October 25, 2024 • 9 mins
In this episode of the AHF podcast, host Joe Schwab interviews Dr. Brian Gladnick from the Carrell Memorial Clinic in Dallas, Texas. Dr. Gladnick discusses his background, the history, and the growth of the Carrell Clinic, along with his research on automated impaction in total hip arthroplasty. His study discovered that selective use of automated impaction significantly reduces fracture rates during surgery. Dr. Gladnick highlights the benefits and offers advice for both current users and potential adopters of automated impaction technology.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:05):
Hello and welcome to the AHF podcast.
I'm your host, Joe Schwab.
Our guest today is Dr.
Brian Gladnick of the CarrellMemorial Clinic in Dallas,
Texas.
Dr.
Gladnick's study,"MitigatingCalcar Fracture Risk with
Automated Impaction During TotalHip Arthroplasty", took second
place at the most recent AHFmeeting.
(00:25):
Dr.
Gladnick, welcome to the AHFpodcast.
Brian Gladnick (00:29):
Joe, thanks for having me.
Honored to be here.
Joseph M. Schwab (00:30):
So first of all, tell me a little bit about
yourself, a little bit aboutyour background and your
practice.
Brian Gladnick (00:36):
I'm here at the Carrell Clinic in Dallas, Texas.
We are one of the oldest clinicsreally in the south and really
even in the country.
We're 100 years old.
We were, our clinic was actuallystarted in 1921, by a guy, W.
B.
Carrell, who started out as a,proponent of, pediatric
deformity and fracture care.
He was actually one of thefounders of the Scottish Rite
Hospital, orthopedic hospitalhere in Dallas as well.
(00:58):
And so, over the last hundredyears, um, what started out as a
very small, uh, children'sorthopedic clinic has, uh, grown
into a specialty orthopedichospital.
We have all service lines,spine, sports, total joints,
foot and ankle, hand, all thatstuff, of course.
Um, and, uh, we have a very,very busy total joints
department here.
I joined the faculty, uh, aboutalmost six years ago.
(01:19):
Um, and, uh, we do about, gosh,22, 2400 joints a year in this
hospital between, we have, uh,five fellowship trained, um,
total joints doctors, um, thatdo that.
And, um, so we, uh, got a verybusy revision service.
We started a fellowship, um, at,uh, kind of that whole process
began a couple years ago.
We're just actually graduatingour first fellow this year.
(01:39):
In recent years, we got we havea 501 c3 Charitable foundation,
so we got approved for REDCapand we were able to start our
institutional registries aboutfive years ago based on That so
it's really improved our abilityto put out good quality
research.
Joseph M. Schwab (01:53):
Where did you do your residency and your
fellowship
Brian Gladnick (01:56):
Yeah, I trained at HSS for residency, graduated
from there in 2015, uh, did my,uh, my fellowship at
OrthoCarolina in Charlotte, uh,graduated from there in 2016,
um, and, uh, spent some timetraveling around a little bit,
went to Switzerland at theSchulthess Klinik and saw
Michael Leunig and those guysfor a little bit, went down to,
uh, Austin saw Tyler Goldbergoperate and I've been trying
(02:16):
something I've been trying to donow every year is take a couple
days off and just sort of travelaround the country and watch
other people operate.
I think it's a really valuablething to do.
Joseph M. Schwab (02:24):
Is, uh, ortho Carolina where you were exposed
to anterior approach, or wasthat with Michael Leunig?
Brian Gladnick (02:29):
Well, even when I was so I when I graduated HSS
2015, it was it was HSS at thatpoint was still very
dogmatically posterior approach,but there was starting to be
some some, uh, people dippingtheir toes in the water.
Mike Alexiades had been doing itfor decades, really, at that
point.
So, but there was some otherpeople kind of starting to get
into it.
So there's still someexperience.
I did see some anti approachthere.
Um, but yes, going toSwitzerland and see Michael
(02:51):
Leunig, operate was just an eyeopening experience for me and,
watching him do what he does.
He's one of the most outstandingsurgeons, technically I've ever
seen operate.
And, um, so then kind of comingback, I really wanted to be at
a, a anterior specific, uh,fellowship, which is why I went
to OrthoCarolina, which is anincredible experience.
And probably the, the, one ofthe few years of my training,
uh, that I ever said, gosh, Iwould, if I would do that again
(03:12):
in a heartbeat, if I could.
Joseph M. Schwab (03:13):
What prompted you to want to study this
automated impaction concept intotal hip arthroplasty?
Brian Gladnick (03:20):
This started at the study that we had at the
AHF, Was really started out askind of an observation that we
had seen over years.
And so, um, when I first startedusing the device, like I said, I
had some brief exposure to itwhen I was in Virginia back in,
like, 2016.
But then I started using it inearnest when I came to Dallas in
2019.
And so, um, when I first startedusing it, um, I was just kind of
(03:42):
blindly just on powereverything.
So broaching on power.
Stem goes down on power, impactthe head on power.
And the thing is, it'scalibrated for the same amount
of newtons of force that youwant to engage the trunnion.
I remember when they first cameout with this thing, it was a
lot of the messaging from thecompanies was, um, this is a,
uh, a panacea for fractures.
You know, you'll never breakanybody with this thing.
(04:02):
It's calibrated, it's safe,you're in line.
And my experience was that thatwas clearly not the case that
every once in a while we were,we were having a fracture.
just as you would if you'rebroaching by hand every once in
a while, you're gonna have afracture if you're doing enough
hips.
Um, and so we went back andlooked.
And in fact, when we looked atthat study, you know, if you
ever look at our overall rate, Ithink it was something like
almost 1600 hips.
We had like 17 fractures as rateof like 1.1%.
(04:25):
was clear to me that there was,it's not a, it's not a panacea,
but it's not, it's didn't seemmuch different than, than
mechanical or handheldbroaching.
And it's just that it's, youknow, there's certain patients
are going to have, have, havefractures.
Um, but one thing that didbecome clear to me, you know, as
we use this thing more and morewas that there were certain
situations in which I was justnaturally saying, uh, that's a
(04:47):
case.
I'm not going to put the finalstem down.
By hand.
And I know.
And so we know it's very earlyon.
It seems like all of ourfractures were occurring, not
with the broach itself, but withthe final stem.
Um, so I would be, you know, andI was ruthlessly aggressive with
this thing, just like full auto,just Wedging these stems in
super tight on then say, okay,it looks great.
I'd take the end, take thebroach out and then when we, and
(05:09):
then you put the stem down, butevery once in a while you'd have
a fracture you go geez, geewhiz, we were, you know, like I
said, ruthlessly aggressive withthese broaches, but then all of
a sudden we put the stem down,we have a crack.
Why did that happen?
Um, and one thing we started tonotice was that.
In situations in which youimagine when you have that final
broach in there and we just lookat it, and if there was a rim,
like a sort of a cushion ofcancellous bone surrounding the
(05:31):
outside of the broach, that wassituation, I was pretty
comfortable saying, okay, it'salmost like a cushion, right?
We're going to, it's going to,you know, uh, be a safe
situation to impact that stem bypower.
Joseph M. Schwab (05:40):
So what did your study actually find?
What were the results?
Brian Gladnick (05:42):
it brought our fracture rate down from like 1.2
to 0.6 by going, by being, goingthat selective.
And I will say.
It was certainly clinicallysignificant to me to see a,
basically a, a 50% reduction infractures.
Joseph M. Schwab (05:55):
Were you using a consistent stem throughout the
entire time?
Were you using a mixture ofstems?
Tell me a little bit about that.
Brian Gladnick (06:02):
Yeah.
I mean, I use, I'm prettyconsistent with my stem.
I mean, I use a triple taperedcollared HA-coated stem in
virtually almost everybody.
Um, I excluded patients that wecemented or certainly any kind
of conversions, revisions,things like those were all
excluded.
So the only people that wereallowed to be included in the
study were primary tripletapered stems.
Joseph M. Schwab (06:20):
Based on what you found, what advice would you
give to surgeons who are usingautomated impaction?
Brian Gladnick (06:27):
First thing I would tell him is to go for it.
It's a, I think it's a real, um,benefit to the surgeon
themselves.
And we actually, we have anongoing, a couple of manuscripts
in publication right now, but a,um, ongoing, uh, multi centered
RCT, uh, prospective RCT lookingat a variety of different
things, not just, you know,accuracy of, of, of component
placement, but also things likeoperative time, um, broaching
(06:51):
time, uh, fracture rate.
Um, and also biometric datalooking at the, the burden of
effort on the surgeonthemselves.
So they had all the surgeons inthe study wearing a biometric
vest with real, real time EMGdata.
So looking at your muscleactivation, your deltoids, your
biceps, your pecs, things likethat.
It's a lot less wear and tear onyour body.
And so I think, you know, we'llbe operating longer and more
(07:12):
comfortably with these devicesas we go forward.
Um, Number two, I think we'redoing a better job putting
these, these stems in, you know,I think if anyone who uses the
device and it's hard to quantifyin the study, but there's
something very palpable aboutwhen you broach with automation
that the consistency of yourbroach envelope is just much
more pleasing to the eye andpleasing to the feel of your
hands than when you're doing itby hand.
(07:34):
Um, I think ergonomically it'seasier to control the broach.
Think about a really tightmuscular patient or you know how
these, you know, think about apatient who, you know, as you
go, you know, As you grow largerand larger in your broach size,
how sometimes the anatomy willforce you into that and increase
an inversion.
You're trying so hard to resistthat, but you're fighting a
belly or fighting their theirtheir musculature, and it's kind
of forcing your hand out.
It's much easier in my mind toresist that using automation.
(07:57):
It's not a panacea forfractures.
You can definitely still cracksomebody with these things.
Um, but there's, if you, uh, ifyou pay very close attention to
the relationship between thebroach and the calcar, if there
is a full circumferentialcushion of cancellous bone
between your final broach andthe calcar, go ahead and put it
down by power.
But if there's any part of yourbroach that's directly
(08:18):
contacting that calcar, just besafe, tap out the stem and put
it down gently by hand.
Joseph M. Schwab (08:22):
Any advice that you would give surgeons who
aren't using automatedimpaction, would this be a, an
indication to consider using itor what's your advice there?
Brian Gladnick (08:30):
You know, I think if you've been broaching
by hand for 20 years, you'revery used to the pitch changes
and the, the, the feel of a stemas it engages, um, you know, the
proximal bone or distal bone,you know what that feels like.
Um, it feels different when youuse automated impaction.
And, uh, and there's some justthings where you have to just
use it to get used to thosethings.
Um, but the learning curve forit is very, is very easy.
I mean, we, we train our fellowson it.
(08:51):
They have it within like a weekor two.
They, they got it, you know,it's not, it's not terribly
difficult.
Joseph M. Schwab (08:56):
So is it going to give you an extra 10 years on
your practice?
Do you think?
Brian Gladnick (08:59):
I hope so.
I'm going to, my, plan is towork until I drop dead.
So that's the,
Joseph M. Schwab (09:03):
Hopefully not anytime soon.
Brian Gladnick (09:05):
that's right.
Joseph M. Schwab (09:07):
Um, well, you know, we really appreciate you
submitting your poster to theAHF this year.
We congratulate you on yourvictory.
It was, uh, uh, an excellentposter.
It had great scores from thescientific committee and we look
forward to you submitting, uh,further research in the future.
Brian Gladnick (09:23):
Well, thank you, Joe.
Yeah, we were, we were honoredto have that, um, to have that
recognition and, um, yeah,hopefully, uh, much more coming
forward.
Joseph M. Schwab (09:29):
Thank you for meeting with me today, Brian.
Brian Gladnick (09:31):
Thank you.
Thank you for your time.
Joe Schwab (09:34):
thank you for joining me for another episode
of the AHF podcast.
If you want more information,you can check us out on
Facebook, LinkedIn, or X, or youcan visit us at our website,
anteriorhipfoundation.
com.
Hello and welcome to the AHF podcast.
I'm your host, Joe Schwab.
Our guest today is Dr.
Brian Gladnick of the CarrellMemorial Clinic in Dallas,
Texas.
Dr.
Gladnick's study,"MitigatingCalcar Fracture Risk with
Automated Impaction During TotalHip Arthroplasty", took second
place at the most recent AHFmeeting.
(00:25):
Dr.
Gladnick, welcome to the AHFpodcast.
Brian Gladnick (00:29):
Joe, thanks for having me.
Honored to be here.
Joseph M. Schwab (00:30):
So first of all, tell me a little bit about
yourself, a little bit aboutyour background and your
practice.
Brian Gladnick (00:36):
I'm here at the Carrell Clinic in Dallas, Texas.
We are one of the oldest clinicsreally in the south and really
even in the country.
We're 100 years old.
We were, our clinic was actuallystarted in 1921, by a guy, W.
B.
Carrell, who started out as a,proponent of, pediatric
deformity and fracture care.
He was actually one of thefounders of the Scottish Rite
Hospital, orthopedic hospitalhere in Dallas as well.
(00:58):
And so, over the last hundredyears, um, what started out as a
very small, uh, children'sorthopedic clinic has, uh, grown
into a specialty orthopedichospital.
We have all service lines,spine, sports, total joints,
foot and ankle, hand, all thatstuff, of course.
Um, and, uh, we have a very,very busy total joints
department here.
I joined the faculty, uh, aboutalmost six years ago.
(01:19):
Um, and, uh, we do about, gosh,22, 2400 joints a year in this
hospital between, we have, uh,five fellowship trained, um,
total joints doctors, um, thatdo that.
And, um, so we, uh, got a verybusy revision service.
We started a fellowship, um, at,uh, kind of that whole process
began a couple years ago.
We're just actually graduatingour first fellow this year.
(01:39):
In recent years, we got we havea 501 c3 Charitable foundation,
so we got approved for REDCapand we were able to start our
institutional registries aboutfive years ago based on That so
it's really improved our abilityto put out good quality
research.
Joseph M. Schwab (01:53):
Where did you do your residency and your
fellowship
Brian Gladnick (01:56):
Yeah, I trained at HSS for residency, graduated
from there in 2015, uh, did my,uh, my fellowship at
OrthoCarolina in Charlotte, uh,graduated from there in 2016,
um, and, uh, spent some timetraveling around a little bit,
went to Switzerland at theSchulthess Klinik and saw
Michael Leunig and those guysfor a little bit, went down to,
uh, Austin saw Tyler Goldbergoperate and I've been trying
(02:16):
something I've been trying to donow every year is take a couple
days off and just sort of travelaround the country and watch
other people operate.
I think it's a really valuablething to do.
Joseph M. Schwab (02:24):
Is, uh, ortho Carolina where you were exposed
to anterior approach, or wasthat with Michael Leunig?
Brian Gladnick (02:29):
Well, even when I was so I when I graduated HSS
2015, it was it was HSS at thatpoint was still very
dogmatically posterior approach,but there was starting to be
some some, uh, people dippingtheir toes in the water.
Mike Alexiades had been doing itfor decades, really, at that
point.
So, but there was some otherpeople kind of starting to get
into it.
So there's still someexperience.
I did see some anti approachthere.
Um, but yes, going toSwitzerland and see Michael
(02:51):
Leunig, operate was just an eyeopening experience for me and,
watching him do what he does.
He's one of the most outstandingsurgeons, technically I've ever
seen operate.
And, um, so then kind of comingback, I really wanted to be at
a, a anterior specific, uh,fellowship, which is why I went
to OrthoCarolina, which is anincredible experience.
And probably the, the, one ofthe few years of my training,
uh, that I ever said, gosh, Iwould, if I would do that again
(03:12):
in a heartbeat, if I could.
Joseph M. Schwab (03:13):
What prompted you to want to study this
automated impaction concept intotal hip arthroplasty?
Brian Gladnick (03:20):
This started at the study that we had at the
AHF, Was really started out askind of an observation that we
had seen over years.
And so, um, when I first startedusing the device, like I said, I
had some brief exposure to itwhen I was in Virginia back in,
like, 2016.
But then I started using it inearnest when I came to Dallas in
2019.
And so, um, when I first startedusing it, um, I was just kind of
(03:42):
blindly just on powereverything.
So broaching on power.
Stem goes down on power, impactthe head on power.
And the thing is, it'scalibrated for the same amount
of newtons of force that youwant to engage the trunnion.
I remember when they first cameout with this thing, it was a
lot of the messaging from thecompanies was, um, this is a,
uh, a panacea for fractures.
You know, you'll never breakanybody with this thing.
(04:02):
It's calibrated, it's safe,you're in line.
And my experience was that thatwas clearly not the case that
every once in a while we were,we were having a fracture.
just as you would if you'rebroaching by hand every once in
a while, you're gonna have afracture if you're doing enough
hips.
Um, and so we went back andlooked.
And in fact, when we looked atthat study, you know, if you
ever look at our overall rate, Ithink it was something like
almost 1600 hips.
We had like 17 fractures as rateof like 1.1%.
(04:25):
was clear to me that there was,it's not a, it's not a panacea,
but it's not, it's didn't seemmuch different than, than
mechanical or handheldbroaching.
And it's just that it's, youknow, there's certain patients
are going to have, have, havefractures.
Um, but one thing that didbecome clear to me, you know, as
we use this thing more and morewas that there were certain
situations in which I was justnaturally saying, uh, that's a
(04:47):
case.
I'm not going to put the finalstem down.
By hand.
And I know.
And so we know it's very earlyon.
It seems like all of ourfractures were occurring, not
with the broach itself, but withthe final stem.
Um, so I would be, you know, andI was ruthlessly aggressive with
this thing, just like full auto,just Wedging these stems in
super tight on then say, okay,it looks great.
I'd take the end, take thebroach out and then when we, and
(05:09):
then you put the stem down, butevery once in a while you'd have
a fracture you go geez, geewhiz, we were, you know, like I
said, ruthlessly aggressive withthese broaches, but then all of
a sudden we put the stem down,we have a crack.
Why did that happen?
Um, and one thing we started tonotice was that.
In situations in which youimagine when you have that final
broach in there and we just lookat it, and if there was a rim,
like a sort of a cushion ofcancellous bone surrounding the
(05:31):
outside of the broach, that wassituation, I was pretty
comfortable saying, okay, it'salmost like a cushion, right?
We're going to, it's going to,you know, uh, be a safe
situation to impact that stem bypower.
Joseph M. Schwab (05:40):
So what did your study actually find?
What were the results?
Brian Gladnick (05:42):
it brought our fracture rate down from like 1.2
to 0.6 by going, by being, goingthat selective.
And I will say.
It was certainly clinicallysignificant to me to see a,
basically a, a 50% reduction infractures.
Joseph M. Schwab (05:55):
Were you using a consistent stem throughout the
entire time?
Were you using a mixture ofstems?
Tell me a little bit about that.
Brian Gladnick (06:02):
Yeah.
I mean, I use, I'm prettyconsistent with my stem.
I mean, I use a triple taperedcollared HA-coated stem in
virtually almost everybody.
Um, I excluded patients that wecemented or certainly any kind
of conversions, revisions,things like those were all
excluded.
So the only people that wereallowed to be included in the
study were primary tripletapered stems.
Joseph M. Schwab (06:20):
Based on what you found, what advice would you
give to surgeons who are usingautomated impaction?
Brian Gladnick (06:27):
First thing I would tell him is to go for it.
It's a, I think it's a real, um,benefit to the surgeon
themselves.
And we actually, we have anongoing, a couple of manuscripts
in publication right now, but a,um, ongoing, uh, multi centered
RCT, uh, prospective RCT lookingat a variety of different
things, not just, you know,accuracy of, of, of component
placement, but also things likeoperative time, um, broaching
(06:51):
time, uh, fracture rate.
Um, and also biometric datalooking at the, the burden of
effort on the surgeonthemselves.
So they had all the surgeons inthe study wearing a biometric
vest with real, real time EMGdata.
So looking at your muscleactivation, your deltoids, your
biceps, your pecs, things likethat.
It's a lot less wear and tear onyour body.
And so I think, you know, we'llbe operating longer and more
(07:12):
comfortably with these devicesas we go forward.
Um, Number two, I think we'redoing a better job putting
these, these stems in, you know,I think if anyone who uses the
device and it's hard to quantifyin the study, but there's
something very palpable aboutwhen you broach with automation
that the consistency of yourbroach envelope is just much
more pleasing to the eye andpleasing to the feel of your
hands than when you're doing itby hand.
(07:34):
Um, I think ergonomically it'seasier to control the broach.
Think about a really tightmuscular patient or you know how
these, you know, think about apatient who, you know, as you
go, you know, As you grow largerand larger in your broach size,
how sometimes the anatomy willforce you into that and increase
an inversion.
You're trying so hard to resistthat, but you're fighting a
belly or fighting their theirtheir musculature, and it's kind
of forcing your hand out.
It's much easier in my mind toresist that using automation.
(07:57):
It's not a panacea forfractures.
You can definitely still cracksomebody with these things.
Um, but there's, if you, uh, ifyou pay very close attention to
the relationship between thebroach and the calcar, if there
is a full circumferentialcushion of cancellous bone
between your final broach andthe calcar, go ahead and put it
down by power.
But if there's any part of yourbroach that's directly
(08:18):
contacting that calcar, just besafe, tap out the stem and put
it down gently by hand.
Joseph M. Schwab (08:22):
Any advice that you would give surgeons who
aren't using automatedimpaction, would this be a, an
indication to consider using itor what's your advice there?
Brian Gladnick (08:30):
You know, I think if you've been broaching
by hand for 20 years, you'revery used to the pitch changes
and the, the, the feel of a stemas it engages, um, you know, the
proximal bone or distal bone,you know what that feels like.
Um, it feels different when youuse automated impaction.
And, uh, and there's some justthings where you have to just
use it to get used to thosethings.
Um, but the learning curve forit is very, is very easy.
I mean, we, we train our fellowson it.
(08:51):
They have it within like a weekor two.
They, they got it, you know,it's not, it's not terribly
difficult.
Joseph M. Schwab (08:56):
So is it going to give you an extra 10 years on
your practice?
Do you think?
Brian Gladnick (08:59):
I hope so.
I'm going to, my, plan is towork until I drop dead.
So that's the,
Joseph M. Schwab (09:03):
Hopefully not anytime soon.
Brian Gladnick (09:05):
that's right.
Joseph M. Schwab (09:07):
Um, well, you know, we really appreciate you
submitting your poster to theAHF this year.
We congratulate you on yourvictory.
It was, uh, uh, an excellentposter.
It had great scores from thescientific committee and we look
forward to you submitting, uh,further research in the future.
Brian Gladnick (09:23):
Well, thank you, Joe.
Yeah, we were, we were honoredto have that, um, to have that
recognition and, um, yeah,hopefully, uh, much more coming
forward.
Joseph M. Schwab (09:29):
Thank you for meeting with me today, Brian.
Brian Gladnick (09:31):
Thank you.
Thank you for your time.
Joe Schwab (09:34):
thank you for joining me for another episode
of the AHF podcast.
If you want more information,you can check us out on
Facebook, LinkedIn, or X, or youcan visit us at our website,
anteriorhipfoundation.
com.
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