response or the Chris Farley response. One is you can either like, some people just freeze up and they just start kind of crying on the inside. That's the, that's the Jordan meme response. Or, or I'm kind of more of the latter, which is the Chris Farley response of just like, what the? You know, just I have to like, I just get really a little bit upset and mostly at myself, right? Like you feel like you've done something that, that created this when in reality, this is like me, you know, this bone, you'll, you'll find in a second, this bone is horrible. Um, but you know, it's kind of like, what do you do next? How are you gonna process this? Everyone has some sort of initial internal response and how are you then gonna, gonna move forward from it, I think is, is part of surgery and, and, and kind of just, you know, you learn yourself and how, how you're gonna move forward.

Joseph M. Schwab 8:56

Well, and is, is your team seeing Chris Farley or are they seeing Michael Jordan? Are they seeing somebody else?

Jeff Barry 9:02

I hope Chris Farley's mostly on the inside. I, I think I definitely let it out a little bit sometimes. You know, my, uh, my helmet in the OR, we have our names on them, like we all have our own helmets, and mine has a little, little fire n-next to it, like a, flame. Um, so there's definitely a little bit. I'll blame my hair color on that one, but but, uh, but yeah, there's a little bit of a Chris Farley. But, but I think, like, it's important that once this happens, you do have to take a step back and be like, you know, "Okay, what the hell are we gonna do next?" Um, and so, like, like, one of my, uh, attendings in training would always, like, say, "If you have something go wrong, like, turn-- like, put a lap in the wound, turn around, go to the back table, like, do whatever you have to say to yourself in your head, and then just kinda list out what the options are and what, what you should do next." So for me, it's kind of like, are we just gonna keep going, like, just leave the troche where it is? Are we gonna abort and change things? Are we gonna call for a troche plate and try to fix this thing? Um, and at the same time, in the back of my mind, I'm thinking about the frailty of this patient that, like, you know, they got no platelets. They're kinda oozy, the whole case. Their BMI is eighteen. They're probably under-- malnourished and kinda very frail. I'm about to throw cement into them in a, in a pulmonary patient. So, you know, all this is kinda going through my mind. Um, but, uh, so we decided to proceed with a cemented stem. I kinda just used that tube and cemented into it. You can kinda see this is an intraop film. You can see how bad that bone is up top. You can't really even see what's going on up there. Um, but we just left the troche where it was. I didn't trial because I didn't wanna break the femur further. And this, this X-ray is really deceiving, um, in the cortical thickness there, but you, you'll see later kinda what, what the bone quality actually was. And, and I kinda went with less is more here. So, you know, the abductor sleeve was still intact. Um, the, uh, the bone is so bad that even if I put screws in it, I don't think it's gonna hold. Um, and I, I took a bunch of that femur, sent it to path just, just to be sure I wasn't doing something or getting into something really weird. Um, and, and we just cemented in. So, you know, this is the PACU, and, and no one will know the struggle, right? Like, this is, this is one of those cases where you, you talk to your buddies, they're like, "Look at this case I just did. Like, this was crazy. Like, the troche just was gone. The bone was horrible. All my retractors are pushing through the bone," and, like, it, it looks like a cemented hip. I don't know what you're talking about. Um, but, but this was, you know, a, a mess on this side. Um, and, and, you know, this is the PACU X-ray. We slowed her down a little bit, how to use a walker. I knew the troche was off. She's low demand. I let her go. Um, and, you know, at, at four weeks, this is what she looks like. You can kinda see that, that troche missing a little bit and the cement over there. And, and at four months, you know, on a lateral, the troche's actually moving with it. Like, it, it's kinda moving as a unit. Like, she's walking with a walker. She's super, super happy and just so grateful and like, "Oh, this is great." When in reality, like, intraop, this is one where you're staring at this hole And you're like, "I don't know what I'm gonna do here." Um, so

Joseph M. Schwab 12:05

so, so let me ask you, at this point, are you feeling like, "Man, I am pretty damn good that I got this," or was this a, "I can't believe I slipped by on w-

Jeff Barry 12:15

This is

Joseph M. Schwab 12:16

based on everything I saw"?

Jeff Barry 12:18

Yeah, this is a, like, Neo in the Matrix moment where you're like, you feel like you dodged the bullet, you know, and you're kind of like, "Whoosh, got lucky on that one." And, you know, it, it-- like, in the moment, I, I think you get a little bit hung up on, like, what is the-- what's gonna happen here? But if you just kinda work through step by step by step, thing, things go okay. And, um, you know, th-this is, uh, every surgeon has these cases where, like, you're trying to describe what happened, the drop, and the X-rays don't really match up. You're like, "Uh, this doesn't look that, that crazy." But when things are so bad or, or so s- the bone is so bad, you, you feel very, uh, humbled at, at, at how bad bone can get, I guess, is, is what I'm trying to say. Um, so that-- this, this side was arguably, like, you know, this, this was, this was a little bit stressful of a side, but, you know, she did really well. She did really well. Um, and so

Joseph M. Schwab 13:11

much happier than having, uh, a, uh, a rapidly progressive osteoarthritic hip, right?

Jeff Barry 13:18

Yeah, exactly. Exactly. And she, you know, went from pretty independent to a wheelchair, and now she's back to, to fairly independent. So, so very happy in the whole. Um, after the surgery, I sent her to get a DEXA scan, and this is the scores that she got on her other femur. So, um, her left femur had a T-score of -5.1. Um, and so, like, just, just to review kind of what T-scores are, you know, T-score is a standard deviation below normal bone. So 5.1 standard deviation is below normal. You're like, "Ah, five, that's not, not so much." But if you think about how a normal distributed standard deviation is, 5.1 is actually one in six million. So in the SFA area, there's like a population of 7.6. This patient's from a little farther away, but still get to the point of like, this is horrendous bone. And, and I don't know why the X-ray doesn't show, but, you know, it, it looks bad, but it's not the worst bone I've seen. But this, this, uh, bone density test is really showing that, hey, this is, this is horrible, horrible bone. Um, and so, you know, uh, Bill Griffin, who was one of my, my mentors in, in, uh, in fellowship at OrthoCarolina, used to say all patients are like satellites. You know, you launch them out into space, and eventually they're all gonna kinda come back out of orbit. It's just a matter of when. and so, y- yeah. So the, you know, the enemy of good outcomes is follow-up. Um, and, and this patient comes back a year later, and this is, this is one of those ones that you see on the schedule, and it says just, you know, follow-up hip pain, and you're just like, "Oh, crap." Like, what, what is this gonna be?

Joseph M. Schwab 14:54

Oh, no

Jeff Barry 14:56

so she's back in a wheelchair, and she says, "I haven't been able to walk for three months," but she says it's her left hip that hurts. And so you're like, "Okay, okay, we got it. All right." So i- looking at this film and being able to compare to others, a- she actually has a missed femoral neck fracture. So she, she was diagnosed-- She lives kind of in the boonies and, um, was diagnosed with just hip pain and arthritis and sent back to us to get evaluated. But she's actually had a femoral neck fracture, kind of a valgus impacted femoral neck fracture, um, for the last three months. You can kinda see in that inferior cortical area on there that it's, it's a, it's, it's definitely off and, and kinda shifted down. So again, this is, this is one that, you know, are like, "Okay, round two, here we go. We're gonna do this again." Um, you know, and I got... You know, this time we're gonna be ready. We get the whole game plan together. We're gonna use a multi-hole cup right off the bat, 'cause we know the socket bone's gonna be bad, and maybe we need some extra screws. This time I'm not gonna break the troch off, so it's not my normal workflow. But before I even drop the leg down, I'm gonna do all the femoral releases, like no stress on the trochanter We know we're not going to trial the cemented stem, so I got to get that neck cut good right off the bat. And I'm just going to be careful every single step of the way, and I'm going to make sure we got everything in the hospital in case we need to do something weird. Okay, so this is the game plan. This is as we're getting ready to hit the cup in. I ream and hit the cup in under fluoro and go into my 90s movies and things. It's wide open. All you got to do is tap it in. Just tap it in nice and gently. I'm walking the resident or the fellow like, I'm going to hit this one in. Just going to hit it nice and gently. Just tap it in. All right, tap it in. A little tap, tip, tip, tappy, tapperoo. God damn. Dang it. You know? And, and this is like, you're like, "Shit." Um,

Joseph M. Schwab 16:53

Hmm.

Jeff Barry 16:54

cup, cup goes straight into pelvis. And, and so this is like, this is pretty, pretty common thing, I think, for us as surgeons is like we know, um, we're, we're worried about a certain part of a case, right? You know there's gonna be a complicated part of the case, and this one is like the femur. Like most of my thought is on the femur. I know that's gonna be tough. The bone's bad. DEXA's minus five. This is a one in six million crap bone. And then you, you-- I, I wasn't totally distracted. Like I knew it was gonna be bad. I'm, I'm being gentle, and still something happens on the other side. Um, and so then you're just like, you're very much, you know, in the like, you know, I'm, I'm the, "God dang it," you know? Like, what the heck? Um, I swear I'm a good surgeon usually. But, uh, but yeah, this is, this is like one of those ones, and now you're, you're back to this kinda Jordan or, or Farley response and, or, or Happy Gilmore response. Um, and you know, you gotta take a step back and be like, "Okay, what am, what am I gonna do now?" Like this is, this is bad bone. I just put a revision cup. I was using a multi-hole cup. Like I was being gentle, and it just went straight in So, you know, I, I'm, I'm thinking through my options, like, do I wanna do a different cup? Do I need to do, like, kind of a tumor-style rebar screws and cemented cup? I do that not infrequently for some, for some metastatic cancer stuff. Do I wanna come back another day? Do I wanna put a cage in, um, or cement a cage in? Do I want to do a cup cage? Like, like, what do I wanna do? Okay, and again, in the back of my mind, I got this medical frailty and this, this kind of not super healthy patient, and I, I still have to do the cemented femur, which I was worried about to begin with, right? So you got all these things, things swirling. Um, you know, I try to assess the defect, which you can tell from this X-ray is really easy to, easy to see. The shin rock just-- you know, the bone is so bad, so bad. Um, but it, but it seemed like the anterior column was out, and the medial wall had kind of blown through, but my posterior column was still intact. So, you know, that-- I, I do a ton of revisions. Like, that, that doesn't-- that problem I can, I can do. I got a column intact. I got some pinch I can get from the ischium to the, to the ilium. I, I can, I can figure this one out. Um, we, we were able to take a multi-hole revision cup, um, go bigger. You know, I didn't, didn't ream. I kinda under-reamed by probably f- I think it was, like, four millimeters in this one, just kinda tap a, a revision cup in there. Still soft as hell. And, and I love locking screws in, in revision cups. Um, this cup has locking screws, and I just filled it up like a Sputnik. You know, I, I, like, tell the fellows, it's like, "Just put the screws everywhere." Even if it's a 15 screw that's, like, you know, two millimeters of cortical bone, put it in, use it as a stud out of this, this Sputnik cup, and just get as much fixation as you possibly can in every position. Uh, from the DA, like, it's really nice to be able to check all these screws to make sure they're not, like, egregious, but, you know, a bunch of these are not, not really in, in that good a bone. But I'm putting it wherever the s- the screw hole was. And, um, you can see from that first X-ray to the second one, like, I kinda rotated the cup a little better to get, get where some bone was. Um And, and yeah, this is, this is still a sinking feeling when every time you put the, the depth gauge in, it just kind of goes and you have no idea. Like it'll just go right through the cortical bone and you're just like, what, what, you know, you have to use C-arm almost to, to see where your screws are. But lock it up, you know, locking screws. This is kind of like an internal cage in my mind is like, I think these locking cups can take away the need for a cage in some situations because it is kind of this fixed angle device in all directions. So, so that's why the Illica, you know, this, this is one where when you're using C-arm a lot, you get, you get kind of these funky things. And if you look at the pubic area here, like this is the, I haven't touched anything. I just kind of moved the C-arm a little bit. It looks like this thing's moving all over the place, but it's just because those screws aren't actually in the, in the pubis. They're kind of like in front or behind. And so it just, it looks like it's, it's a mess, but you know, it seemed to have good fixation. I was able to kind of grab it, shake it with a Coker, wasn't, wasn't falling out. So I'm okay with that moving forward. You know, these are our PACU films. I put her on 50% weight bearing for a bit. I hate to, I hate to limit people after primary, but, but you know, this, this bone necessitates that. Let it grow in a little bit. We actually got away with the femur, no problems this time, right? So we did all the releases. We're, we're worried about stuff. We, we got away with the femur and no issues, but

Joseph M. Schwab 21:51

Of course

Jeff Barry 21:51

you know, yeah, of course. But, but the cup was definitely a, a little bit of a nightmare. So, you know, this is, this is her at three months. She's walking again. She's more limited by her pulmonary function actually than, than things. And she's very happy. Both times she had to go to the ICU post-op. I didn't really go to that very much, but her blood pressures were just low. It was a long case. Like we didn't take that long. Like this, this kind of salvage stuff didn't take that long, but you know, just with, with an O2 requirement and, and a baseline and kind of wanting to watch her, they sent her to ICU for short term. But you know, she, she is, she's a nurse. She knows what, what happened. She knows this isn't kind of like plan A, but still like the nicest and happiest patient. So, you know, I'm, I'm seeing her again, I think in a couple of weeks for her seven month or eight months, something like that. But hopefully she's, seems like she's doing well. I can see PT notes and she's still walking around and doing everything. So hopefully no satellite crashes.

Joseph M. Schwab 22:48

for hip pain at the clinic. Um, can you go back to that previous one? And maybe it's the quality of this, uh-- Yeah, that one right there. Maybe it's the quality of this X-ray, but, you know, you had remarked earlier, at least on the right-hand side about, you know, there was that intraoperative film where her diaphyseal, uh, cortical, um, you know, thickness appeared pretty reasonable. It, it seems to be much less reasonable looking on, on this X-ray, and maybe it's a projection or it's a, uh, a, a, uh, you know, something about how they took the image issue. But at least on the right side, the, the diaphyseal cortical bone is now starting to look kind of a little moth-eaten. I mean, it looks pretty irregular,

Jeff Barry 23:33

like that on bo- it kind of looks like that on both sides, actually. And, and I, I think it really is just the, it is technique or, or, or films. This was done at one of our satellite clinics, so the, the films there are a little funky. But yeah, I, I think that, you know, clinic to clinic, like you get used to what your clinical films look like and, and kind of that often gives you a better sense of like what the bone quality is, because you're used to seeing your, your gating, your exposure. And so I think when we get these films from outside hospitals that have been gated funky or, or changed, it, it definitely will, will throw you off. And that's where I think like in this situation, the DEXA is the objective like density test. Like I think I have a good eye for like Dorsi and kind of I try to plan ahead when I'm gonna cement, but, but this was a little bit of an eye-opening, one of like, "Hey, this actually looks okay, but I'm pushing on it and it's, and it's bending." Like maybe there's some pathologic metabolic process going on here. You know, I, I don't know what it is, but, but this is, this is, this is different. And the DEXA seem more in line with what we're seeing than the, than the plain films for sure.

Joseph M. Schwab 24:35

Well, I think we're gonna have to call that the Berry test from now on, right? If a cortical-- femoral cortical bone flexes with pressing,

Jeff Barry 24:42

Yeah, exactly. Exactly I, I thought it was interesting to, to bring up, and this in my mind was, was a very similar case, but I had a different role in this one. And, and I, I thought I'd bring this up just because, like, when we're in the heat of the moment and we are the primary surgeon, it's often very hard to distance yourself from, from what just happened and, and get some clarity in thinking. And, and this was one that, um, I, I was not the primary surgeon. I, I had a different role in this one. And I, I think it just-- it, it speaks to, or hopefully I can speak to kind of the, the, the process-y differences that, that at least went through my head. So this is one that had a femoral neck fracture. Um, one of the fellows was on call, and this was their case, um, to take care of. They also had a distal femoral nonunion below it with a nail. Um, and so, you know, to treat the femoral neck fracture, that, that retrograde nail had to be switched to a short nail. The trauma team also put a plate on, and then they were gonna do this, this total femoral neck fracture. And, and so the fellows, by the time they got to the part of doing the hip, you know, they're the only surgeon in the hospital from the arthroplasty perspective. They go to put a cup in and, you know, they didn't, they didn't get good serum shots. But they actually created a discontinuity putting the cup in. So the whole pelvis discontinuous, like fracture all the way across. Um, and, uh, again, this is a renal patient. You can tell this is a little more, you know, apparent on the X-ray how bad the bone is. Um, but this is one where, you know, at nine thirty at night, I had a call from the, the fellow and was like, "Hey, uh, can you come help us?" Right? And so this is a little different. Like, this is, I get to come in on my white horse. I have time to think about things like, you know, I'm kinda game planning. It's like, okay, just cement the femur. I'll be there. We'll, we'll help you fix the socket. Um, and so I, I think that this-- these, these types of situations where you have a second to step back and really think about, like, okay, what's my plan? Like, I'm gonna ask for this, this, this, and this. Like, I'm gonna be the quarterback as soon as I walk in. Like, tell circular, get this. Rep, get this. You know, uh, scrub, get this ready. Um, I think things, things go a lot smoother than when you're doing the Chris Farley and like, "Okay, give me this. Actually, I want this," and like, call for that, and like, things are just scatterbrained. Um, and, and if you have that second to really just plan ahead, direct traffic, let everyone know what's going on and, and kinda what you need to be successful, the thing goes a lot smoother. And so in this situation, we actually were able to do a cup cage really quick. So I think this took, like, thirty-five minutes from the time I scrubbed in to the time I was finished with the cup. And, and everything was ready 'cause I had called in and asked for it and said, "Have this there. I'm gonna do this, this, and this. Have the cement ready for the inner cup." And we were able to just kinda slam this thing in really quickly. You know, a different, different scenario than the last one. Both columns are out. It's not something I'm gonna just rely on a few locking screws inferiorly. But, you know, this is, this is a, a very similar problem intraop, um, but with a, a very different workflow in terms of how we got to, got to the same outcome. Um, but yeah, just, uh, just thought that was interesting. So, you know, my takeaways from this case are bad bone can get really bad, and, and a minus five standard deviation is really rare. Um, and then beware of the trap side, right? So you, you know, think of sports. There's like the trap game where you got the big game you're thinking about and some, some nothing ahead of it. You know, it's the f- it's the cup and a femoral neck fracture. It's the femur and a DDH case with a, with a Crow four or three. It's, it's that other side that you get, you get blindsided by. Um, and then the less is more or less can be more thing is a, a predominant theme. And, you know, this is a patient who y- you always hear run towards your complications. Like, I was rounding on this person every day. You send them more messages. You see them more frequently post-op. You give them more time every, every time, and, um, you know, that- that's how you take care of these patients. But, you know, uh, uh, just, just tongue in cheek, like, nice disposition risk factor, healthcare provider risk factor, follow-up risk factor, right? All these things are, are, are, are troublesome.

Joseph M. Schwab 28:45

Um, well, uh, Jeff, that, that's a, that's a great case. Um, and, and, and I have a question for you. You know, based on your-- the, that second case that you showed where you get to be, you know, riding on the white horse, right? You get to be the hero. Is your-- If you envision your role in that scenario, where it wasn't your case to begin with and, and you didn't have to be sitting at home thinking about it, planning it, um, you got to come in and got your head straight. When you find yourself in the next version of this nurse's case, right? Are you going to be thinking to yourself, "How can I be my own hero on a white horse?" Or are you gonna be thinking, "Who do I need to call to be my hero on a white horse?" Meaning, is this something you wanna grow within yourself, or is one of the messages, um, to learn to rely on others and what they can bring, um, to a, a challenging situation?

Jeff Barry 29:46

Yeah, I think that's a really good question. I mean, I, I think that, you know, the skill set for, for, for, you know, surgeons that do a lot of revisions like myself is, is definitely there to take care of any of these problems. But sometimes the, the mental clarity aspect is not there when you're, when you're in the moment. Um, and you know, I do ton of customs, ton of cup cages, ton of all these like big things. Um, but definitely there have been instances, um, where, you know, y- it might not even be an arthroplasty surgeon, it may be a trauma surgeon in the room next door that you're just like, "Hey, can you come over here and can I just bounce something off of you?" Or, "Can you just look at this and like tell me whatever you-- comes to your mind? Like, just give me another reasonable person to, to talk to here." If you're with an R2 like that, that's not a great sounding board, right? Like a, like a second-year resident's not a great person to be like, "Hey, what do you think? What, what, what should we do here?" Uh, you know, sometimes the fellows are actually very helpful and, and especially early in my practice, like I actually loved bouncing stuff off the fellows 'cause they're very close to you and it's like in, in terms of your training and experience-wise and it's like, "Hey, what, what, what should we do? Like, you know, what, what do we come up with? How do, how do we MacGyver this thing back together?" Um, now I, I, you know, hopefully eight years into practice, I, I am a little bit better at kinda stepping back and kinda thinking and, and be like, okay. Luckily, you know, the, these primaries, these are, these are few and far between where, where these issues happen. But, you know, on revisions you get, you get used to being caught off guard by, hey, that's not what I was expecting, or hey, this, you know, femur just cracked or whatever. Um, so I, I think the more revisions you do, the more used to it you get for the, the troubles in primaries. But the most humbling are the straightforward cases, right? That have trouble. I don't, I don't expect a primary hip to have trouble, and so when it does, tho- those hit the hardest and those are like, okay, you, you definitely play back that one in your head a few times that, that evening

Joseph M. Schwab 31:46

Well, a- and that was gonna be one of my questions is, you know, you, you're used to these revisions. You've got a revision mindset certainly when you're going into revision cases. And is this an issue of bringing that revision mindset to primaries so you don't ever get caught off guard? That's also gotta be kind of exhausting, right? Because, you know, revisions, while they can be exhilarating, putting that amount of time and energy and effort and thought and, and worry to a certain extent into every primary has gotta be, uh... That's gotta be just as exhausting, if not more so

Jeff Barry 32:16

Yeah, I don't think that's necessarily a sustainable practice, but I, I think that the-- You know, all of us are, are creatures of habit, and we have our workflows, right? And if you have a workflow that is complication avoidant, right? So like certain steps you know are maybe a little more dangerous, and you're kind of verbalizing that and, uh, at least in my setting, I'm teaching, and so teaching fellows and residents, and you're, you're looking for the problems before they happen. Um, I think that is the-- You know, uh, avoidance is better than trying to fix it later. And so, you know, for, for these situations, you know, this ca- you know, we, we learn from our last whatever number of cases, right? Those are the ones that stick in our minds. So-- But, but certain things will stick with you, and they will become new, uh, stepwise things you take forward. So, for example, in this now, I, I do the femoral releases of the, of the conjoin and the piriformis now for a lot of the femoral necks and for the really bad fractures, so that I don't pull that troche off, um, or, or this doesn't happen again on the troche, which, which didn't used to be my normal workflow. It's a little harder to do it when the femur's not down and under, but, but if it takes a-another 30 seconds and, and then those bad bone, bone patients, that, that might be what's needed.

Joseph M. Schwab 33:33

So the one other question I was gonna ask you is, um, obviously you do have learners. You have, uh, you have fellows with you, you have residents with you, and clearly you took something educationally away from this case. Do you think the learners who were there with you took those same lessons? Did they take different lessons? What do you think they took away?

Jeff Barry 33:55

Yeah, I mean, I-- you'd have to ask them, obviously. I mean, we, we kind of, uh, we, we discuss kind of what's going on, and I'm sure they see the, uh, you know, the, the stress in the, in the sur- in the attending surgeon when things are going wrong. Um, so, you know, I, I think that when I was a trainee anyway, and I was seeing, seeing troub- tough problems, like, I always took away kind of what their thought process was, or what are they thinking? Or I would-- You know, you don't ask them in the moment. That's a very dangerous move as a, as a trainee. But, you know, you, you kinda see, like, what is their workflow? Did they step to the back table and kinda think about stuff? Did they suddenly start to find the need to irrigate for another mir- minute or two? Did they kinda just go somewhere else? You know, go to the femur and come back to the socket, or, like, what was their workflow? Um, and I've kinda tried all those through the course of practice, and, and I th- I think I've come to my own response, uh, strategy, which is, you know, I, I kind of am more of the put the thing in the wound, turn around for a second, like, just game plan. What do we have open? What are my options? Pick one, and then what do I need? Communicate with the scrub, communicate with the circulator, like, "Hey, shit just hit the fan. Like, let's turn down the, the EDM music for just a little bit and kind of we're, we're gonna focus a little bit more for a second. Like, this is not a typical primary anymore. I need your, need your help." Um, and then go back to, to fixing the problem. And, and I think that's been the best way for me to kind of just recenter, get the blood pressure back down, and, and go at, go at the problem at hand. And then, and then you get into revision mode. You get into normal, like, fix-the-problem mode, and it's just another case.

Joseph M. Schwab 35:36

And was this a communication issue with the anesthesiologist as well? Obviously, given the, given the frailty of the patient, was that, uh, also part of your communication strategy?

Jeff Barry 35:46

Yeah, for sure. I, I think that, um, you know, you gotta be, gotta be communicative with the other side of a drape for these sick patients and, um, uh, yeah, it's like, "Hey, I just..." You know, for the cup one, for example, it's like, "Hey, I just added probably another, you know, 20, 30 minutes to this case. Just letting you know, like, it's gonna bleed a little bit until I get a, get a liner back into this socket, and, you know, you might wanna have-- If we didn't have the platelets in the room already, like, maybe call for that stuff. If we didn't cross for some blood, make sure you got that." Um, and then, you know, for the, for the femurs on these patients, I am, I am super cautious about cementing femurs. Um, I will, I will tell them at the timeout, like, that's part of the timeout when we're gonna cement. Like, "Hey, we're gonna cement," you know, whatever anesthesia intern is on the other side of the thing. Like, "Please keep the oxygen at 100. Like, run fluids a little higher. Like, I know they might have to pee or get CAFFed afterwards, but, but let's not kill them from cement syndrome." Um, so, you know, that, that's something that's already in my workflow. Luckily, that hasn't been something I've experienced, but if I cement enough, I'm sure it will. Um, but, but yeah.

Joseph M. Schwab 36:57

Um, o-one last question because at least the first side you indicated was on a normal primary total hip day. And I don't know if it was first case, I don't know if it was last case or somewhere in the middle, but assuming it wasn't the last case of the day, and maybe it was, how does that affect w- you know, not just your workflow, right, your timing, because you're used to setting aside a certain amount of time for a primary and if you're going back and forth between two rooms. But how do you take that into the next room, or how do you not take that into the next room?

Jeff Barry 37:32

Yeah, that's a, that's a really good point. Yeah, I do-- That was, that was kinda middle of the day, you know, maybe second or third case of the day. You know, we run two rooms and have multiple cases after that. I, I am not an overlapper, so I don't let other people start a case while I'm in a different room. So, so that aspect of the stress is not there. Um, like I didn't have another patient under anesthesia yet, you know, it's not something where I have to worry about that, and that's part of the reason I don't overlap ever. Um, it's allowed in our hospital with, with a fellow who's helping you or another attending on backup, but I just-- That should not come into it where I'm gonna rush something because another patient's already under anesthesia or already gotten their spinal and that's kinda ticking. Um, so luckily that, that's a decision I made a long time ago that I'm just like, "I don't wanna deal with that added, added aspect of things." Uh, I don't know how surgeons who do do that, and they're in one room and kind of another room's going, like I'm way too much of a control freak to, to, to give away that to, to, to a trainee. Um, but the, the, like bringing it to the next case is like, is, is totally a, a hard, a hard thing to do. I-I-It's impossible not to have it somewhere in the back of your mind, right? Like it-- you, you definitely have to take a second to take a deep breath though, and like in between the cases, like do whatever you gotta do. Like go get a glass of water, like take a second to go get a snack downstairs. Like for me, it's just like I kinda will just, just sit down and kind of look at the what happened, and I like to debrief myself and kinda go through like, "What could I have changed? Um, was it an avoidable thing that I made a mistake or was this kind of a, hey, this is, this is just a bad situation that, that something was gonna happen?" And I think a lot of times we're-- our, our ego's able to be like, "Okay, that was something that was probably, you know, not 100% your fault. Like there, there's some other stuff there." Like y-you know, you do these, you do these things like you do, um, like a Crow-4 or something, right? Like that's like a 25% major complication risk. If that, if that has a complication, you can't beat yourself up over that. Like certain things are gonna happen. You do your best, you try to learn from them, but, but there's a certain risk that, that is, that is just inherent to the procedure, so you have to kinda keep that, that ego to your advantage sometimes. It, it some-- Usually it's bad, but sometimes it can be to your advantage, and in between those complication, I think that's where it's good to just take a second, think about what should you have done differently, avoid it the next time, and then, and then move forward.

Joseph M. Schwab 40:12

A- and, and to be honest about it, how much of that type of debrief when you do it in a situation like this, how much of it is truly constructive and how much of it is a little bit of just beating yourself up for something that maybe you could control, maybe you couldn't? What, what's it like for you?

Jeff Barry 40:29

Yeah, and I mean, you definitely beat yourself up. I, I think I don't-- I'm, I'm decent about beating myself up later in the day, um, you know, not, not in during the middle of the day. But like I, for example, have a, a, a text thread still with all of my co-fellows from eight years ago. Uh, and we, we-- It's kind of like our confessional. Like anytime we have a problem, we go and we, we have, have confession where we're like: "Hey, look at this shit I just did. Like, I'm an idiot. Like, would you guys have done anything differently?" And, and it's a nice way to just be like, "Okay, wipe your hands clean. Like, I told someone about this. Like, it's, it's gonna be okay now." So I think having that support network wherever you get it is, is good. Like I have good partners as well that I, I can do that with. But if you're by yourself and you have no one to kinda share this with or, or kinda talk it through like afterwards, I, I think that's where you can get into trouble

Joseph M. Schwab 41:26

Uh, that's, that's interesting. I've heard the, the confessional story from a few other people. I think this is a, uh, I think this is a rich area to explore at some point. Uh, um, well, Jeff, thank you so much for, for sharing this case. Um, thank you, you know, quite honestly for what you did for the patient. I, I'm-- You know, she, uh, a- as miserable as it might have been during the case itself, it, it looks like things have, have gone okay for the moment. I hope when she shows up for her next visit, there's nothing about pain listed on the, uh, on the reason for the day's visit. Um, but

Jeff Barry 42:00

she

Joseph M. Schwab 42:00

thank you for being, being honest and, and sharing this case with our listeners. I really appreciate it

Jeff Barry 42:06

Yeah, of course. Thanks for having me. This is, uh, uh, y- as we mentioned before we came on, a little bit cathartic to go through it again. But, um, yeah, these are, these are good. I, I think it's good to share these, these bad outcomes. Like, we do thousands of these that work really well. Hip surgery's amazing. But, um, but yeah, y- you're always gonna get these if you do enough of them, I think.

Joseph M. Schwab 42:26

And 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/@anteriorhipfoundation, 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 fracture-free