Complex primary THA with AA (S+N Surgeon Roundtable)

What do you do the moment a calcar crack appears? Where does the cup go when the spine won't move? And which complex primary belongs in an ASC — and which one absolutely doesn't?

This episode launches a six-part surgeon roundtable series recorded in partnership with Smith+Nephew — peer-to-peer conversations aimed at one thing: practical, reproducible techniques you can take back to your operating room. First up, the complex primary total hip: severe dysplasia, post-traumatic anatomy, obesity, osteoporosis, and Dorr A femurs — the hips where the margin for error shrinks and the plan gets tested.

Three guests join Joe Schwab: Dr. Jessica Hooper, who leads an outpatient joint program and knows what complex work can be done safely in an ASC; Dr. Stephen Duncan, who operates from hip preservation through revision and sees exactly which traps in a primary set up the revision that follows; and Dr. Chad Watts, a high-volume hip surgeon focused on making every step repeatable.

The conversation gets concrete fast: structured planning two weeks out (CT for version, long-leg standing films — "hope is not a plan"), go/no-go criteria for the anterior approach, the low-small-medial cup strategy in dysplasia versus the oversized-cup trap, locking-screw cups in deficient bone, why triple-taper stems changed the fracture picture, automated impaction, the full decision framework for an intraoperative calcar crack, controlled medialization under fluoro (and the case for sharp reamers), where each surgeon falls on the spinopelvic spectrum, when dual mobility earns its place, and what changes between ASC and hospital workflows — including how to teach plan B and plan C so, as Dr. Duncan puts it, "plan C should not be chaos."

⏱️ Chapters:
00:00 A new roundtable series
02:06 Keeping high-risk primaries safe in an ASC
02:59 The step Chad Watts never skips
04:08 The traps that set up tomorrow's revision
05:05 What dysplasia and post-trauma change in the plan
07:39 When not to go anterior
09:00 Non-negotiables: templating, version, limb length
10:25 "Hope is not a plan": CT and long-leg films
11:41 Restoring the hip center without over-lengthening
15:09 A preservation mindset in dysplasia
16:51 Dorr A femurs: exposure and broaching principles
18:17 Where fractures happen — and how to prevent them
19:57 Intraoperative cues to slow down
23:00 Stem design, triple tapers, and automated impaction
28:18 Calcar crack: the decision framework
34:33 Keeping the room calm and controlled
35:39 Avoiding over-reaming in compromised bone
37:21 Hitting narrow cup targets under fluoro
40:13 How much does spinopelvic mobility matter?
44:01 Where dual mobility earns its place
46:24 Reproducible workflows: ASC vs. hospital
50:23 "Plan C should not be chaos"
51:48 Closing advice: mindset shifts and patient selection

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This episode was recorded in partnership with Smith+Nephew — Life Unlimited.
Learn more at https://www.smith-nephew.com

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.

#AnteriorHipFoundation #AHFPodcast #TotalHipArthroplasty #THA #AnteriorApproach #HipReplacement #Dysplasia #CalcarFracture #DorrA #DualMobility #SpinopelvicMobility #OutpatientSurgery #SmithNephew #OrthopedicSurgery

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Transcript

Joseph M. Schwab 0:21

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. Today's episode is something new for us. It's the first in a series of six surgeon roundtables we've recorded in partnership with Smith+Nephew, conversations that bring together surgeons who do this work every day peer-to-peer with one goal: practical, reproducible techniques you can actually take back to your operating room. We're starting with a big one, the complex primary total hip arthroplasty. Severe dysplasia, post-traumatic anatomy, obesity, osteoporosis, Doré femurs, the hips where the margin for error shrinks and the plan can get tested. How do you decide which cases to take through the anterior approach, and what does preoperative planning have to answer before you make an incision? What do you do the moment a calcar fracture appears, and how do spinal pelvic mechanics change where the cup needs to go? Well, three guests join me for this conversation: Dr. Jessica Hooper, who leads an outpatient joint program and brings the perspective of doing complex work safely in an ASC. Dr. Stephen Duncan, who operates across the full spectrum from hip preservation to revision and knows exactly which traps in a primary set up the revision that follows, and Dr. Chad Watts, a high-volume hip surgeon focused on making every step of the workflow repeatable. What I think you'll appreciate most is how concrete this gets. Do this, avoid that, and why. So let's join the conversation jessica, I wanna ask you, you lead an outpatient total joint program. When you're thinking about high-risk primaries, is there a principle that you use that keep cases sort of safe and reproducible in an ASC environment?

Jessica Hooper 2:24

Yeah, Definitely, I would say planning ahead. Um, simple. But, uh, that means with, the or staff, with the surgical team members, um, the reps, and also with anesthesia so that everyone's on the same page about what we need for the case. And, um, likely case duration. Um, I think. In general, in the outpatient setting, we would try to keep things as simple as possible. Um, and so it's important to that all members of the team are aware ahead of time. If anything from the norm, uh, uh, differing from the norm is happening, uh, to try to maintain efficiency as much as possible.

Joseph M. Schwab 2:59

Chad, y- you. also perform a high volume of hip replacements. If you were to pick out one step in your anterior approach, primary workflow that you never skip because it consistently helps you prevent a complication, what would that be?

Chad Watts 3:18

Oh, it's a tough. tough tough question, trying to pick just one, one step. Right. I think the beauty of a, of a nice surgical flow is that really every step kind of sets you up for the next step. And so I really try my best not to skip any steps. And I think that's really, really probably the secret. But I think when you look at just preventable complications, um, in my mind those are probably almost always due to exposure issues. Right. And I think especially starting out when I, I when I was Beginning, and I think probably one of the biggest struggles for newer surgeons is really that, cer- that femoral exposure, right? It's late in the case. You're getting tired and sweaty and wanting to be done, and it's just tempting to maybe start broaching before you're really ready. Um, I think for newer surgeons, that's really gonna be the key is just don't start broaching until, until you're really set up for for success there.

Joseph M. Schwab 4:08

Hmm. And Steven talking about anterior approach and revision work, when you're actually seeing a complex primary, uh, is there a common trap that you see that sets up a case to maybe become a revision later?

Stephen Duncan 4:29

I mean, it's just like I said. It comes down to the planning. So if you failed to plan for, say, poor bone clot on the socket side where you don't have a revision cup with maybe locking screws or you didn't quite understand the version on the femoral side, and you get in there and the version's forty degrees and you don't have a version-changing stem, that's a failure to plan and. Really all the pre-op planning, I do it two weeks ahead of time. Um, so that reps have everything available so that they're not scrambling to bring something in that may not live in your city is, is helpful not only for the patient, but also for the reps that, uh, you don't want them having to be the courier at two AM trying to get stuff at the airport.

Joseph M. Schwab 5:05

Yeah. And so let's talk a little bit about complex primaries and, and case selection and, and Steven, I'm gonna stay with you. When you look at a complex primary. Think of a, a Crow3, co Crow2 dysplasia, severe deformity, post-traumatic changes maybe, or obesity. What factors fundamentally change your plan, uh, specifically when you're thinking about doing it from an anterior-based approach?

Stephen Duncan 5:33

Yeah, I mean the socket side is not always super challenging and maybe in the dysplastic case when they have a high hip center. But it's really the femoral side. And uh, as I said earlier, uh, planning for what stem you need, do you need a version-changing stem? 'cause you may need to prepare for a little bit bigger release. Maybe you're not doing a bikini that day where you have to get more up on the TFL, and you gotta be able to put a straight stem in or. Perhaps you could get away with a shorter stem in that obese patient, so you don't have to do as big of a release. So again, really understanding the femoral geometry is really what drives probably the, the harder anterior stuff to make it easier.

Joseph M. Schwab 6:09

So Jessica, from an outpatient setting, uh, is that the same factor that influences your sort of pre-op planning or what do you think about for optimization?

Jessica Hooper 6:22

Yeah, I think beyond what Steve just mentioned, um, the other thing that I'm thinking about is how much equipment I'm gonna need to do the case and then how long. The case I expect it to take, um, because as we know, outpatient centers are not really set up to process a huge amount of trays and have multiple options for your, your plans, A, B, and C. Um, so do I need a lot of equipment? Is my, is my first question that I'm asking myself. Um, the second one would be if I'm removing hardware, how long do I realistically expect it to take? Um, because. you know, Going back to the, the thing, the piece about efficiency. Um, if I'm, you know, fighting to get an old femoral nail out, uh, that block time at that outpatient setting might be better used by more simpler cases. Um, but I do, um, I will discharge some more complex primaries from that hospital setting. Um, so not necessarily in a surgery center. Um, and I think those patients can go, um. Home safely if they have good social support. Uh, you know, the patient doesn't have any other medical issues that would preclude them from going home safely. And then, um, how extensive of a reconstruction is done during the surgery? So if is there major blood loss or any issues like that?

Joseph M. Schwab 7:40

Chad, are you doing all of your say, higher-risk primaries through an anterior approach, or if not, what are your personal sort of go no-go considerations.

Chad Watts 7:52

Yeah, I mean, I think anterior approach is definitely the default. That's, that's where I'm doing the vast majority of them. Um, there are a handful of things where, um, if I see I'll tend to do a more laterally based or posterior approach. You know, that'd be things like, just totally unacceptable soft tissues from the front. Um, hardware that needs to be removed and can really only be done well or safely from the back. Um, a head or top calcification that's more posteriorly based that I need to excise. That would be hard to get to from an anterior approach. Um. Non-unions or fractures, of the greater trochanter that need to be stabilized. Uh, typically I'll do, uh, from a laterally based approach. Um, then the other thing we see sometimes is, is, uh, especially in like debilitated folks, maybe in the hip fracture population, most commonly people that have been in a wheelchair for a long time, they come in with significant flexion contractures through their hips and their knees. Um. As a HANA table user, um, can be pretty difficult sometimes getting good exposure on those folks. If they've got significant flexion contracture, usually they've got really bad bone that accompanies that. So a lot of times I'll, I'll typically go through a more lateral based approach, uh, for those patients as well.

Joseph M. Schwab 9:00

Hmm. Jessica, are there sort of non-negotiable questions when you're thinking about doing more complex primaries through an anterior approach? Things that you might want answered preoperatively, like for instance, templating or figuring out a limb length strategy or what your femoral version might be, or instability risks.

Jessica Hooper 9:21

Yeah, of course. Um, I always template my cases and also try to do it a-ahead of time as well. Um, my default for the majority of cases is a short, uh, triple wedge taper stem, um, which does work well in, for most, um, femoral morphologies. But I think there are certain situations such as very poor bone quality, um, in which I'd w-want to have a cemented stem option. Um, something with. You know, a huge amount of femoral anteversion, um, and I need a stem where I can set it. Um, those are things I need to know ahead of time. Um, And then I think limb lengths depends a bit on the situation. Um, you know, are you able to, to restore the hip center to the native position? Um, has the patient always been short or are they short because of post-traumatic situation osteonecrosis? Um, I get a standing x-ray, um, also to see how they stand, if there's any spine issues that play a role in that as well. Um, and um, I think most of the time. I am shooting to restore their limb length as much as I can, but it's not always possible.

Joseph M. Schwab 10:25

Hmm. So Steven, you also mentioned preoperative templating, I think you said two weeks ahead of time. How valuable is your structured pre-op planning in helping you sort of anticipate challenges and align your plan, what you wanna do with, um, what you have available to you in the operating room?

Stephen Duncan 10:49

uh, I'm a big F1 fan and from the movie, S- and Sonny Hayes says, hope is not a plan, right? So if you don't plan appropriately, you're gonna be fooled. And, uh, being a hip preservation at its h- uh, heart, we're starting to understand more version abnormalities. And so I'll get long leg standing films and if you notice some abnormalities at the lesser. but Sometimes you'll see at the knee, if they have a really internally rotated profile, they may have more version abnormalities that you're not picking up just on an AP pelvis. So we'll utilize CT scans to truly define what their anatomy is, so that way you can have a better sense as maybe they have fifteen degrees of anteversion, but gosh, I thought they had thirty. and vice versa. Maybe they have sig-significant retroversion where I think the anterior approaches could probably tolerate a little retroversion, but if they have significant retroversion, you may be fooled and go, gosh, I didn't have a version tint and STEM that day. So that information's very valuable.

Joseph M. Schwab 11:42

Chad talking a little bit more about some of these complex primaries. When you think about folks with, um, uh, acetabular dysplasia, post-traumatic hips, um, how do you prioritize restoring, um, center of rotation, achieving good femoral coverage, protecting the soft tissues, while also avoiding over-lengthening?

Chad Watts 12:05

Yeah, I think that's, uh, that's a good goal. All those things you just mentioned, that's, that's basically what we're shooting for. I think if you look at dysplastic hips, um, seems like back in the day in training, the debate was always, you know, do you, do you go for a high hip center, and anatomic hip center? Um, and when you look at that actual definition of what a high hip center is, it's, it's raising the, the hip center like 15 millimeters or more, which. Really is uncommon. And I, I haven't met anybody that's really a proponent of that approach, although I'm sure they're out there. Really what I've seen more nowadays is, you know, pretty much everybody's in favor of more of an anatomic hip center. Uh, you know, and in dysplastic, there's a couple ways you can do that, right? You can, you can stay small and medialize, and there's other folks that tend to go with a little bit of a bigger cup and, and try to avoid going through that medial wall. Um. In my experience, the latter of those approaches where you, where you stay big and avoid going through the, through the medial wall, kind of sets you up for a, for a few complications. One of those is soft tissue impingement, like you mentioned. You're gonna tend to have the edges of your, of your socket proud and prominent, and that's also gonna push your hip, you know, down and away. So you're gonna tend to have too much offset, and you're gonna have a tendency to, to maybe even over-lengthen them sometimes in those sorts of situations. So, me personally, I really am a proponent of, you know, I, I try to keep my cup a little bit on the smaller side, and I'm definitely not afraid to medialize a bit, right? So when I'm reaming I try to, you know, I, I visualize, I'll put a reamer or maybe a, a cup trial in and try to get a sense of where it's gonna wanna sit. And then as I, ream, I'm gonna go nice and slow. I'm gonna stop and check multiple times visually and put my finger in there and feel the walls, and, you know. uh, Keep an eye with fluoro and then just do a nice controlled, usually kind of medializing that cup in a little bit. And then I know I'm medial enough when, when my, when my cup walls are covered and, and I feel like there's enough superior bone coverage. Um, and then in those patients, typically I'm using a REDAPT cup, which has been honestly a, a game changer with these situations. The ability to put locking screws in these patients who don't have a ton of bony support. Um, you know, you get that cup medial, put some locking screws in both above and and below. Um, and it, you get great fixation that way. Plus it, it's covered. You're not gonna have soft tis- have soft tissue impingement. Plus then when you go to the femoral side, uh, you're not fighting with a cup that's, that's too low and too lateral. Um, which I feel like really sets you up to be able to be a little bit more, gives you a little bit more flexibility on the femoral side. So you're not fighting that quite so much.

Joseph M. Schwab 14:50

And Steven, I wanna ask you talking about acetabular dysplasia with your sort of preservation background preservation mindset. Does that push you to be a little bit more conservative with patients with painful dysplasia, or does this, do you rethink your approach to them entirely? How do you approach it? That would be, say, different than a classic, um, joint replacement surgeon.

Stephen Duncan 15:16

Yeah, I mean, I'm, well, I'm not a push for doing a PAO, um, one 'cause in the post-PAO patient conversion to total, uh, as Chad alluded to, I mean, there are challenges when they still have that, uh, vertical socket. And so By doing the correction, y-you make it easier assuming that you don't severely retrovert them or get a malunion, or non-union for that matter. But it does make the conversion a lot easier, um, to put a more or less a standard cup in. if you actually brought their hip center down a little bit, so, um. I've found it's been easier to do those conversions. Um, PAO for us is now, it's an outpatient procedure, um, takes a little over an hour. So where it used to be this God-awful, you stay in the hospital for days on end. Um, now we actually sort of push the indication because long term, uh, I do think it makes it easier for the next surgeon to potentially convert them over.

Joseph M. Schwab 16:06

And Jessica, any pearls for managing these types of patients specifically in an outpatient environment?

Jessica Hooper 16:14

Yeah. Um, I. Think the, the biggest ones that are haven't been mentioned yet are probably the non-surgical aspect. So what's the social factors and support for the patient? Do they live really far away? Um, are they, do they have enough people who can help them at home? Um, usually the patients are younger, um, who are. Dysplasia patients having, uh, conversions to total hips. So they, uh, I think ex- setting expectations with them too, um, is important. And then, uh, if they have any other medical comorbidities that would affect their ability to tolerate perhaps a longer anesthesia, um, and more blood loss.

Joseph M. Schwab 16:51

Hmm. Um, I wanna switch gears a little bit and talk about the femur. And Steven, you mentioned the femur as being an important, uh, sort of consideration in your approach. So when you're dealing with real dense femoral canals Dor a femur, uh, through an anterior approach, are there specific exposure or broaching principles that you emphasize to avoid either fracture or perforation?

Stephen Duncan 17:19

So one, yes, as you alluded to, uh, y-you got to see it. Um, and making sure that you're actually in the canal. So it's the benefit of doing da. You can use fluoro, uh, specifically if you're starting out to make sure that you're in the canal. Um, we have rasps that, uh, can help open up that. Uh, bottom part, uh, you do have to be comfortable in sometimes opening up reamers, uh, 'cause you don't wanna pot your stent distally. And so being comfortable getting that straight reamer in, um, and not reaming acetabular sub bone. Um, so being able to expose the TFL to get that femur up so that you can ream the bone appropriately and be okay. Sometimes, yes, you're gonna put a cable on prophylactically, there's no harm in putting that on. You know, an ounce of prevention goes a long way. And sometimes we'll even touch on that dreaded thing called cement. Um, Sometimes you gotta cement these femurs once in a while, and so having that discussion with anesthesia to say, Hey, you know we're gonna cement today. Maybe we wanna give him some fluids so that no one wants to do chest compressions.

Joseph M. Schwab 18:17

Uh, Chad, wh where do you most often see fractures occur, and what do you do to prevent them?

Chad Watts 18:26

Yeah, so I think, I mean, your most common fractures, right, there's, there's gonna be the calcar cracks, the greater troche fractures and the perforations, right? And the, to me, the, you know, the calcar cracks are gonna be that anteromedial crack. It's usually, you know. Older women, maybe with a smaller, smaller neck, um, that's gonna happen. You know, putting in a, putting in a tight roach or tight stem, maybe even taking a tight roach out, um, you're gonna see those pop up. The greater troche fractures are kind of typically, um, you know, tougher exposures, right? You're tending to maybe you're pushing or pulling on things a little bit harder than you should be. Um, especially in pe-people with bad bone. And again, your perforations are gonna be more like Steve alluded to, where you just don't quite have that exposure, right? You're trying to cheat that stem in there, even though you're not, you don't quite have uh, line of sight and, and your, and your stem in the right angle. So I think kind of acknowledging when they happen is important because then you can kind of anticipate what's coming and do your best to avoid those. Right? So, so again, at the end of the day, having a good exposure and if your exposure isn't good enough, then you, then you pause and you get better exposure. Um, and again, triple taper stems to me have been a game changer. Um, I used to use more of a rectangular stem and you'd, you'd, you'd... even in a perfect exposure, sometimes you'd still get a little anteromedial calcar crack. Um, and with the triple taper stems, it's almost like, that's just, it just doesn't happen the way it used to with the, with the rectangular stem. So that's honestly been the biggest game changer in my practice from a fracture standpoint.

Joseph M. Schwab 19:58

Jessica, are there intraoperative cues that you see that tell you to kind of maybe slow down or reassess what you're doing during your femoral prep?

Jessica Hooper 20:09

Yeah, Definitely I think first when I first externally rotate the femur, uh, before I drop the leg. Um, just noting how difficult that is. Um, is it hard to get the leg to 90 degrees? Is there a lot of tension? Um, when we externally rotate that. Tells me, um, maybe I need to pause, maybe I need to think about extending proximally, uh, releasing some of the TFL off of the pelvis, uh, to just help get that exposure so that I can see. Um, and then the second one I would say is, is once the femur is exposed and starting to broach. Looking at my templated size and if a, a small broach, so way under where I expect to be isn't advancing easily. Um, stopping, uh, or taking an x-ray, bringing in the fluoro and taking an x-ray with the broach in to make sure that I'm aiming in the right direction or I'm not directing the broach out, uh, posteriorly, um, is hugely helpful and I think, um, prevents a lot of complications.

Joseph M. Schwab 21:06

Mm-hmm. And staying with you, Jessica, how do canal morphology and maybe bone quality influence your femoral strategy when you're doing a complex primary, especially. When you're sort of balancing, you know, fixation of the component, protecting the soft tissues, and being able to do this in a reproducible way.

Jessica Hooper 21:27

Yeah, absolutely. I think the um. It it influences stem choice, you know, simply, um, I think the, the triple taper stems are really versatile, and I would say I probably use them for, you know, 90% of my primaries. Um, but the, the, the other 10% either with really poor bone quality, um. Really small patients, um, abnormal version on the femur. Those are things that I, that I notice, um, and pick up in my templating, um, so that I can anticipate challenges, prevent fractures, um, or prevent mal, uh, malrotating my stem while I'm, while I'm broaching. Um, and, and knowing if I have to go away from that, that triple taper. Um. I think that another one too, that, that we probably talk about less is the, um, patients who are very small but also have a lot of offset. Um, that can be kind of a tough one to, to plan for. Um, because if your, if the, if your go-to for really small patients or, um, dysplastic patients is, is a Wagner-style stem, it doesn't really have a lot of offset options. So, um. You either have to compromise on that, um, and accept less version or think about something else. And I would say in that setting, um, cement can be a good option, um, or even going to a short revision style stem, which are a bit longer, but tend to have more options for setting offset.

Joseph M. Schwab 23:00

So you've all kind of mentioned, you know, using a a, a triple tapered stem and it, you know, it seems to me as though the market has been moving towards that. So Steven and Chad, I just wanna ask you. um, When we're talking about these different femoral morphologies, these different canal morphologies, how do you think about stem system design? Um, for example, s- the, the catalyst stem as part of achieving, uh, your predictable fixation while still allowing you to make some changes intraoperatively to achieve stability or verify leg lengths?

Stephen Duncan 23:40

So with Catalyst, I mean, I came from using Polar and Polar's a great stem, but a little longer. And it, it basically, the canal sort of dictates how that stem's gonna go in. Uh, catalyst being shorter, if you look at the morphology of the proximal femur we'll have some that have very little offset and are more or less valgus. And then you have some that are more varus. And as Jessica alluded to, if you. Maybe if the person has got a a lot of offset, you wanna leave them some varus, uh, and that stem tolerates it very well, versus the one who doesn't have a whole lot of offset, you can actually put him in valgus. And the nice part is, is when you, uh, pair it with automated impaction, it kinda tells you where that stem is supposed to stop as opposed to the, what I call the a thousand times that you have to do a stem before you feel comfortable knowing that this is what's actually gonna work.

Joseph M. Schwab 24:24

And, and we'll talk a little bit more about automated impaction later, but Chad, I I wanna ask you, in these dense femoral canals, is there something in your hands that makes femoral preparation sort of more reproducible? And it, it could be something like the sequence of instruments that you use, or your pacing, or the use of imaging, or maybe it has to do with how you choreograph your team. What, how do you feel about that?

Chad Watts 24:51

Yeah, no, I think, um. I definitely add a couple steps in those, in those patients. And, and really, I, I start thinking about even from the initial exposure, right? I mean, in those patients, maybe I'm making the incision a little bit longer, and a little bit different spot, you know, as I go through the, the preceding steps, I'm really focusing on trying to make my femoral exposure, uh, optimal. And then, um, once I get to the femur, I, I definitely add a couple steps. So usually I'm starting with a canal finder and then going to a, like a rat tail rasp. Which I think most systems have, uh, just making sure I'm in the canal, I'm oriented, I know where I'm going, and then I'll take a rongeur and kind of open up some of that. Proximal bone tends to be quite hard, uh, so I'll take a little bit of lateral and posterior lateral bone. And then if, if I have any concerns getting that initial, uh, starter broach down, like Jessica mentioned, I'll bring fluoro in and just check an AP and a lateral. Make sure I'm happy with my orientation. And again, a lot of times as Jessica mentioned. It's gonna tend to kick that, kick that stem on the lateral view. You might notice you're headed quite posteriorly. And so that's a sign to take a little bit more of that posterior lateral bone, which usually opens things up quite a bit and lets you, lets you have better access to the femur. Um, you know, and then I, in those patients I always have, uh, flexible reamers around just in case I need them. It's not super common that you need them with the triple taper stems, but, uh, when you do need them, it's, it's, uh, invaluable to have those around just in case.

Joseph M. Schwab 26:18

Hmm. And Steven in, you mentioned automated impaction. Um, do tools like that, um, help reduce th-the variability of what you experience in tougher primaries or how do you s-assess those tools, those types of tools?

Stephen Duncan 26:38

Yeah, I mean, I'm always a slow adopter of new technology and, uh, as I've gotten used to using the automated impactor, it really has made life easier. where, um, Usually we'll do a two-broach system. We do a starter, then go to the templated size. And it-- when you're doing six to eight cases a day, I mean on number eight, your mitochondria are a little worn out. So hitting a trigger versus hitting something 200 times and still being able to do stuff after work is kinda nice.

Joseph M. Schwab 28:18

So Jessica, I wanna come back to you talking. Uh, I think, uh, Chad had mentioned about calcar fractures. So if you see a calcar fracture occurring and it's during a, a more complex primary, Walk me through kind of your immediate decision framework w-- through recognition of the problem, your assessment of maybe broach stability, what your concepts are for fixation, and whether you're gonna stick with Plan A that you came into the operating room with, or whether you're gonna be thinking about other plans.

Jessica Hooper 28:52

it depends on which part of the case it occurs. Um, you know, if, uh, it's, it's a, it's a complex hip such that the, you know, patient is very small, has small offset, it's harder to get enough, uh, mobilization of the femur. Um, you know, I think at that time, it, the, the most likely fracture that happened before you start broaching would be of a greater stroke while you're trying to bring the femur up out of the, um, out from behind the, the acetabulum. Um, so, you know, I think, um In that situation, I would, I would probably proceed with broaching as planned, bring the, you know, bring the leg up, reduce the hip, um, and then take a lot of fluoro shots and really kind of better characterize the, the size of the troche fracture and the extent of it, um, and how much it moves as I'm, uh, you know, evaluating mobility of the hip. Um, and if it's, uh, a relatively large piece, it has both the, um, abductor and vastus attachments on the fractured piece, um, often I'll leave it, um, and it'll, you know, the, uh, the digastric muscles will hold it in place, so it, so it'll essentially scar in there and won't really cause a problem, um, in terms of stability for the pa- or pain for the patient. Um, but if it's a smaller piece, um, it's more of a tip, uh, or if it's, it's like a, you know, a huge, massive fracture that's extending distally, then, um, often that'll necessitate a second more lateral incision to be able to actually, uh, you know, do appropriate fixation of it. Um, and then, you know, thinking about calcar fractures, um, in general, I would say they're less, you know, definitely less common using a short triple taper stem than they are with certain other types. But, um, I think it's important to just be very vigilant in watching for them. Um, looking at the calcar while you're, you know, both, both broaching, um, and also taking the broach out. Sometimes you'll notice it then. Um, and sometimes it's even just more kind of punctate bleeding on the calcar. Um, and so if I see that, I... What I'll do is uh, just take the, take the broach out, raise the leg up, um, and then I, I, you know, get a better idea of how, how far the fracture extends. You can extend this incision better, um, really see if it just is, is truly just a calcar crack or if it extends much more distally bel- beyond the lesser, um, past tables, Um, usually just one proximal to the lesser, but occasionally a second one if it, if it does extend a bit more distally. Um, then reexpose the femur, proceed with broaching, um, and then check stability as I normally would. Um, and I think in that situation, I would say the bone quality would determine most if I protect the weight bearing or not. Um, I, I haven't had it happen to me yet. Say knock, knock. But, um, but, uh, you know, I, I, having a calcar fracture or a huge fracture that extends really distally, um, I think that would then cause me to basically change my, my, um, stem choice. You know, h- really have to expose a lot more of the femur, um, multiple cables potentially, m- perhaps even a plate, depending on what the situation is. Um, and then if that were the case, I would likely go with a more diaphyseal engaging stem, uh, just to make sure that, you know, give the best, the, the best, the patient the best chance to heal.

Joseph M. Schwab 32:16

Hmm. Uh, and a couple of quick follow-ups on this. So you started out talking with troch fractures, and it-- I-- it's very common that I hear, you know, when you've got those sort of digastric troch fractures, um, that people will leave them when doing it from an anterior approach. Um, does it at all, um, affect what you think about their postoperative stability? And do you change to something like a dual mobility construct, um, i-in those circumstances, or would you just do your normal primary articulation?

Jessica Hooper 32:52

No, it wouldn't necessarily make me switch to a dual mobility. I, I would say that's probably a situation in which I, I would probably try to evaluate posterior stability, like take the, um, the foot out of the table lock, I guess, or the boot, unlock the boot from the table, if you will. Um, I, you know, flex the hip up to 90 and then internally rotate to see if that piece is gonna impinge anywhere. Um, and I think if that were the case, I might try to give a little bit more offset or, um, and/or, you know, I, I don't know that a dual mobility would necessarily add much in that situation. Um, I think, you know, from a stability perspective, the, the tension on the vastus, um, keeps good tension on the abd- on the abductor muscles. So I, um, I haven't really f- found myself in a situation where I, I feel like the stability's not great and, you know, with the, with the fracture and that dual mobility is the answer to fix it necessarily.

Joseph M. Schwab 33:48

On the calcar cracks that you mentioned, are you putting in, generally speaking, collared stems or non-collared stems? And does that affect your decision about how far you will go to look for the propagation of a fracture and whether or not you put cables?

Jessica Hooper 34:05

I do use a collared stem routinely. Um, I don't think that it would make me less likely to put a cable if I, if I saw a calcar fracture or, um, make me not expose fully. Um, you know, I, I've, I've heard it kind of anecdotally of people otherwise being like, "Oh, it's like you have a collar, it's fine," but I don't know, it just kinda doesn't really sit, sit so nicely with me.

Joseph M. Schwab 34:33

So Chad, what keeps I, I haven't operated with you, so I don't know how you're gonna answer this question, but when one of those calcar cracks occurs, what keeps the room calm and controlled? What-

Chad Watts 34:49

Calm and controlled. Yeah, so I, um, I think age and experience. I think yes, my or team, I'm definitely more calm and collected than maybe I used to be when these sorts of things pop up. But I think, honestly, I think it just takes, you gotta change your mindset a little bit, right? You gotta get out of efficiency mode and, and get into, okay, we're gonna fix this calcar crack mode. And I think. you know, having cables there obviously makes a difference, right? I've heard of people, you know, not having cables at their ASC. That sounds crazy, right? So, I mean, you gotta have equipment there to deal with these issues when they come up. Um, you just gotta know the steps, right? you just, you just gotta do it one step at a time, just like Jessica mentioned. Um, you know, and, and things you're gonna be applying. But it's the, the big thing is you just, you deal with it, you acknowledge it, you fix it right now, so you don't have to pick, come back and fix it next week. Um, you know, and then you get on with your day.

Joseph M. Schwab 35:41

Stephen, uh, we're gonna swing back to the acetabular discussion for just a minute, and I wanna know, when you're dealing with a complex primary or maybe somebody with compromised bone quality, what are you doing to avoid over-reaming or maybe unintended drift in your acetabular orientation? While still trying to achieve your stable acetabular fixation.

Stephen Duncan 36:06

I mean, in large parts we used to start, you know, eight sizes below the templated cup size. And as we've migrated along, we've learned probably use a bigger reamer and fewer of them to help kinda avoid over-medialization. Um, and so that's been one change. Usually we'll measure the head size, just to confirm, and usually you're, if you measure like a fifty, you're putting a fifty-four cup in. Um, the other part too is, uh, I, I really like fluoro. Um, and so what we'll do is we'll park fluoro Over the hip itself and do controlled medialization. Um, I actually use the lift to and put the reamer into my shoulder. So instead of pushing, I'm actually pulling in a controlled fashion. And you can see how far you're medializing. And uh, it-- the other part too is know how new or old your reamers are. 'Cause if you have brand-new reamers and you go uh, full bore action, uh, or a resident or fellow, and all of a sudden you're staring at iliacus, um, you, you get a little sad. So I always ask the, the rep, you know, how old are the reamers for the day to know? Do we need to push a little bit or a lot that day?

Joseph M. Schwab 37:08

Hmm. Do surgeons get to use new reamers? Is that a thing? I, I wasn't aware that that was an option. Um

Jessica Hooper 37:16

If you have a good rep

Stephen Duncan 37:18

how OCD you are.

Joseph M. Schwab 37:21

um, uh, but uh, Jessica, I wanna ask you when, um, as speaking of acetabular preparation, when your orientation targets, you know, it used to be that we wanted to be 15, 20 degrees either side of something and 10, 15 degrees, either side of something else. Um, but nowadays we're going by degree. Right, and so when you've started to narrow your orientation targets, and maybe you're taking into account functional position and spinal pelvic motion and all sorts of things, and you have a really narrow target, you wanna do what is helpful to you within an acetabular platform to both hit your functional goal without maybe over-expanding your exposure.

Jessica Hooper 38:09

Or, Uh, using the fluoro first and foremost. So I always try to. In the very beginning of the case, get a shot of the pelvis with the fluoro that looks like the pelvis does on the standing x-ray of the patient from pre-op. Um, and then slide it, you know, boom, in the fluoro from a, from a pelvis to a hip position. Um, and I do ream under fluoro always. Um, on the cases where the, the margin for error is small, let's say, um, I always feel the walls anteriorly and posteriorly first with my hand to know how, how thick or thin they are. Um. and Then I actually always ask to have sharp reamers, uh, um, because if you don't, and you're, you, you're, I find that my arm toggles more when I'm, when I'm reaming in 'cause I'm having to push harder, so I might jostle up or down. Um, and then instead of having a nice hemispherical shape, it's more oblong or just abnormal shaped. Um, so keeping a sharp reamer helps and then in an, in a normal, um. Let's say a normal pelvis, normal spinopelvic mobility. Um, I usually, I tr often a one-shot ream it, Um, so just do my, my final reamer size and then put in the cup. But these ones that, that it's a little bit, um, you know, more delicate, let's say. Um, I'll ream and then stop kind of, kind of reassess with my hand, making sure I'm where I wanna be and then go ahead, um, and do that more times. So just slowing down I think helps a lot.

Joseph M. Schwab 39:37

And Are you guys reaming with straight Reamer handles? With offset reamer handles? Um, Steven, what do you use?

Stephen Duncan 39:47

Uh, I'm a straight reamer person. I think I can control it a little bit better. Um, and you can still do it through a relatively small incision without, uh, buggering up the tissues.

Joseph M. Schwab 39:56

Jessica, how about you?

Jessica Hooper 39:58

Straight. as well

Joseph M. Schwab 40:00

Okay. and Chad.

Chad Watts 40:02

I use an offset reamer. I think it's a little bit easier to get past the femur and uh, gives me a little bit, uh, uh, better access in tighter windows.

Joseph M. Schwab 40:13

Mm-hmm. So, um, Chad, Jessica mentioned, you know, spinal pelvic. Mobility issues, spinal pelvic imbalance in complex primaries where you suspect, or maybe you've done some radiographic evaluation and you've got concerns about spinal pelvic mobility, how does that change your planning and how does it change the target for your cup position?

Chad Watts 40:36

Yeah. Um, that's a complicated topic. I'm a simple man. Um, I try to, m- not to make things too complicated, um, you know, but I think, you know, when you're seeing people in the office. You can pick up a lot of these things, right? You look at their, You have a pelvis x-ray, and you can, you can see the bottom of their spine. You can see if they've got hardware in their pelvis. You can see if their, you know, spine comes off at a 45-degree angle to the road through their pelvis, You know, you can see if they're, if they're standing with a, you know, outlet or relative inlet view on a standing AP pelvis. And I think that's, that's kinda how I clue in that maybe there's some. Um, some abnormalities we need to pay attention to. So just like I think Steve and Jessica both mentioned it, when I'm, when I'm reaming, when I'm setting up fluoro, I, I try to match that to their standing AP pelvis that we had in the clinic. Um, and then I more or less try to put my cup in based on that orientation. Again, making sure that I'm not leaving the cup proud or prominent where it's gonna rub or irritate on the soft tissues. And again, if it's a patient I'm worried about that has a significant deformity, then I'll just go to a dual mobility implant. Um, you know, which I think a dual mobility implant through an anterior approach, the risk of dislocation would be quite small.

Joseph M. Schwab 41:47

Yeah. And so if we were to classify surgeons as, and, and I recognize this is a spectrum, but talking about spinal pelvic. Mobility. There are surgeons who are, that is everything that they evaluate is spinal pelvic mobility. On the other end of the spectrum, there are the surgeons who say we're doing it through an anterior approach. You don't even have to think about spinal pelvic mobility. And then I would say there's a, a large group of surgeons who are in the middle. I like to think about it, but it's a complicated topic. I like to make it simple. Sort of like you said, Chad. Chad, I think I know where you fall there, but Steven and Jessica, where do you guys put yourself on that spectrum?

Stephen Duncan 42:26

So when I first started, I was a posterior surgeon. Uh, and so yes, I cared, uh, because hips dislocate out the back when I finally went and saw the glory of going through the front. Uh, mind you, I do think you have to preserve soft tissues. Um, I mean, as a hip preservationist, it makes zero sense to me to cut out a capsule. Um, and so s- saying to Chad, you target their functional position, but if you keep the capsule, you d- don't touch the posterior stuff. They just, they don't seem to come out.

Joseph M. Schwab 42:55

And Jessica, how about you?

Jessica Hooper 42:58

Yeah, I, um, I'm in the middle of the spectrum, but I think through the, through the anterior approach, I think there, it's very rare that you have somebody that, um. uh, uh, That I have someone that I'm really concerned about. Um, I think as Chad mentioned it, but like the, the, s- the standing pre-op AP pelvis gives you a lot of information about where they stand. Um, I do, I do often get. The lateral x-ray of seated and standing pelvis too. Um, just to pick up if they have any, any stiffness, um, or hypermobility. Conversely, and honestly, a stiff, a stiff spine, you know, where the pelvis is gonna sit. The x-rays show you that, so then you can adjust your cup position accordingly. And those people, I'm not usually using, um, uh, dual mobility or anything more than a standard bearing, but the, the hypermobile ones, um, or. uh, patients who have a long, um, spinopelvic fusion, I often will go with the dual mobility for it, just so just kinda hedge my bets. But, but the, I agree that the dislocation risk is very low.

Joseph M. Schwab 44:02

Hmm. And Steven, both Chad and Jessica have mentioned use of dual mobility in certain selected cases, in selected high-risk primaries for you. Um, where might a dual mobility option, like OR3O fit as your preferred choice or maybe a targeted choice?

Stephen Duncan 44:24

I mean, yeah. Ortho is, uh, with their dual mobility with its Auxinium And then, um, uh, for the liner and then also with the, uh, Auxinium, uh, inner ball, uh. it, It definitely helps your jump distance compared to just the standard, uh, kinda, uh, flat poly. Uh, and the better part too is if you look at longevity data, um, having most of the articulation at the inner portion, you do get the jump distance part. But one of the little things we don't really talk about is what's the longevity of the implants? And with some of the data coming out from Lancet recently where it should be a 30-year hip. If we go back to using a smaller head, which we typically have a 22 and 28 head, y- maybe we get some better longevity where we can say perhaps we'll get more 50 years out of some in, uh, these constructs. 'cause we're using them in some of these younger patients, whether it's the dysplastic or you know, we've got the scoliosis patients now with dysplasia as well. So thinking about some of these younger patients I do think that, uh, we can maybe get some long-term-- longer-term survivorship for these folks as well. with using the dual mobility

Joseph M. Schwab 45:23

And with your history with hip preservation, and I know over the last 30 years, hip preservation has really started to understand a lot more about things like acetabular version, native acetabular version and orientation. Has that affected the way you think about functional Cup position in a complex primary?

Stephen Duncan 45:47

Yeah, I mean, it's always interesting. So if we see somebody who has more of the anterior pelvic tilt where um, we're worried maybe they will come out the back. Do we need to then, uh, spend a little bit more time on dialing in their cup position? Taking down some of the osteophyte where if we match their position, perhaps will they come out through the back on an anterior approach, which again, should not happen. But yeah, it, it really does force me to pay closer attention to what that acetabular version's doing. Maybe not as much on the abduction side as we've learned, but really the version is what really drives a lot of the instability picture that we see, whether it's through the front, through or through the back.

Joseph M. Schwab 46:24

Hmm. So I wanna shift gears just a little bit, um, because we've got an ASC sort of specialist and we've got, you know, folks based in a hospital and I wanna talk about. um, Workflow and especially workflow for reproducibility. 'cause whether you're working in an ASC or whether you're working in a hospital, everybody doing total joints wants to be able to do them reproducibly. So Jessica, I wanna start with you talking about a reproducible workflow for complex primary totals, um, specifically through an anterior approach. What does that look like in an ASC From your perspective, if you can walk us through things like patient optimization, planning to instrumentation, intra-op decision-making, and discharge readiness. And I recognize that's a big question. So, uh, w- really just hitting the highlights of each of those areas.

Jessica Hooper 47:17

Okay. I'll, uh, I'll try to be as succinct as possible. Um, but so healthy, patient, good social support. Um, the. Complex case is not too complex. Let's say, uh, you know, not removing like 40-year-old overgrown nail and, uh, in someone who's also had a, a terrible acetabular fracture failure, like that's gonna take you a long time. And that's not an appropriate case for the outpatient setting, but maybe prior PAO, um, short nail that has failed somewhat acutely. Um, if the patient is healthy, I think those are reasonable cases to do in an outpatient setting. Um. I think the goal really is to avoid decision-making, Uh, meaning that you've planned the case ahead of time, you've thought it out, you're not changing your mind during the case and and calling for instrumentation that you either, uh, may have in the basement or wish that you had with you. Um, and that helps keep things moving, um, and, and. Keeps your day rolling basically without compromising, um, on the reconstruction you're doing for the patient.

Joseph M. Schwab 48:28

Hmm. And Chad, when you were to take this concept into a hospital setting, what changes, if any, would you, uh, would you implement?

Chad Watts 48:41

Yeah, I mean, uh, as Jessica mentioned, I think the ones you're doing in the hospital are just gonna be more complicated, right? So in my hands, if, you know, if, if. If we have the equipment at the ASC, if we have the hardware removal sets at the ASC, um, we're not needing any fancy revision equipment from an implant standpoint, then we're gonna do those at the ASC. Um, in the hospital setting, you know, they're gonna be more complicated. The benefit is you typically are gonna have more access to, uh, to some of those sets and, and revision implants and that sort of thing. So, so I think it definitely takes a little bit more planning. Just make sure you have plan B and C around just in case you need it. Um. You know, but it-- I think at the end of the day, that just gives you a little bit of extra, um, breathability and, and the reassurance that you've got everything you, need, uh, should issues or surprises arise.

Joseph M. Schwab 49:30

Does having the availability of that instrumentation in a hospital setting make it so that you can really plan less if you want to.

Chad Watts 49:39

Well, yes, there's that. As long as they have it there, right. And as long as somebody else isn't using it. Right. So I think as long as you're communicating. Hey, I've got this case coming up so the reps know, so the hospital knows, uh, you know, it's always, it's, it's, it's never fun when you get there and, and two different surgeons have the same case on the same day and there's only one set of something. Right. So, so I think just communication a little bit of early planning and communication is really the key there to avoid those surprises.

Joseph M. Schwab 50:06

Sounds like it changes the type of planning you might want to do before using, uh, going into a case like that.

Chad Watts 50:13

Right? Yeah. It's, it's. I guess less of the fine details and more of just kind of the bigger picture. You know, what's plan A, what's plan B, what's Plan C, and making sure that's available.

Joseph M. Schwab 50:23

Steven, what aspects of these types of sort of high-efficiency workflows, um, do you feel influence sort of safe, repeatable decision-making, specifically in the setting of working with trainees?

Stephen Duncan 50:39

Yeah. So, uh, I always call plan C should not be chaos, right? Um, and so knowing the surgical approach such that when it happens, meaning you. Let's just say destroy the femur. you're not freaking out. And so, uh, as-- when people go to courses, I always say, plan for the worst. This is when you can actually do it. So do that surgical approach. Know how to work around the vastus, underneath the vastus, and so that when you do break the femur and you gotta put cables above and below the lesser, it's not a first time thing that you're doing, but you've actually practiced it and you actually look slick at doing it. And that way people in the back corner aren't going, what in God's name are they doing right now?

Joseph M. Schwab 51:21

I think that's solid advice. And you've all been really generous with your time. I just have kind of a closing question for each of you and Steven, I'm gonna start with you. When you look back, um, through the list of complex primary cases you've done, uh, specifically through an anterior approach, could you share with us one mindset shift that really changed how you would approach these type of patients?

Stephen Duncan 51:50

So it sort of comes from my PAO experience. Um, we would do, um, uh, basically that release between TFL to get down, uh, to do the, uh, iliac osteotomy part. Then when I was doing DA early on, I was like, I don't wanna touch the TFL at all. And then I, I kinda had this aha moment where I go. Well, we can actually touch the TFL and release it and they do just fine on PAOs. So for me it was being comfortable doing the TFL release. I actually, when I fix it now, I actually do anchors 'cause it actually holds a pretty more robust, uh, repair. Um, and I don't worry about it anymore. Where I used to when I first started.

Joseph M. Schwab 52:26

Hmm. Uh, Jessica, if you were to give advice to someone early in their anterior approach journey who's maybe starting to take on more complex primaries, what's the one thing you'd tell them maybe not to compromise on, especially if they're doing this in, um, outpatient settings?

Jessica Hooper 52:46

I think be diligent about patient selection. You know, the, the first complex cases that someone's doing through an anterior approach. pick one thing that's complex, right? If it's the first time you're putting in an augment in, let's say, uh, you know, do it on a thin patient that has good hip mobility and a normal femur, right? Um, don't. Don't, you know, pick a, a morbidly obese patient with a really stiff hip, um, and, uh, you know, terrible cardiac disease as your first person that you're gonna try to do this on. So I think be, be realistic about your abilities and, um, smart about how you select patients and the more comfortable you get, uh, and kind of prove to yourself that you're, that you can do it. You learn things like Steve mentioned, you, you know, you learn how to release the TFL, how to feel comfortable doing that. You see how the patient does post-op. Um, I think you can then kind of. Start to take on more in a, s- in a smart and safe way.

Joseph M. Schwab 53:40

And it sounds like insist on Sharp Reamers each time. Is that right?

Jessica Hooper 53:44

Always.

Joseph M. Schwab 53:45

Always. Um, Chad as, um, as techniques and, and implants and planning tools continue to advance, um, what excites you most about where anterior approach, specifically complex, primary anterior approach is headed and maybe what surgeon responsibility comes with that progress?

Chad Watts 54:11

Yeah, I think, you know, it's just a, it's a great time to be a hip surgeon. I think, you know, when you look back at, you know, the implants they used to have with crappy cups and small heads and bad poly, and you know, now we've got. locking screws and 3D-printed cups and triple taper stems and dual mobility. I mean, We've just got so much access to, you know, this technology that just makes our job so much easier. Um, it's gonna be better for the patients, it's better for us. It's less stressful for us, it's more efficient for us. Um. You know, it's, it's just awesome, you know, and, and, and things like automatic impaction. I'm so grateful for that. Um, my shoulder's grateful for that. The idea that maybe someday I won't have to wear lead during a total hip. That probably excites me more than anything else. Um, so it's, it's just a great time to be a hip surgeon. And I think, you know, at the end of the day, what our responsibilities are. I think not to innovate for innovation's sake maybe is one thing, right? I mean, we, we have things that work really well. Um, right. We don't wanna cause, uh, come up with something new that has unintended consequences. And I, I think that the thing that's always looming over us is just the, the financial aspect of, of these technologies, right, is, you know, we, c- we can take, um, we can take a surgery and make it really expensive if we use all the bells and whistles and trying to figure out like, where does, where are we really gonna get our value? How do we, how do we improve outcomes without. Without breaking the bank and, and being financially responsible in tough economic times. So I think that's, that's probably gonna be the biggest role, you know, in the, in the near future.

Joseph M. Schwab 55:59

Well, I'd like to thank all of you for joining me today for this roundtable and, this discussion of complex, primary approach, for total hip through an anterior approach. and I really appreciate having all of you today on the AHF podcast. Thank you for joining me for this episode of the AHF Podcast, and thank you to our sponsor, Smith+Nephew. 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