JointMedica & the Hip Resurfacing Comeback

Hip resurfacing was written off after the metal-on-metal era — but the patients kept coming back happy. Two surgeons who never stopped offering it explain what changed, and what a vitamin E polyethylene bearing does to the failure mode that ended it.

For hip surgeons weighing whether resurfacing belongs in their toolkit, and for anyone interested in where orthopedic implant innovation actually comes from.

Sharat Kusuma left clinical practice to lead JointMedica as CEO, developing the PolyMotion resurfacing device. Craig Della Valle, of Rush University Medical Center in Chicago, took Sharat on as a fellow nearly twenty years ago and is now an investigator in the device's IDE study. Both learned the operation in the Birmingham era — Craig with Derek McMinn, Sharat during six months in England with McMinn, Ronan Treacy and Andrew Manktelow.

Neither of them skips the hard parts. Craig is candid about revising his own metal-on-metal failures, about resurfacing taking longer and paying the same as a total hip, and about how much of the case rests on results he cannot randomize. Sharat argues the real ceiling is instrumentation rather than the operation, and that implant companies — not surgeons — should carry the burden of making a difficult procedure easy. They disagree, usefully, about how familiar the PolyMotion cup will feel the first time a surgeon picks it up.

A long stretch of the conversation is about the anterior approach specifically: whether resurfacing is harder or easier from the front, what the capsulotomy actually demands, and why centering the guide pin in the femoral neck is the step still waiting to be solved. If you do anterior approach hips and have wondered whether resurfacing is a reasonable extension of what you already do, start there.

⏱️ Chapters:
00:00 Why hip resurfacing is getting a second look
02:40 The problem a stemmed total hip still doesn't solve
05:29 Learning resurfacing in Birmingham and the first 20 cases
08:50 Dislocation, fracture and infection rates in resurfacing
13:55 The coming wave of periprosthetic fractures
19:20 Practicing through the metal-on-metal fallout
27:17 Is hip resurfacing niche? Sizing the candidate pool
33:22 Inside PolyMotion's vitamin E polyethylene bearing
40:50 Why cup stiffness affects acetabular bone response
45:02 Anterior approach resurfacing: synergy, not rivalry
55:36 Centering the guide pin and avoiding neck fracture
1:05:15 Telling a surgical fad from a real advance

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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.

#AHFPodcast #AnteriorHipFoundation #HipResurfacing #PolyMotion #JointMedica #AnteriorApproach #HipArthroplasty #MetalOnMetal #BHR #VitaminEPolyethylene #IDEStudy #SharatKusuma #CraigDellaValle

Transcript

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Joseph M. Schwab 0:23

the AHF Podcast. I'm your host, Joe Schwab. For years, the conventional wisdom has been that hip resurfacing had its moment and lost it. My guests today think that story isn't over. Dr. Sharat Kusuma is an orthopedic surgeon who traded the operating room for the corner office and now leads JointMedica as its CEO. He's joined by Dr. Craig Dellavalle, one of the most recognized voices in adult hip and knee reconstruction. We're going to get into why they think resurfacing deserves a second look, what JointMedica is building, and what the road from surgeon to CEO actually looks like. So let's get right into it. Sharat, Craig, welcome to the AHF Podcast

Craig J Della Valle 1:10

Thanks for having

Sharat Kusuma 1:11

you, John. Thanks for having us. Appreciate it

Joseph M. Schwab 1:13

So you two have known each other, and correct me if I'm wrong on any of my history, since Sharat was a fellow on your service, Craig, almost 20 years ago. Before we get into any of the science of what JointMedica is doing or hip resurfacing, what's the first thing that comes to mind when you think back to that time together?

Craig J Della Valle 1:36

I think it was a day like today. We just had a big thunderstorm come through Chicago, and I think I took Sharat out on my boat at that point after the operating room, and it was a day just like today. It was like one of those days where it rained really hard, then the sun came out, and I think we were in the playpen in Chicago. That's where I feel like is my first real memory of, of Sharat was taking him out on the boat, I think

Sharat Kusuma 2:00

I'll share one more memory. Craig was obviously a little more junior faculty at that time, and we can joke around as friends. I remember infection and a lot of it. Doing, doing those together and times have obviously changed, right? But we had a good time. I remember going late 10, 11 o'clock at night frequently with the last case of the day would be in some disaster-oma. Um, but you know, it was obviously great, uh, great training. So I, I do remember going through that and of course the department's changed. But yeah, just, uh, we had a good time, um, writing papers together and doing cases together and, uh, obviously a phenomenal education, uh, going through there

Joseph M. Schwab 2:40

So Sharat, let's talk a little bit about JointMedica, um, because for those of our listeners who maybe haven't heard of JointMedica or, uh, are familiar with it only in passing, tell me the problem the company is trying to solve and maybe a little bit about why that problem still exists after years of us innovating on total hip replacement

Sharat Kusuma 3:05

Sure, and, and th-this is, by its inherent nature, the question you ask is a, is a loaded one because many will say there is no problem to be solved, why do you even exist? And, and that's, of course, sort of the dilemma of trying to be an innovator, especially in orthopedics, but maybe in even, you know, uh, medical specialties beyond that. The problem we're trying to solve is the following, and again, folks have different beliefs on this, but if you talk to surgeons like Craig, myself during my clinical career, we have this assumption that I believe is a bit self-serving, that total hip is a perfect operation. Everybody's thrilled, everybody's happy, everybody's great, every, you know, everybody's, uh, has this perfect forgotten hip score, and there are no issues. And, and I think that's a bit of a narrative we probably tell ourselves because it makes it easier to not push for innovation. I hope that doesn't come across as-- And so those of us who've do- tho-those-- And I'll tell, just to kind of give you a little more context, Craig taught me how to do partial knee replacements as well, and this has been an age-old debate, and, and, you know, I don't, I don't, I haven't talked to Craig in the last couple of years about partial knee replacements, but, you know, similar to resurfacing, and if you do draw the analogy between partial knee replacements and resurfacing, people with a well-done partial knee are a different animal than people with a total knee. And I've got patients of my own, and, you know, Craig was very influential on me in, in this regard as well, in addition to many others. Anyway, the problem we're trying to solve is giving people who have, who are relatively physiologically young, I'll say leave their numerical age aside, a hip that feels like they never had their hip done. And, and I, I-- my sense is that's not the ca-- Ye-yes, total hips are great. Yes, total knees are great, but if we, if we really sort of push ourselves for, for, for, uh, you know, a perfect arthroplasty, a perfect joint replacement, I don't believe a stem total hip achieves that yet, just like I don't believe that a conventional tri-compartmental total knee solves that yet. So that, that's the problem we're trying to solve, is giving people, uh, function where they, they don't even remember which hip they had, and they just do everything they wanna do without any thought of restrictions or anything. And that was my experience in my career doing resurfacing, uh, after I learned from Craig. So I'll stop and, uh, we, you know, we can discuss further, but that's what we're trying to solve

Joseph M. Schwab 5:29

Craig, I wanna ask you, the problem that Sharat just described is, is that the same one that you'd name from your own clinic? Would you frame it a little bit differently? Uh, how do you think about it?

Craig J Della Valle 5:41

Well, I, I, you know, I think about it a couple ways. You know, the reason I got interested in hip resurfacing was Aaron Rosenberg and I were talking just as hip resurfacing was kind of hitting the, the scene, and we both came to the conclusion, someone at Rush should know how to do this. You know, I feel like at a tertiary care center, one of the things that you do is you try new things, and I think a lot of surgeons make, uh, decisions about a new implant, a new technology, a new something without giving it a try, and I think it's hard to intelligently talk about a topic unless you've at least tried it. So the story's actually very funny. So I was supposed to go to Canada to go learn how to do resurfacing, and I got to the airport, and it said, "Please scan your passport." And I'm like, "You don't need a passport to go to Canada. It's just Canada." So I go to the next kiosk, and they say, "Scan your passport." I'm like, "What is wrong with these machines?" I go to the desk, and they're like, "You need a passport to go to Canada." I'm like, "When did that happen?" They're like, "Monday." I'm like, "Would've been nice if you guys sent me an email or something like that." So I missed my flight to go to Canada to learn how to do hip resurfacing. I then looked at my calendar and said, "When am I gonna go?" And the only thing that really made sense was going, uh, over US Thanksgiving, 'cause I didn't have any surgery scheduled, and I'm like, "Cool, I'll go to Birmingham for Thanksgiving." And I met, uh, I met all the folks in Birmingham, and I love stuff like that. You know what I mean? There you have a bunch of people who are really excited about something, and, uh, studied it so many different ways. So I basically went to the co- went and learned how to do it. I'd scheduled two resurfacings for the Monday after Thanksgiving, and I'm like, "Let me do, like, 20 of these and kinda see how it goes." And I will be honest, so at the time that I was learning resurfacing, we were doing the two-incision hip. So we were doing total hips through these little percutaneous incisions, uh, with fluoroscopy and all that other stuff, and God, I felt, like, dirty, like I'm making this giant incision, complete capsulotomy, all this other stuff. And it was actually my nurse, Kim, who said, "You know what, Craig? I think we should put our resurfacings on the two-incision hip protocol." And we did that, and the patients just did really, really well. I mean, I think there's a lot of reasons to consider hip resurfacing. One is, as, as Sharat had said, I mean, I think at the end of the day, I, I understand the viewpoint of a lot of orthopedic surgeons who say, "This is crazy. This is ridiculous. Hip replacement's a fantastic operation. The durability's unbelievable. Um, the complication rate is low. Uh, you know, you're messing with something that is pretty close to perfect." And it is, but it isn't perfect. I mean, we still have dislocations. We still have periprosthetic fractures. We still have infections. And I would tell you, in my experience, um, we've never had a resurfacing dislocate, as far as I know. We've had one periprosthetic fracture. One of my patients was, like, on a, a scaffold, like a three-story scaffold, and fell and got a subtroch fracture. Um, and we've only had one acute postoperative infection that somehow healed. I thought for sure it was gonna be a problem, and it healed. And maybe that's the patient population. There's lots of potential bias in there. But the patients do really, really well, and, you know, I am very permissive with them. You know, we tell them to start stretching at six weeks. We tell them they can start running a mile or less at a year, and at two year-- and at, at six months, run a mile or less. At a year, they can do basically every- anything they want. And we've had patients do triathlons, marathons, super-- ultra-marathons, Tough Mudder, Spartan races, active duty military, active duty firemen, and do, like, really impressive things. Now, there are those who would say, "Well, where's your randomized data that says they couldn't do it with hip replacement?" Agreed. Understood. But there is something to it, and I, I think, like a lot of things, I just don't think we understand it 100%. Maybe it's the anatomic head size. Maybe it's not putting something in the canal. I don't know what it is, but the patients do really, really well and they're happy. And then there's also maybe a less popular reason to consider it, is there are 100% patients who want an alternative to a conventional hip replacement. And I have very good friends who say, "Yeah, those people are not right, and we could get them a psychiatrist to help them get over the fact that you're gonna remove their femoral head." But 100%, and I'm sure Sharat, I don't know if you saw this in your practice or if you see this now, I'm sure you do. I'm sure you have people reach out to you say, "I don't want a hip replacement. I want something else." And that may be a bad reason to consider it, because basically, for lack of a word, it's a marketing angle, you know? But there are 100% there's a patient population out there who wants this, and at least for me, given the positive results I've had, and we'll talk about metal-metal I'm sure, um, oh, and but even considering my metal-metal failures, you know, the patients do so well. I think for me it's been hard to give it up because the patients do so well and they're so happy, and there's people come and see me all the time and want an alternative

Joseph M. Schwab 11:27

And so when you started on this journey, when you went to Birmingham, you came back, you had-- you kind of lined up, you know, the next 20 or so hip resurfacings. Was that the same year that Sharat was a fellow?

Craig J Della Valle 11:39

It must have been. Was it, what year were you a fella?

Sharat Kusuma 11:42

you for your very, very fir- I was in the, I w- and, and we scrubbed in

Craig J Della Valle 11:45

Yeah, so it must've been. I mean, it was, I went to Birmingham, I worked with Mr. McMinn. I was just, again, I love stuff like that. I like history. I love people who are super committed to something. And, you know, at the end of the day, is Mr. McMinn a controversial phys- figure? Absolutely. Does he like being a controversial figure? Absolutely. Um, but the guy's really smart, he's really innovative, and it's not like he's, like, casually interested in it. Like, they did so many good studies looking at every different facet of the procedure. And I think for me, one of the things I think that worked, for lack of a better word, was I'd seen enough variation in the way that people do operations that I said, "These folks have spent a lot of time thinking about this. There's no way that me just learning how to do this is gonna have some idea that's gonna be better. I'm gonna do it exactly the way he taught me. Exactly." And I literally, again, I went to the training, and I came home that Monday, and I did it exactly the way he taught me. I didn't vary anything, 'cause again, they had good results, and they still have good results, so I didn't mess with it in any way

Joseph M. Schwab 13:01

So

Sharat Kusuma 13:02

part of the story, just real quick, worth mentioning, Joe and Craig, is that, you know, we associate this with Derek, and of course, I trained with Derek as well after I left Rush and learned resurfacing. But there are lots of other, I'd say, good clinicians, good clinician scientists who believe in this co- Even, even John Charnley, if you go back

Craig J Della Valle 13:18

Oh, absolutely

Sharat Kusuma 13:19

read, read historically, the belief was always that resurfacing is sort of the default way to treat hip. And, and the reason it didn't work back in the '60s and '70s was not because the biology of the operation was flawed, right? It's not like the femoral head died or something. It didn't work because we didn't have materials in the '50s and '60s and '70s that could work. But I mean, it, you know, we, we talk about Derek a lot. We all, of course, know Derek very well and respect him immensely. Lots of brilliant surgeons looked at this problem and said, "Wait a minute. Why am I doing an intercalated amputation and chopping off this large segment of the, of the hip? Let me try to, uh, let me try to do something else, so maybe perhaps slightly more elegant." Uh, and there's, and Joe, there's one other thing as far as the problem we're tr- that I think is worth commenting on, and, you know, Craig goes to all the meetings. There's a fairly big tsunami of periprosthetic fractures that is here, that's coming for patients who are in their 70s and, you know, 80s, you know, who had hips done 10, 15 years ago. Of course, the Mayo published on it. That's a devastating problem to fix, and I, I suppose part of what was my motivate, and I'm kind of pivoting back to the clinical side of my career when I was young, when I saw the revisions we did at Rush with Wayne Paprosky and Craig and others, revising failed total hips is a pretty destruct- can be a pretty destructive operation. And so, you know, part of me being a young surgeon was I wanna try to preserve as much native stuff as I can, because fixing problems with more native stuff in the, in the, in the body is easier than fixing stuff when I put long, you know, cementless ingrowth in a-- And of course, stems, which I get that, right? But, you know, we create, these are definitive op- When you do a total hip on somebody or a total knee on somebody, there's no going back. I mean, there's no, right? If they don't, if they're not happy, there's nothing to do about that. So I think just the idea of being perhaps elegant in our treatment of these problems and trying to be as anatomy preserving as possible, and our, of course, our cardiology colleagues have thought this way for a long time, right? The way that things have evolved in cardiology, you know, whether it's open heart surgery pivoting to robotic or, you know, open valve replacement to, you know, transcatheter valve replacement. So that's a little bit of my, back to your q- I was thinking about your question, what problem are we trying to solve? I think it's multifaceted. But anyway, I'll let Craig, you know, Craig continue on, on his, uh, the points he was making.

Joseph M. Schwab 15:41

Well, so a quick question here. So y- that f- initial experience that you had with a few cases, the maybe 20 cases or so, you're doing most of these together. Was there a specific moment-- You described, Craig, kind of some periods where, um, suddenly you maybe had an idea that, uh, "I'm gonna do it this way. I'm gonna, uh, you know, I'm gonna offer it to these types of patients." Was there a specific moment for either of you when resurfacing went from an, an idea that you thought maybe should be a, a, an arrow in my quiver, so to speak, to the thing you really wanted to focus on and specialize in and become exceptional at?

Craig J Della Valle 16:21

I think for me it was more, to be honest, arrow in the quiver. It was one of those things where, again, I thought someone at Rush should know how to do this, um, and offer it and study it and try to understand it. Um, and I remember when one of the last things that Derek said to me when, when I visited him was, "Craig, if you do this operation in young males with osteoarthritis, you're gonna have good results." And even though, you know, the implant was, had wider indications at that point, those are the folks that we stuck to, you know, big younger males with osteoarthritis, and I think that's one of the re- reasons why my experience was so positive with it

Joseph M. Schwab 17:00

Sharat, how about for you?

Sharat Kusuma 17:02

I can share. So, and th-this is a pivotal moment for me, maybe slightly different than Craig's. Craig might remember this, but when we were at Rush, we had a couple of visiting, uh, kind of quasi professor. There's a guy named Andrew Maintelow from, from Nottingham, UK, who is a, an excellent hip surgeon, spent most of his career revising just absolute disaster, you know, custom tri-flanges and ETOs, you know, five-a-week kind of thing. He came to visit us at Rush during one of our joint conferences shortly after I was on Craig's service, and I remember this. Again, this was 2007, 2008, kind of at the peak of resurfacing. Andrew said, "Sharrot, listen." Similar to what-- and, and Andrew's not a, you know, he's not a, um-- he was not conflicted. He's not an implant inventor. He sort of had really nothing to gain other than, you know, he said, "Sharrot, I see that you all are dabbling in resurfacing here." And similar to what Derek, the advice that Derek gave to Craig, Andrew said the same thing. He said, "Sharrot, this is a great operation. I've been doing it for ten years now. I've done it in close friends and colleagues, and if you learn it well, it's a fabulous option." And so, you know, when-- a-and again, of course, Ronan Tracy, I, you know, I, I met him along the way. I'd met so many thoughtful clinicians that are honest about reporting their results. When I saw what they were saying, I, I felt compelled, even just as a, as a thoughtful, thinking person, to, like Craig said, go to the place where they're doing it and make sure that the, the hype is either real or not real. And so, after I left Rush, I actually spent six months in England and spent some time with the three of-- with Andrew, Derek and Ronan, and I was just amazed at what I saw, because I was able to be in the follow-up clinic, right? And see young, active males who were ten years out, that were done in 1997, that were coming in, and I, I was just-- and I, and I'd done clinic, no, you know, no offense, I'd done clinic at Rush and saw total hip patients, and it was a different person. The, the guy who was fifty-seven who'd had the resurfacing at forty-seven versus the guy who had a total hip at for- they were different. The way they behaved and acted was different, and I saw it with my own, you know, and again, I don't have the randomized data, but it was pretty compelling. That was my sort of one-year aha moment over the course of finishing fellowship with Craig and Aaron and Wade and then going over to, to seeing, spending extended time, you know, seeing patients in the follow-up clinic that were many, many years out. It was pretty compelling

Joseph M. Schwab 19:20

Hmm. And so Craig, you kind of foreshadowed this a little bit, but I know a lot of our listeners are, um, residents, fellows, and people who are coming out at a time when, you know, maybe their understanding historically of hip resurfacing is that it's not a very successful operation, or it's had problems. So in the early 2010s, resurfacing's reputation took, you know, kind of a real hit because of what you mentioned, partly getting caught up in, in metal-on-metal fallout. Couple of questions about that. We don't have to get into the science per se, but y- you having spent time creating expertise in this operation, what was it actually like practicing through that period? And did your patient conversations change during that time?

Craig J Della Valle 20:12

I guess they did and they didn't. I think we were always a little, uh, nervous about the metal-metal bearing. You know, my other senior partner is Josh Jacobs, who's one of the people in the world who knows more about metallurgy, bearing surfaces, and metal-metal. Um, and a lot of that came from You know, George Galante, who had a big interest in the systemic effects of hip and knee replacement. Like when I was a fellow, all of a sudden I'd get a page and it'd be like, "This is so and so funeral home. Uh, one of Dr. Galante's patients passed away, and you're supposed to come here and get their hip replacement." I'm like, "Excuse you?" So they had a big interest in the systemic effects of joint replacements, and that's where they got the expertise in retrieval analysis and also measuring serum cobalt and chromium. Um, so there was a lot of concern about the metal-metal bearing. So I think we were-- I was, I was always a little cautious, um, regarding the, the bearing surface. And, you know, I never did that many metal-on-metal hip replacements. Almost all the metal-metal bearings I did were, were to the resurfacings. So I never had like, uh, uh, a large number of failures. And, you know, to my point I guess a little bit earlier, there were certain resurfacing designs that had a much higher rate of failure, and the Birmingham didn't. And I think some of that was that, you know, the people, you know, around the BHR, they, I guess they had enough failures and they kind of figured it out and studied it, and either they made the right guesses or made the right choices. And the BHR, again, other than the metal-metal failures, um, and even the metal-metal failures with that particular implant, I don't think were as high as some other implants during that time period. So again, it's frustrating and I-- For me, and this kind of leads into how Sharat and I reconnected and why I decided to do the PolyMotion device, was it's frustrating when you-- a patient comes in. I don't think anyone who, who... I don't think any orthopedic surgeon likes complications. I think if you ask most of us, that's the worst part of our job, is managing our own complications. You know, at the end of the day, you feel like, is there something I could have done different or better, and then this patient wouldn't be having a problem? I think that's the nature of the personality for someone who goes and says, "I wanna be a surgeon or an orthopedic surgeon." So it's frustrating when someone comes into your office and you look at the X-rays and you're like, "Yeah, I don't think I could have done anything different," and they've got a problem and you're revising them. So I mean, that was and still is frustrating when you see that, because again, I don't, I don't mind doing revisions, I just don't like re-operating on my own patients, 'cause again, it, it pisses me off. You know, like, is there something that I could have done differently? Um, I feel like most of the patients, we explained to them that there was a risk, and I think, you know, relatively quickly we knew that there was a risk. Um, but again, I listened to Mr. McMinn, and I did mostly young males with osteoarthritis, and my complication rate overall was low And even in the darkest days when it, it started to be like, well, is there medical legal risk here, et cetera, et cetera, I just kept having patients come in who were happy, and it was hard to ignore the fact that these patients were doing so well and doing so much that I never walked away from it

Joseph M. Schwab 23:45

Hmm. Well, and Sharat, so you described, you know, kind of coming out of your fellowship and building a really resurfacing-focused practice, and this would've been right as the field was kind of starting to sour on it. What was that like for you?

Sharat Kusuma 24:00

Well, so yeah, I mean, I left Rush and ended up joining, uh, another Rush fellow, former, Ray Waslewski in Columbus, and joined his practice. And so as far as what it was like, I suppose I had a fair amount of confidence that the thing worked, because again, I had spent extended time, you know, with-- It's like going to do the th- Oxford Fellowship in Oxford, or going to do the, you know, the, uh, the Karai Fellowship in Annecy or, you know, something like that. I, I, I, so I was very nuts about, like Craig, doing the operation exactly like every single retractor, right? Every ins-- exactly the way that Derek and Ronan did it, the way that-- and Andrew did it. And, um, and I just found that patients would find, y- y- you know, and I didn't do it for marketing reasons. I thought it was a better mousetrap, and I guess I thought at, you know, at age, at that time, age thirty-three, if I needed a hip, that was the hip I would get, so I should know how to do that hip, you know, based on what I-- So the practice building for me was pretty straightforward, and like Craig, again, you know, I was very neurotic about every step of the operation, indications. I ended up having pretty good results, and the few failures I had, they were on me. They were my fault. I either anteverted the cup too much and had a little bit of edge loading. That, that's on me, right? I had the cup a little bit vertical. But the ones where they were, you know, down the pipe, um, like Craig said, they were unbel-- I mean, un-just unbelievably happy patients. The, the best patients I had in my arthroplasty practice, and it just kinda became this, you know, Columbus, Ohio, which is a decent metro area, people were coming, you know, finding you from all over without any sort of marketing or anything. And I guess the other, I don't know, Craig, if you had this experience, but here's what I, what I found most compelling. There were like farmers from rural Ohio, right, who, who drive tr-- and they said, "Hey, I heard about this thing," you know, a sixty-five-year-old, and, you know, "This is what I want." And this is not some, you know, bougie downtown Chicago, you know, lawyer who, who-- You know, there was just people like, "I n- I need to make sure I can farm." And, you know, firefighters again, and they had done the research, and I was like, that's, that's very interesting, that a person who otherwise would just sort of walk in, you know, from rural Ohio, would walk into a clinic and say, you know, "I've done-- This makes sense to me." And they had heard about, you know, they had a friend of a friend or something who had had it. If it doesn't work, why does that keep happening? Why, why, why does that movement continue? In fact, what I find most fascinating about all this, and Craig, you know, chime in if you disagree, what's kept resurfacing alive is probably the patient-to-patient word-of-mouth referral as much as-- because there's so much negativity around it. Patients who have it, and, you know, these patients obviously, you know, some of them do research. They tell their friends, "I had this." They meet the friend. I mean, that's what's keeping this thing alive. You know, surgeons want it to die for sure, you know, take it out back and shoot it for sure. But really the public and the patients are what keep it alive. There's gotta be something there because it was such a bad thing. Why would that keep happening? And I'd be curious, you know, your, your, your-- both of your thoughts on this. But, um, those are interesting things, whether it's in, you know, any kind of product, right? Why don't products die? Well, they don't die because they're solving a problem for somebody who's the end user that's not any one of us on this call, but actually the person who, who uses the product every day in, in, in their life.

Joseph M. Schwab 27:17

Well, and, and Sharat, you've said publicly, um, that you don't see this product, the PolyMotion product, right, hip resurfacing, uh, from, uh, Joint Medica's perspective as a niche product. And I think you floated a number maybe as high as about 30% of hip arthritis patients being sort of potential candidates for this. Um, uh, just plainly, where does that number come from?

Sharat Kusuma 27:42

Well, I, I don't know if folks would consider, you know, a third a niche or not, but what Cr- Craig just said it earlier, young men who have arthritis, that's a pretty large segment of the population. You've got otherwise relatively normal anatomy who don't have AVN, you know, who don't have some weird, you know, old, um, you know, dysplasia or something like that. That's where that number comes from. Um, you know, whether that seems high or makes me a, a, a nut job on your podcast, et cetera, but, uh, there are a lot of young a- active males who have arthritis who are looking for this. So that, that's where the number came from, uh, Joe

Joseph M. Schwab 28:17

does that match what you're seeing in your, in your own practice or maybe in the, even in the IDE study that you've been doing so far?

Craig J Della Valle 28:26

I, I, you know, I don't, I, I don't know. I mean, I, I think some of it may be, uh, selection bias or the fact that I do it bias, 'cause I get, you know, people in my practice sending him to me s- these folks specifically to me. You know, I, I don't know what the right number is. I don't know what the indication was. I think, you know, frankly, I think one of the things that limits it is it's hard technically to do the procedure, and again, I, I think metal/metal definitely didn't help. So I think the combination of those two things, uh, limits the applicability of it. I think with, with the PolyMotion device, um, if the results are going to be as good as we think that they're going to be, 'cause again, when I look at my own results, in my hands, the most common failure wires was adverse local tissue reactions from the metal and metal bearing. Um, so I think if I take that away At least for me, it's, it's, quote-unquote, "easy to make the argument for the operation," but it's technically more difficult, and you don't get paid more to do it in the United States. You bill it as a total hip. So it, it definitely is, uh, you know, I don't think the casual hip surgeon, you know, I don't think the surgeon doing, you know, two or three hip replacements a month, I don't think this is-- I don't think that's an operation that they're going to be comfortable doing. So I think it has to be for someone who's interested in learning it and, you know, doesn't-- I mean, again, I think it's like everything else. You get good at doing things. I think most surgeons who do resurfacing would say that it takes them a little longer to do resurfacing. There are some parts which are great, you know, the cups monoblocks, you're not putting in liners, and if you're someone who trials when you do your hip replacements, you save potentially a little bit of time there. And there's no trialing. You know, once it's, you know, once it's in, it's in. You know, often-- You know, when I first started doing it, first couple of years, you know, fellows would call me back to the room, and they'd be like, "You know, it doesn't really feel that stable." I'm like, "So what would you like us to do?" You know, there's no option. You know, once it's on there, it's on there. There's no modular parts, so it definitely saves you some time with that. But I think in general, it's a technically more demanding operation that takes a bit more time. And at the end of the day, you know, I don't know if either of you saw the, uh, AAHKS newsletter the other day that looked at the proposed rates for total hip replacement, I mean, for Medicare.

Sharat Kusuma 31:08

Saw it, yeah

Craig J Della Valle 31:09

it's,

Sharat Kusuma 31:11

Race to the bottom

Craig J Della Valle 31:12

we could, we could have a whole other podcast about why I opted out of Medicare and what the experience has been, but I mean, at the end of the day, that's why. I mean, you know, it's reached that point. It's less than one thousand dollars is what they're proposing on the national average for payment of hip replacements. So again, I understand that there's a barrier there for the average person who's doing it, and you look at an operation where I'm not gonna get paid more, and it's technically more difficult. Um, you know, it's definitely a barrier

Sharat Kusuma 31:39

can we talk about this for me? This is an interesting dynamic. Uh, I don't know that I believe that the operation being technical for-- particularly more difficult is a good reason. That, that... and this is where you sort of mix the, the combination of the business side of, of, uh, running a company with being a clinician. Companies can make it easier to do operations, uh, right? I mean, that's what companies should do. And so, you know, there's a huge element, and as I've made this transition over, that's a solvable problem. And that, that, you know, the fact that it hasn't been solved doesn't make it a b- a bad operation. Just like if you look at the use, you know, this will be a controversial topic again for, for another podcast about unique compartmental needs and robotics, et cetera. But I believe there is some data that shows that in lower volume, and Craig, you, you read the literature more than I have a chance to recently. In lower volume uni surgeons, using a robot makes it more reproducible. You know, whether, whether you love it or hate it, leave that aside, operations like this can be made easier, and so at least one of our passions is, is not just to be, you know, not to bring the implant to the market, but also to bring it to the market in a way where we make it easier to do. That from a commercial, strategic, just being a, a, an industry person is, is just absolutely essential to the entire... You know, it's not just enough to do the testing and bring the implant to market. You've got to make it where-- And I, and I just feel, you know, part of my journey of what motivated me, motivated me to do this is I think companies can do a better job of that, of making operations easier and easier and easier to do. And that, uh, in fact, I think it's the responsibility of companies to, to do that, and we certainly believe that at our company and it's one of our passions in addition to bringing innovative, uh, devices to market. So

Joseph M. Schwab 33:22

Well, and I-- we're gonna talk a little bit about the, you know, how you might be making it easier, but let's talk a little bit about the product itself. So a, a couple of questions for you, Sharat, and I'm, I'm just gonna give you some quick questions, a-almost sort of 30-second version of this. So first of all, the name, PolyMotion. Tell me where it came from, and secondly, um, PolyMotion's bearing surface is really the distinguishing factor between it and previous generations of hip resurfacing, at least as far as I can tell. So what's different about the bearing surface from the systems that you trained on or that you were most familiar with going in? Explain to our

Sharat Kusuma 34:02

Yeah, I'll answer them in, in, in reverse order. Actually, part of what I believe, and, you know, Craig, you chime in here, what makes the PolyMotion implant attractive is that it's sort of the devil we know, and we know it very, very, very well, as a matter of fact. It's, it's fairly vanilla in terms of it's a vitamin E, highly cross-linked polyethylene that a lot of the listeners of your podcast have been using for, gosh, what, 20 years or so. And then the bit-- And on the head side, it's a metal head, cobalt chrome, you know, highly polished cob- You know, th-this is a bearing surface that we sort of know when it goes south, why it goes south. And so as far as saying it's diff-- yeah, it's different than other resurfacing bearing surfaces, but part of what at least, you know, I don't, I don't wanna make any marketing or regulatory claims because the products are not approved yet. But in terms of the facts of the device, it's a cobalt chrome, which we've been using for 60 years, obviously without a trunnion, on somebody's femoral neck with a vitamin E, highly cross-linked bear that is now almost ubiquitous in, in, in, you know, I don't know what Craig uses for his primary hips lately, but that's why I think one of the appeals of this is that it feels familiar. You know, it's not some unknown, you know, strange bearing surface. So that, that's the first... So that, that's what the bearing surface, it's a monoblock cup with a titanium, you know, uh, uh, surface on the back. That's an ingrowth surface. As far as the name PolyMotion, I don't know that the orthopedic industry is gonna win any awards for marketing the way that perhaps Apple or, or Microsoft or Coca-Cola do, but it was, it was the name when, when, when the, when the, when we bought the-- When I say we, we can talk about the financial structure if you're interested. But when we bought the company, uh, from the McMinn, from the McMinn family, if you will, they had already named it PolyMotion, and I, I don't think, you know, they spent-- they didn't hire, um, you know, IDEO or some, you know, top marketing firm to name the implant. They just, they,

Craig J Della Valle 35:57

of unpronounceable non-word that goes across 13 different languages,

Sharat Kusuma 36:05

there's also one other sli- there's also one other little thought here is that B, remember BHR, right? BHR, PHR are just easily, you know, it's where there's a familiarity for, for those who are in the market. But those are some of the reasons where the PolyMotion, it's polyethylene, it provides a range of motion. That's where the name came from. But again, you know, I don't think the name sort of, um, will end up driving the success of the implant. I mean, my sense is if we make a good implant with good clinical results and we make it easy to put in, that's probably what's gonna drive more, you know, more success. But that's the story of how, how it came about

Craig J Della Valle 36:37

Joe, could I push Charat on something? And it'll help him in the end, but he might not, he might not like me for 30 seconds. I would challenge you on, on one concept. I think when an orthopedic surgeon picks up that acetabular component, that is not typical. You know what I'm saying? 'Cause it's basically vitamin E poly with beads on it. Can you talk a little bit, Charat? 'Cause again, it's one of the things that I guess being someone who was comfortable with resurfacing, comfortable with, uh, cobalt chrome, vitamin E cross-linked polyethylene bearing, but the cup doesn't look so normal. So can you tell us a little bit about the clinical history behind that kind of cup? 'Cause there's one there, but I, I wasn't familiar with it. And can you talk to us a little bit about the, the cones on it, the two cones, And how that came up? 'Cause again, I think it's just, it's unique, and I don't think it's a-- I don't think it's that familiar to the average orthopedic surgeon

Sharat Kusuma 37:36

I guess what I'm saying, here, here's a picture of it if you can see it on, uh, there we, there we go, right there. So that's what Craig is

Craig J Della Valle 37:44

when you put it in your hand, it's like air. You know? It's like, it's so light, you know?

Sharat Kusuma 37:50

so a couple things. Yeah, yeah. Uh, Craig, what I was more referring to is the, the perhaps the bearing coupling feels

Craig J Della Valle 37:56

Oh, absolutely.

Sharat Kusuma 37:57

We that the, but, but

Craig J Della Valle 37:58

is different. You know? It's not,

Sharat Kusuma 38:01

Well,

Craig J Della Valle 38:01

not run-of-the-mill. It's not

Sharat Kusuma 38:03

one thing worth knowing, and obviously I've gotten to know Ronan, Tracy, and Derek, we've been very, very well. You know, the BHR was not a device that just sort of sprung out of the womb as a perfect final finished device, right? Derek and Ronan went through multiple iterations between 1989 and 198- 1997, you know, making minor changes in the implant to get to the BHR that ended up being clinically fairly successful, and Craig talked about it earlier, you know, well, there were some combination of metallurgy and luck and other things perhaps, but right, the PolyMotion has gone through the very similar iterative pro- which I think folks hopefully can understand that. So it's back to the clinical history. We have roughly three versions of the device that's starting back in 2014 or so. You know, this has been a long project. As you all know, developing m- developing implants for any, in any field of med tech, it's not like you just come out with the final version and it works perfectly. You have to do some iterative, um, process because, you know, you never know how one little change in an implant... That's been one thing that I've learned kinda going from being a doc or, you know, an operating orthopedic surgeon to being in industry. You have to be very careful when you make changes in an instrument, right, or the feature of an implant. But top level, Craig, the first version of w- what we'll call the PolyMotion that now dates back to almost 2015 was actually a cross-linked polyethylene without vitamin E with the titanium coating just plasma sprayed on there the way you would plasma spray onto a, you know, um- A, a taper lock stem or something, right? One of the-- It was a very sa- And that, that, you know, they did a bunch of th- They did about 100 of those. They followed them for three years. They saw, and of course, they saw that the coating didn't stick very well, right, after a few years. And then again, the, the, the loosening rates were very low, but then they said, "Okay, this coating technology doesn't work. Let's go to a next pro-" So there was an iterative process of learning how to get titanium to stick to a piece of cross-linked polyethylene, you know, that, that, that has been, you know, 12, fif- 13 years in the making. And so anyway, and then as far as the cones, Craig, the cones were designed, again, thinking about failure modes, to provide significant amount of initial implant stability, similar to how the way screws would. And of course, as you know, one of the early f-- you know, we don't talk about it a lot, but one of the early failure modes of resurfacing was not only femoral neck fracture, but it was putting in a monoblock po- uh, cobalt chrome cup that never got appropriately fixed into the acetabulum in the first place, right? Some of those cups would spin out early, right? So these learn-- you know, Derek and Ronan have, you know, whatever, 40 years of learnings around resurfacing that went into the device, which is what gives it the, uh, the confidence. But anyway, that's sort of the clinical history of how it evolved. You know, it didn't come out of the womb in this final version that you call, you know, that looks, you know, unique, et cetera. Now, there's one more part of the story that's very worth, uh-- Joe is sitting in Switzerland right now. There's a very well-known Swiss company called Mathys, M-A-T-H-Y-S, that has been making cups like this ki- you know, with some features of this for many, many years with excellent clinical results. Yeah, and again, the fact that it never came to America, you know, I, I, you know, is, is, is perhaps unfortunate because a lot of surgeons in other countries, in Australia, in Switzerland, in Germany, and others have been using cups like this for 30 or 40 years with excellent clinical results. And the interesting thing is because the modulus of elasticity of this polyethylene, right, this cup, is so close to that of the native bone, there have been some nice papers published that show that over time, the bone behind the acetabulum actually responds better to a cup that has a modulus that's closer to that of a, you know, even a titanium or a cobalt chrome cup. So there was a lot of sort of, uh, biomechanics and biology, Craig, that went into this development that, you know, probably we won't have time to cover every bit of it on this podcast. But I guess the main point I wanna make is this has gone through a similar iterative process where they made a couple changes, followed a bunch of patients, saw what fa- you know, and, and, and so this, you know, this kind of this final version, it's been a long time in the making, very similar to the way uh, the VHR. And I would call it responsible implant development is what I call it because, you know, that, I think that is the way to do it. You have to do a few patients, like you said, you did your 20, saw how they did, right? And then, you know, sort of, uh, in your first, uh, in your initial VHR experience. It's been a similar iterative process here. But I agree, it's a different technique, but I'm hopeful the bearing surface feels familiar to people because it's something they've been using for a while.

Joseph M. Schwab 42:33

and, Craig, since you have been using it in the trial, um, y- you know, you pointed out this difference in how the acetabular component feels, right? Even though the polyethylene is a polyethylene we might be used to, right? That spray titanium, uh, backing and we used to-- When I was in fellowship, we put in a lot of Mathys cups and, and we used to call them-- I, I used to call them ghost cups because you'd see them on the X-ray and they,

Craig J Della Valle 42:57

Yeah, it looks

Joseph M. Schwab 42:57

a shadow of a cup, right? Uh, and, but, um, are, are there other differences that you've noticed in the OR? Not stuff on paper, not stuff in the design aspect of it, but other aspects of this that you've noticed that are different. Is it, uh, when you compare it specifically to your experience with the Birmingham?

Craig J Della Valle 43:19

Uh, fortunately, no. I mean, it looks really cool on the X-rays, but in terms of, you know, at the end of the day, I guess my bias is it's hard to get a resurfacing cup in because the exposure's difficult. Um, so I'd say it's the same. Um, but fortunately, my PolyMotion patients look exactly like my BHR patients, which for me has been a good thing

Sharat Kusuma 43:49

But Joe, b- but Craig, back to the point, you know, this is, this is fun to discuss, you know, in sort of real time on a podcast like this. This is part of what's made this fun working, you know, again, with someone who was formerly a mentor. You know, uh, when you give me feedback that, "Hey, your instruments don't w- you know, I'm having trouble with them," we can rapidly iterate those and, and we're actually in the process right now of making some changes to our instruments that we believe... You know, back to your point around just, you know, taking it up to a 30,000-foot view, I think it's, it's some of the gr- best work an implant company could do in addition to developing new metal and plastic stuff that goes in people, is actually the instruments and m- and, and learning in real time. You know, ev- every time Craig did a ca- and I was with Craig for a lot of cases, we would take notes on, like, tiny little things that were making the spikes difficult to prepare. And Craig, we haven't a- actually have had, had a chance to show you these, uh, improvements yet, but we will very soon. That's been one of the most gratifying things about this whole sort of clinician, you know, CEO kinda thing is, um, is being able to make those changes rapidly and, and, you know, encourage our engineers to make, you know, to, to make it easier. That's been a fun part of this whole journey that, um, you know, I guess I never would have had if, you know, hadn't made the career, career switch, so yeah

Joseph M. Schwab 45:02

and, and let's talk a little bit about instrumentation and approach and, and I'm, I'm gonna focus a little bit on approach, 'cause obviously we're the Anterior Hip Foundation podcast, and Sharat, you specifically have, I think, referred to anterior approach resurfacing as, I think the phrase was synergy not rivalry, um, specifically with the anterior approach. Tell me a little bit about what you mean by that.

Sharat Kusuma 45:28

What, what I mean, you asked me a question earlier, right? What problem are we trying to solve? I would ask the, the, the, the legion of, of highly experienced, knowledgeable, thoughtful clinicians, what problem was the anterior approach trying to solve back when it came, right? And if you think about those, it's all-- we're all thinking about the same thing. What we're thinking about is trying to preserve soft tissues. Well, why not also try to preserve bony tissues? And so, you know, when you-- when I-- well, the reason I talk about synergy is the whole, at least-- and I, I'm not an anterior approach guru by any stretch of the imagination. I learned from Craig how to do a good posterior approach, and I know that's heresy on this, on this, um, this podcast, but, you know, uh, I think we had a pretty good run doing that approach. Craig, I think you're still doing that on all your primary hips at the moment, and you, you know, I'd certainly let you do my hip any day of the week. So Joe, but I mean, what I meant by that is often positioned as this debate that, well, resurfacing is somehow conceptually or religiously or what- whatever, ethically or, you know, uh, uh, conse- uh, uh, antithetical to resurfacing. That's not the case at all. If, if anterior hip surgery is all about maintaining muscular attachments and soft tissues, well, then why not extend that, uh, that passion and belief for that to preserving the bony side of the, of the, of the anatomy as well, which we know is, is probably equally as important as the soft ti-- and it's a, it's a system, right? I mean, we were designed with soft tissues and bones to be able to, you know, obtain with the nervous system as well, to be able to drive optimal mobility. That's what I mean by that. And so what's been fun about this whole thing is we have some anterior approach surgeons who are in our ID study, who are some of our key opinion leaders, uh, at Joint Medica, and we listen to them hanging on every word because we know that if we wanna make this thing successful, we need to make it successful in the hands of everybody. There are plenty of s- yes, anterior approach surgery is whatever, fifty or sixty point, you know, fifty-five percent, but there's another forty percent of a pretty big market doing another approach. We, you know, our-- my passion as a leader of the company is to make it appro- where everybody with any approach can come to the table and have a great experience, and that's what it's all about. And so, you know, I'm happy to talk more about it, but that's what I mean when I say that, Joe, is the synergy is save the soft tissues and the bones, not just one or the other, so.

Joseph M. Schwab 47:45

and Craig, how about you? Where, where do you personally land on-- Well, specifically, let's focus on anterior approach resurfacing. Is it something you're doing? Is it something you're watching? Or are you a skeptic of it?

Craig J Della Valle 47:57

So when I first started, it made sense to me because we were very-- I, me, I, I was worried about the blood supply of the femoral head. So again, to your experience, I started thinking through, is this something that we should be doing a trochanteric flip osteotomy? Uh, should we be doing it through a Harding approach to more better preserve the blood supply of the femoral head? And then, of course, you know, the resurfacing people from the UK were like: "Yeah, we already did that study. It doesn't make a difference." They looked at Hardings versus posterior, and there was no difference in femoral loosening. There was no difference in cup position. There were really no differences in outcomes, whether they were done through a Harding approach or whether they're done through a posterior approach. And I remember early on, I'm sure you know Michael Mont, great guy, outstanding surgeon. I watched him do a surgical, uh, to do a resurfacing with a Harding approach, you know, an anterolateral, take off the anterior third. And, you know, again, good surgeon who'd done a lot of them, um, and he did them no problem. So, you know, in an age where people are routinely doing revisions anteriorly, I, I, I don't think doing resurfacing anteriorly is an issue at all. I think a good anterior surgeon's gonna be able to do it, and someone who casually does anterior approaches is gonna struggle, and I think the same thing through the posterior approach. I think it's, uh, again, it's a harder operation, but you get a skilled surgeon who's comfortable with the surgical approach, I don't think it's an issue at all

Sharat Kusuma 49:21

And Joe, what we've seen just real quick to kind of e- echo Craig's point, you know, Mike is of course one of our study investigators, thrilled to have him on our team as well. But what we've seen in the ID study is patients have done, you know, have, have had, uh, similar recovery. It's similar, you know, similar, let's say ear- early, um, uh, early clinical result agnostic of approach, and the anterior approach surgeons, you know, ha- have, have, have, uh, contributed to our understanding of how to make great instruments, as have the posterior approach surgeons. And so, you know, we're incorporating all those learnings. Uh, we intentionally pick surgeons, let me say, for our study so that we would have a representative sample from all the different approaches. Because again, I firmly believe that we want to provide a great intraoperative experience for all surgeons independent of what, what approach they're coming from, uh, to the hip

Joseph M. Schwab 50:08

Do you feel there's something specific that has to be, um, true more so for anterior surgeons to feel comfortable adding resurfacing to their toolkit than posterior surgeons? Or is it the same approach regardless?

Craig J Della Valle 50:24

Yes. Um, I th- at least, uh, well, I think certainly for a posterior approach surgeon, you know, talking to Derek, getting to know Ronan, I think when they started looking at, okay, this is-- I, I think they clearly recognize it's a more difficult operation, and when they started to teach other surgeons, they immediately looked at people who were doing revisions and who were doing complex things because they're good hip surgeons. You know, I think for me, the hardest thing when I'm trying to teach other people resurfacing, and even this is controversial, I, I feel like in my hands, I pretty much need to do a complete capsulotomy, and I think for a lot of posterior surgeons, they don't-- they're not comfortable and familiar with how to release the anterior capsule. So I think for me, I need to release that capsule 360 to be able to get the femur out of the way to expose the acetabulum and to resurface the head. I think if anything, anterior surgeons, you know, all the time are releasing the posterior capsule, so if anything, it should almost be more natural for an anterior surgeon to h- be comfortable, 'cause I think most anterior surgeons are probably doing anterior capsulectomy as the first part of their operation, and I think in selected cases they're, they're releasing the posterior capsules. I think they're comfortable doing that. Just a little harder when the femoral head and neck are in the way, you know?

Joseph M. Schwab 51:51

Yeah, and we've, we've had Justin Kaab on before. Yeah, uh, I'll give you a moment, Sharat. We've had Justin Kaab on before and, and he's talked about his technique and, and demonstrated it nicely at some of the meetings doing his resurfacing through an anterior approach, and he's doing a full circumferential capsulotomy as well. Yeah. Very important aspect of the operation

Craig J Della Valle 52:13

I think, uh, for me that's one of the... I, I think it is, but, you know, it's interesting. I'm on this group chat, this world hip resurfacing chat, and it's always so interesting. You know, for me, a- as much as I love going to meetings in the United States, I, I personally learn a lot more when I go abroad, and it doesn't matter if it's English-speaking South America, Asia. I always learn so much more 'cause there's people who are thinking differently and doing different things, and I'm on this world hip resurfacing chat and, you know, they're doing stuff that I wouldn't think would be compatible with good results, and these are folks doing stuff differently and they're like, "Oh, you don't need to do a complete capsulotomy. I do XYZ." So again, I think there's always room for innovation. It's always fun to be around smart people who are passionate about something and try to learn as much about it, and as Sharat had said, innovate and make things better for our patients and for us

Joseph M. Schwab 53:10

Sharat, what did you want to add?

Sharat Kusuma 53:12

I, I mean, I was thinking about your question. You, I, I believe the question was, what are elements that are going to be, and I'm paraphrasing your words but a little bit, but what are the elements that are going to be critical for anterior approach surgeons to, um, I think adopt resurfacing was, was roughly the question you're asking and, and, and I'm not an anterior approach surgeon, so I may not be the most qualified to-- You may have actually be better qualified to answer that than I am. But I guess what, what, you know, it's the same belief that we talked about earlier about the synergy. It's, it's a synergy, the same passion that comes from that, you know, that those of you who are anterior approach surgeons believe it's a better mousetrap, a better way to get into the hip, a better way, you know, you lease a long, I, I presume you believe, you know, better long-term function and better everything. I suppose you have to have that same belief that while there, there's some benefit to preserving bony tissues as well, if you don't believe that, then, you know, it's probably not for you. But if you do believe with the same passion that the soft tissue treatments that, that you're employing in your, you know, your standard hip replacements are beneficial, you have to have the same belief that, that the, the maintaining bony tissues is also gonna have additional incremental benefit. That's what I, I think is gonna be required for at least some segment of anterior surgeons to, to adopt this. I mean, and I'll also say one more thing, and this is why it's fun, is we're, we're spending a lot of time as a company thinking through from an instrumentation standpoint, what are some of the exact fit, you know, mousetraps, you know, widgets we're going to need to be able to make it easy for you, a-as easy and pleasurable, I guess I would say, to do a resurfacing as to do your standard anterior total hip. And so that, I think those are... That, that's the company part of it, that, that, you know, we've got to make instruments that where you come out and say, "Gosh, that was amazing. That was slick. I enjoy doing that." If that's not the case, then I don't think we've met the bar that needs to be met for the anterior audience

Craig J Della Valle 55:15

I think if an anterior surgeon is able and comfortable doing an isolated cup revision through an anterior approach, I don't think they're gonna have an issue doing a resurfacing. I think it's a lot of the same skillset. Learning how to mobilize that femur and get that femur out of the way so you can get to the cup, I think it's a lot of the s- I feel like for me, it's a lot of the same skills,

Sharat Kusuma 55:36

But the one other

Craig J Della Valle 55:37

learning how to mobilize the femur

Sharat Kusuma 55:39

is getting that head around, be able to put that pin in the center. There probably is some technology as a company that we, and we are working on it actively, that makes that step easier to where that step goes away in a total-- You don't have to find the center of a femoral neck doing a cup revision, right? But in, in a reservicing, you've got to not only do what you eloquently described on the cup side, on the head side, you've got to figure out some way to help them get that guide pin right down the center of the neck, so they don't end up with femoral side of complication. So I would, I would add that one nuance that, you know, in addition to the skill set, uh, my sense is we, we've got to solve that mousetrap, solve that problem as well on the, on the femoral side for anterior surgeons.

Joseph M. Schwab 56:18

a- and as a, as a self, uh, uh, self-described, uh, hip resurfacing troglodyte, I mean, that's the whole operation is my understanding, right? Is getting that pin in the exact right trajectory that you want, getting your-- the position of your femoral component

Craig J Della Valle 56:35

I think, I think it's probably easier. If you've never done it before, I, I think it's almost like doing, uh, you know, putting a sliding hip screw in. It's not that hard. I think most people who could figure out how to do, like, an anterior hip could figure out how to get that guide pin in the right spot. And again,

Joseph M. Schwab 56:50

necessarily the difficulty of it, but the, uh, the importance of getting it correct

Craig J Della Valle 56:57

Yeah, it, yeah, I, I don't maybe, uh, you know, I feel like when we first learned it, we were really worried about femoral neck fractures, really worried. And, you know, I feel like there's two basic axioms: avoid notching and avoid varus, and be respectful of the soft tissues. I think that's important as well. I think if you can do those three things, I think the risk of femoral neck fracture in general is gonna be low. Now, I think through the IDE study, we've seen that there can be some nuances with surgical technique and instrumentation that may make that rate low, a little bit lower. But in general, I think if you avoid notching, avoid varus, and are respectful of soft tissues, uh, I think it's a relative, it's relatively easy to a- avoid that complication to get the femoral head in the right spot. It's not that difficult

Sharat Kusuma 57:46

Joe, the way I'd answer the question is it's one of those things, y-you know, and I, I love thinking about, like, the cognitive burden of a s- you know, as kind of as a company leader now and how do I reduce that for, for customers, right? It's one of those things you never had to think about it before when you're doing a total hip, and so it's just one of those, you know, it's another added cognitive burden of, you know, just something that I don't have to think. So if I-- I would agree with Craig, it's generally pretty easy. I would agree with the, with the, uh, articulately described axioms he mentioned. But when you're first learning it, if you've never had to think about it before, it's one of those things like, gosh, you know, I hate thinking about this. C-can you make it easier for me to not have to think that? Maybe I would, as a, as a, as sort of a person talking to customers, that's the way I would articulate it slightly, is that, that if I could take that cognitive burden down, that's going to be a benefit to the new learner who's already learning a couple of other new things. And the other piece I would say, Joe, that I fully agree with Craig on this, when we first were doing resurfacing back in the mid-2000s, it was femoral neck, femoral neck, because all the early complications were related to femoral neck fractures, right? We didn't see the delayed complications later,

Craig J Della Valle 58:50

And I'll, and I'll fix that. We stop worrying about neck fractures almost completely.

Joseph M. Schwab 58:54

Hmm.

Sharat Kusuma 58:54

would agree with Craig. But if you remember, when you went to

Craig J Della Valle 58:56

had to be some benefit to it. Oh, yeah, absolutely

Sharat Kusuma 58:58

you hated having, it was like, it's like having a paraprothetic, um, you know, calcar fracture with stem. I mean, y- I'm sure, Joe, when you were learning anterior hips, that was a very common thing that happened to people, right? When they were learning in their first 100 cases, they'd have a lot of sort of calcar issues. Once you get rid of that, we, if we can make that go away, I'd say it's a similar dynamic in the resurfacing that composition is equally important, but you gotta, you got, yeah. It, it's, it's, um, the femoral size may be overstated a bit

Joseph M. Schwab 59:24

Hmm.

Craig J Della Valle 59:25

The oth- the other thing I think that really helped me, and I'm pretty sure either McMinn or Tracy or one of those folks helped me understand this, if you think about resurfacing the neck and if you wanna centralize that stem on the neck, kind of ignore the head and focus on trying to be in the center of the neck, it almost always gets you in the right spot. 'Cause it doesn't look right. You know, when you're first doing it, you're like, "Whoa, that's not right. I'm taking a bunch of bone inferiorly. I'm just skimming it on the top. That's not right." And then you throw the drill on there and you're like, "Oh, that does look right. It's right centered on the neck." So that would, that I would say would be the technical tips, like avoid varus, avoid notching, and think about trying to resurface the neck and being centralized on the neck. I think that's one of the things that really helped me from a technical perspective

Sharat Kusuma 1:00:14

And Joe, as we're looking at sort of technology to, to augment this, you know, PSI, patient-specific instruments, has taken a, a, a beating, a bludgeoning over the last 25 years, you know, whether it's knees or whatever. I believe as a company person now that a PSI guide for the femoral resurfacing side could be a really s- uh, excellent application for that kind of technology to make that step very easy. Again, agnostic of approach, you put the guide, we've tested some of this in the company, you put the guide on, you know, you, you put the pin down the center, and then cognitive burden gone, right? And so these are, these are some of the things we're thinking through as a company back to Craig's point around, well, the common podium argument is hard to do, that's why I don't do it. Well, if I can take that objection away, I, I've made a, I've made a even a more compelling argument to, to learn the operation. So

Joseph M. Schwab 1:01:07

Well, so you guys have been really generous with your time. I've got a few closing questions and I, I, I don't wanna take up more time than, uh, um, than, uh, I, I requested of you, but you've brought up so many great points today that it feels like we could have two or three more episodes just talking about some of the issues you've raised. But, um, Craig, I, I wanna start with you. If we were to do this interview again, say in 10 years, what do you think we would be talking about as the biggest misconception about resurfacing right now?

Craig J Della Valle 1:01:47

That's a good question. I hope what we're gonna be talking about, and I'm not sure if this answers the question, is that the PolyMotion device got rid of the metal-metal failures and brought the complication rate of conventional hip replacement and resurfacing to the same level I think the complications still might be a little bit different. I honestly believe the anatomic, uh, head size lowers the risk of dislocation. Um, and I hope we'd be talking about, yeah, again, that I think that, uh, getting rid of metal/metal equalized the complication rate and that that hip resurfacing skill or that hip resurfacing offers a higher level of function. I think that's what we'd be talking about. I hope that's what we're talking about

Joseph M. Schwab 1:02:33

Sharat, how about you?

Sharat Kusuma 1:02:37

Yeah, I mean, I, I would echo everything Craig said. Uh, I hope we're talking about, with an open mind, that there are several excellent solutions for primary hip arthritis in different patient populations and that, that, that our profession openly embraces that, yes, there are, you know, the armamentarium should be broad and, and you know, if someone chooses to do total hips in 100% of their people, that's fine, but they also shouldn't be chastising the person who's taking the time to learn a different procedure and, and, you know, demonstrating that the results can be excellent at scale. You know, again, not in 1% of the population, but in 10% or 50 or, or 20%. I hope we're talking about that. I also hope we're ta-- and this is maybe a slight variant on, on the themes that Craig, I hope we talk about how innovation in orthopedics used to be difficult, but our company sort of demonstrated how to get through, and that's something we haven't touched on at all and, you know, you know, in this podcast, which I think is a, is a fascinating topic that I'd love to talk about with more of my surgeon colleagues. What we're trying to do at Joint Medica is really leverage our surgeon key opinion leaders and working closely on the reg-- 'cause again, regulatory affairs, you know, globally has become a very challenging, you know, both for the regulators and for companies, right? And you know, I can tell

Craig J Della Valle 1:03:59

And the surgeons

Sharat Kusuma 1:04:01

And, and but, but, but Craig, I guess what I'd say is I don't think, and I don't mean this with any, this is not disparaging in any way, I don't think we spend enough time, Joe and Craig, at our academic meetings talking about how surgeons can help implant companies drive innovation. We spend more time talking about just our own, kind of our own arena. You know, I, I hope we talk more about, well, hey, Joint Medica is a company that actually showed how to bring together surgeons, regulators, engineers together to innovate. Because again, let's talk, let's be honest about it. The innovation in our field over the last twenty years probably hasn't been as, as, as dramatic as perhaps it's been in cardiology, you know, in o- in other, in other areas. I mean, l- if you look at the cardiology, you know, space, right? I mean, think about transcatheter valve replacements and, you know, uh, cardio, uh, electro, uh, electrophysiology, your defibrillator, cardioverters. I, I'd like to hope that we're talking about, you know, the co- this company demonstrated how that partnership can help accelerate innovation cycles in the implant space in orthopedics. Again, I think that has slowed, and I think the empirical, you know, review of the market would demonstrate that. So tho- those are the themes I hope we're talking, talking about in addition to the clinical side of things.

Joseph M. Schwab 1:05:16

Hmm. Craig, if you could have a conversation with the junior attending who was maybe just starting to do these, you know, you, uh, back in 2007, um, what would you tell yourself about where this is gonna go and something you'd wish you knew now or w- you wish you knew then that you know now?

Craig J Della Valle 1:05:46

I have no idea. Um, again, I'm probably not answering your question. I think the smart things that I did was, uh, I think people go to a course and they don't have something on the schedule, and then there's this delay between kind of being taught it and trying it yourself. So I think, like if you're gonna go to a course and learn how to do something, I think you kinda need to like do them close to each other, and you gotta like keep at it and give yourself, you know, the ability to get through some of the learning curve before kind of making a decision

Joseph M. Schwab 1:06:24

Sharat, what does it mean to you to be building the next generation of this procedure that you first watched Craig perform?

Sharat Kusuma 1:06:35

Yeah, and I mean, d-divorcing from, say, the procedure itself, what I find most gratifying, and I hope we end up with more former clinician leaders, you know, in implant companies, right, and in pharma companies and in, you know, healthcare policy. It's just been a real career privilege to have, have had a career, you know, having been fortunate to train with folks like Craig, who are as well-respected, and having learned from them, and to be able to take that legitimate clinical experience, right, and then using that to drive d-the decision cycle within a company every single day, that, that-- I think there's some pretty interesting opportunity there. Again, back to what I'm, I'm very passionate about, about the partnership between surgeons and, and companies that could be augmented. It's, it's a privilege really to be able to work with, with former mentors and colleagues like Craig and, and Mike and, and other, and Ronen and others, to be able to be translating the, the, the insights at such a rapid velocity into the development cycle in a company. It's, it's truly a privilege. And again, like I say, I hope that I, I take that privilege very seriously and, and, and the responsibility of it. And, um, it's very meaningful to, to be able to work... Th-that they have the trust i-in, in me to, to, to, you know, put these implants in their patients and to work with us so closely, it's a responsibility I, I take very, very seriously and, um, it's, it's incredibly meaningful to be able to do things like that. And I hope it can inspire more y- you know, clinicians and docs to, to maybe spend some time, more time helping to innovate in the healthcare industry, because I think our broad segments of our industry need more folks who practice medicine driving the innovation. I think we have just a lot of innovation that's driven by maybe folks that haven't had a chance to be in the clinic and take care of patients, and that, that is such an important element if you're gonna innovate, whether it's digital health products or instruments or whatever it is, right? If you've never been in the trenches, it's hard to know what, what docs and patients need. So, um, I, I take that privilege very-- it's very meaningful.

Joseph M. Schwab 1:08:46

Craig, last question for you. Um, any advice to our younger listeners about how to sort through fad from, um, you know, maybe the next big revolution?

Craig J Della Valle 1:08:59

Yeah, I think it's hard. I think, uh Yeah. I mean, I think, you know, as we talked about in the beginning, I got interested in resurfacing because I felt like I'm in an academic center, someone here should learn it. And I think maybe that's what you do if, if you're lucky enough to be in a group where there's a couple folks doing adult reconstruction. I, I, I think it's nice to help develop someone as a specialist in, in some little niche thing. Patellofemoral arthroplasty, partial knee replacement, managing periprosthetic infection, doing hip resurfacing. I think i- if you're lucky enough to be in that situation where you have a, a couple of surgeons who are working together, work together to help someone develop a clinical expertise. Because at the end of the day, there's definitely something to be said for the more that you do something, you get better at it, you understand the indications better, you understand the nuances of the operation. So like when I was a resident out at Harborview, um, the traumatologist each had their own little niche thing, and they would send each other the pylons, the calcs, the pelvises, the acetabulum. They kind of sorted it out amongst themselves, or I guess maybe the chair did and said, "Okay, I want you to really develop some expertise in this." Um, I th- I think that's a model that works, and if you have that ability either at, again, an academic center or if you're in a private practice group where there's a couple folks who have the opportunity to practice together, pick something and really try to become an expert in it. Um, I think it gives you the ability to take better care of patients. You know, academically, it gives you opportunities for research, to be able to talk about things intelligently. At the end of the day, not everything you try you're gonna like, not everything you try you're gonna think is gonna be good. And I guess the biggest one is don't do stuff just because that's what you were taught. So like the biggest example for me is I, I was on the plane, I was with my daughter, she's seven, and we were, we were on the plane, and I always grab a couple of magazines. I still like having paper magazines. I'm 56, I still like paper, and I still like reading it. I, I grabbed my general opponent joint surgery, and, um, the one versus two-stage exchange paper was in that edition, and I was really proud reading that. I mean, I remember enrolling my first patient in that study and being terrified that I was doing something bad. I remember I did my first resurfacing, being terrified I was doing something bad, making this giant incision, the patient's gonna do terrible. And I think we all need to challenge our own beliefs and then study them. You know, because I think there's a lot of things we do out of tradition, and not maybe as many things that we do because we have good evidence to support doing those things. So I think we all need to challenge our own beliefs. Like we were talking about earlier, like travel. Do a traveling fellowship like Sharat did. Try to learn about something else because there are new ways to do things and think about things that can improve not only our patient's quality of life, but your own as a surgeon. I always say that, like one stage exchange It improved my quality of life. Like not having to worry about scheduling two surgeries, not having to worry about checking labs every week, not having to worry if the spaker- spacer's gonna dislocate or break or something terrible's gonna happen. You know, and again, I was really nervous doing those first cases, and I think we all just need to, like, take a step back and challenge ourselves and say, "Really, why am I doing this?" And study it and learn about it

Joseph M. Schwab 1:12:26

Hmm. Well, gentlemen, I, I really appreciate you joining me today on the podcast, and, um, from a clinical perspective, from a med tech perspective, it was, um, really fantastic to hear your thoughts and, and, uh, I'm really excited to see, um, what you're able to do with, uh, with PolyMotion and with, with JointMedica as a bigger company. So thank you so much for joining me today on the

Craig J Della Valle 1:12:51

Thanks for having us. It was fun.

Sharat Kusuma 1:12:53

Thank you, Joe. It's, it's an honor to be up. Appreciate the opportunity and hearing, hearing our story. Thank you so much

Joseph M. Schwab 1:13:00

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 and conversations 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, healthy, and maybe resurfaced