August 29, 2025 • 56 mins
Welcome to another insightful episode of the AHF Podcast! Join host Joe Schwab and special guest Dr. Bob Sershon from the Anderson Orthopedic Clinic as they dive into the challenges and solutions for performing anterior approach total hip replacements in super morbidly obese patients. Dr. Sershon shares his journey, training, and experience, providing invaluable tips on managing these complex cases. Learn about the importance of preoperative planning, patient selection, implant choices, and innovative techniques to ensure the best outcomes. 🦴💡 🎥 Highlights: - Dr. Sershon's background and practice - Impact of COVID on practice development - Challenges in performing anterior approach total hip replacements in super morbidly obese patients - Importance of preoperative planning and shared decision making 🗝 - Tips for handling large pannus and fat distribution - Implant choices, including stems, cups, and automated impactors - Detailed case studies and step-by-step surgical techniques 🛠 - Tips on post-operative care and follow-ups Don't miss this episode packed with practical insights and expert knowledge from the Anterior Hip Foundation (AHF). Perfect for orthopedic surgeons, residents, and anyone interested in complex joint replacement surgeries. 💼👨⚕️👩⚕️ 📅 Subscribe for more episodes every Friday! 🔗 Connect with us on Apple Podcasts, Spotify, YouTube, and your favorite podcast apps. Keep your hips happy, healthy, and not too obese! 💪🩺
This episode is sponsored by ZimmerBiomet. Visit https://www.zimmerbiomet.com for more information.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:24):
Hello, and welcome to another episode of
the A HF podcast.
I'm your host, Joe Schwab.
My guest today is Dr.
Robert Shan at the AndersonOrthopedic Clinic, and he's here
to give us another cut for timeepisode.
Dr.
Shan, welcome to the A HFpodcast.
Why don't you tell our listenersa little bit about your
(00:46):
practice, your training, andwhat you're gonna talk about
today?
Bob Sershon (00:51):
Yeah, I appreciate it.
Thanks for having me on.
Um, yeah, so Bob Shan AndersonClinic, uh, Anderson Clinic
trained actually, um, fellowshipback in 20 18, 20 19, joined the
practice right after that.
COVID hit, which was, uh,interesting being first year in
practice having that stuffhappen.
(01:12):
But, uh, it actually was endedup being great for me because a
lot of the other places shutdown and a bunch of revision
volume and all the complex stuffthat couldn't wait started to
come in right away.
So, um.
Things, they couldn't wait.
They had to go.
That was still medicallynecessary.
So it built a pretty quickpractice through that.
And, uh, over time, you know,when you do enough complex
(01:32):
stuff, you kind of get known asthe guy in the area that's doing
that.
So, um, a lot of the, uh, moredifficult cases, more complex
revisions, seeing things likethat started to stroll through.
So, um, now, you know, we're,we're.
Out in Alexandria, Virginia, uh,really over the, uh, entire
Northern Virginia area rightoutside of DC And, uh, my
(01:53):
practice is only hip and kneereplacements.
Uh, we're very subspecialized atthe Anderson Clinic.
Basically, all of our partnersare fellowship trained one way
or the other, and just stick totheir subspecialty.
So you won't see me doing anyankles or wrists or anything
like that.
Uh, never did, never will.
So, uh, probably terrible ofthose now.
Um, but, uh, yeah.
(02:14):
Yeah, that's it.
We got great fellowship, do someresearch, um, you know, real
proud of everything theinstitution's done so far and,
you know, good talking aboutsome, uh, big people on big
cases.
Joseph M. Schwab (02:26):
Well, and we had you invited, you came and,
and were part of the a HF uh,uh, annual meeting this past
year in Nashville, and you arepart of the revision session.
And we're intending to give thistalk, uh, as a part of that
session that, uh, session wasso, uh, popular and had so much,
uh, involvement from, uh, ouraudience and so much discussion
(02:48):
back and forth that we literallylost time for your talk.
And so, uh, for better or forworse, you get to be the second
in our, uh, cut for time series,uh, here on the a HF podcast,
and you're gonna be talking tous about.
Uh, doing anterior approach inthe super morbidly obese
patient.
Is that correct?
Bob Sershon (03:07):
Uh, that's, that's right.
And then we got, uh, one morecase that just to add on, um, if
we have time revision, uh,morbidly obese patient.
Joseph M. Schwab (03:16):
Let's, uh, let's get to it.
The floor is yours.
Bob Sershon (03:20):
Great.
Great.
So, um, here we go.
These are my disclosures, youknow, um, involved with Zimmer
Biome and day care, so.
High BMI, total hips, we knowhigher wound complications.
It's not just from the front,from the back as well.
Higher rates of PJI, higherrevision rates.
Really just any complicationessentially.
(03:40):
You name it.
We found that it's, it's higherwith higher BMI.
Um, and then, you know,unfortunately on the flip side,
a lot of these patients aredoing it to, to lose weight and,
you know, they, they reallydon't afterwards.
And, uh, you know.
Reasons why, who knows?
Lifestyle life choices.
It's just been too long forthem.
Uh, that's something I used totalk to people in clinic about,
(04:02):
and Joe, I don't know if, if, ifyou talk to people in clinic
about that afterwards, but, uh,I, I've stopped discouraging,
um, them saying, Hey, you'reprobably not gonna lose weight
after this.
I give'em a chance.
Uh, in my opinion, I Do.
You do the same or.
Joseph M. Schwab (04:16):
Yeah, I, you know, it's, I, the weight
discussion's always interesting,but it's, it's not likely that
unless they gained a whole bunchof weight in the, you know, two
years or so before they, uh, gottheir hip replacement because
their hip was bothering them.
It's unlikely they're gonna loseit afterwards, but I, I don't
usually mention it.
I encourage'em to be as activeas they want to be.
Bob Sershon (04:36):
Yeah.
Yeah.
And I, and that's the route togo of it.
You know, in the back of my mindI just say, all right, we're
doing this for pain relief andhopefully better function if the
weight comes.
That's a huge plus.
So.
Uh, you know, where that goes,you know, in, in our world
unfortunately is, you know,harder surgery, arguably worse
outcomes and not necessarilypatient reported outcomes,
right?
'cause they get, they getsubstantial relief from that
(04:57):
aspect, but we're talkingcomplications.
Um, and then is it worth therisk?
I mean, you have a lot ofinstitutions on bundled
programs.
Um.
Yeah, some people get dinged forhaving complications at their
institutions, readmissions,reoperations.
And so some people just won'teven take these patients on and
they've drawn these hard cutoffsthat makes access for them
(05:17):
pretty hard.
So, uh, we don't have that, uh,at our institution and we, we
take all comers and we try toindividualize it because the
risk is really gonna be sharedright between the patient and
the surgeon.
So, um, it's not our hip that'sgetting infected, it's, it's
their hip and they have to livewith that.
And that's, that's a tough thingto live with.
So.
Um, we, we just do shareddecision making and, and if we
(05:38):
feel like their pain andfunction are significantly, uh,
impacting their life, then we goahead with the replacement
knowing that hey, they, theymight have a complication that
somewhat of normal weight didn'thave.
Um, we're just verystraightforward about that.
So, you know, dealing with thispopulation and preoperative
planning is so important.
So, um, you have, you know, theexam mobility, I'm not just
(06:02):
talking about their mobilitywalking in the room, I'm talking
about the mobility of theirpanis, right?
So you have some people thathave a very mobile panis.
Um, it, it moves, it gets out ofthe way easy.
Uh, you know, some people youlooked underneath.
I got a little bit of what we'llcall some funky stuff, and
that's something that you, youreally wanna, you know, uh, pay
(06:24):
attention to because you don'twant fungal infections and
things like that.
Those are notoriously hard totreat.
So that's someone where you maysay, oh man, I actually have to
go through the back on this one.
Uh, just to avoid any type oflocal, um, contamination, uh,
booty check, right?
I, I teller fellows do bootycheck where, where do they store
their fat?
'cause some people actually fromthe front.
(06:47):
All their fat is storedposteriorly and, and actually,
you know, they may be morbidlyobese and have large bellies,
but maybe it's mobile.
You tape it outta the way.
Um, they don't really have muchin the way of soft tissue in the
front, and it's really not thatmuch more difficult of a case to
do so where they store theirfat.
Really, um, uh, important for,for DA and then leg lengths.
(07:10):
You know, I, I tell the, youknow, the fellows, Hey, we wanna
be close.
Like we, we wanna, leg lengthsare one of the biggest things
for litigation and patientsatisfaction.
Um, but you know, if you have togive them a few more millimeters
of offset or length in order togive yourself a, a stable hip in
this population, feel free toplan to do that.
(07:31):
Um, in terms of implants.
You know, you could use whateveryou want.
It's dealer's choice.
I think all the data at thispoint though, um, from both
anterior posterior is pointingtowards these triple tapered
stems with a collar, uh, thecup.
I like to use a cup that you canget a large head and a smaller
cup.
So, um, almost every company atthis point now, you can get a 36
(07:51):
head or larger to size 50, uh,which is, which is great.
Um, some companies are alreadyat a 52, you're starting to get
a 40 head in there.
Um, that's, that's definitelypositive.
If you can't, uh, consider dualmobility, maybe this is a
population at increased risk ordislocation.
Um, whether or not that's alsotrue from the front, that's
probably debatable, but, uh, itis something that you want to
(08:13):
keep in mind.
Uh, constrained line.
I mean, I think that's justoverkill on a first timer.
Um, automated impact or, I, Ilove using these things, you
know, whether you're using.
You know, we could do brandedby, by company, you know,
concise or hammer one of thesethings.
Uh, I think it saves a ton oftime.
It gives you consistentimpacting all the way through
(08:34):
for me, it really helps mecontrol the version, uh, of the
STEM as it's getting sent on theway down.
Um, which is, which is great.
Then also your other technology.
These are larger people.
So you know, if you're doingthis off table with no fluoro, I
would say that that's a hardtask.
Um, it's hard to feel theirmalleoli, everything's draped
out.
(08:55):
Uh, I, I prefer in, in mypractice to use some sort of
navigation, um, ai, roboticplatform, mixed reality,
whatever people want to use.
Then have offset ready.
And by offset I'm talking offsetreamers, offset insertion
handles, offset broaches, offsetinsertion.
Anything that you can do to haveoffset, even the hand table, if
(09:15):
you're using a table, uh, youknow, they have the standard
hook and the high offset hooks.
So these are all things thatyou're gonna wanna have ready,
maybe not necessarily used, butat least have ready, um, when
you're, when you're planning forthe surgery.
Joseph M. Schwab (09:30):
Do.
Any challenges with the, do yousee any challenges with the
automated impactor in, in theselarge individuals?
I know, uh, or is it, is thatjust taken care of by the
offset, um, you know, broachhandles and things like that?
Bob Sershon (09:45):
I, I only use the, the straight impact, or I, I
haven't used the offset.
I, I've had it ready inpreparation of, Hey, they're
just too big.
I can't get this out of the way.
But I, I've personally not runinto the issue.
Um, I, I don't know, have, haveyou.
Joseph M. Schwab (10:00):
No, I, I mean, I, it's, it's interesting that
you mention that, right?
Because, um, you know,originally when I first started,
uh, well over a decade ago.
I, I think I was using offset oneverybody just'cause I thought
that was, would be easier.
And I've gotten to the pointwhere I just, I rarely use
offset even in the more obese,uh, patients.
(10:20):
And, uh, with something as bigas a, as some of these automated
impactors are, it seems to befar enough away from the
patient, even in obesesituations that it hasn't, I
haven't noticed it beingproblematic.
Bob Sershon (10:34):
Yeah, I'm, I'm right with you on that.
I think they do have offset.
Articulations or handles thatyou could pop in there if you
need.
Um, but I do wonder how muchpower is, is lost through that.
Um, but, uh, may, maybe I'llgive it a whirl one day, but,
but for now, I just haven'tneeded it.
So, um, so here we go.
You know, 55-year-old femalecoming in, BMI 55.
(10:57):
Uh, she traveled two hours forsurgery because nobody locally
was able to take care of her,whether or not it was from
cutoffs or they just couldn'thandle the case.
It, you know, that's debatableproblem's been going on for
years.
Um, you know, really these, thispa this population usually comes
to you trying extensivenon-operative treatment.
Um, most of these patients, atleast that I've seen it.
(11:19):
Has some type of intraarticularsteroid injection, which, which
for me is really just diagnosticis, is it really coming from
their hip?
Um, especially when they don'thave, you know, severe erosive
bone, bone arthritis, like I'llshow you on the next case.
Um, so, and we do all thatplanning and here we go.
So here's, here's the, uh.
Intraoperative views.
I'm trying to give you all ofthe same patient here so that we
(11:40):
can see.
But you know, even with her onthe table, she has such a large
panis that it is completely overthe operative site, even with
Lang supine.
Um, the uh.
The center, you know, leg holderthere if you will, um, between
the legs you could barely see.
It's kind of poking its way out.
But she's one of these peoplethat has a large mobile panis.
(12:03):
Um, and so you would say, Hey,this actually isn't that
terribly difficult of a caseonce you take the outta the way
and you let the fat fallposteriorly as well as you could
see.
I mean, it's hanging down therepretty low.
Um.
Pre-op fluoro views are, youknow, you just wanna match
(12:24):
exactly what you got.
Pre-op uh, there's, there's beendebate back and forth about
standing versus supine viewsand, you know, functional range
of motion and all of these, all,all of these other factors.
What, what we found at ourinstitution.
We tried doing standing viewsfor a while.
Um.
With patients like, like this,they're morbidly obese.
(12:47):
You, the pan is hanging so lowthat you have a really hard
time, at least we did gettingquality x-rays and then
reproducing their standing filmsupine.
You were doing all these crazythings with fluoro.
Um, so we actually.
After trying standing, went backto supine films on everyone.
(13:07):
All of our surgeons, uh, at theclinic, for the most part,
they're, uh, are doing da andthat's how we positioned during
surgery.
Um, so, so we've continuedgetting, getting supine and just
matching supine.
And, uh, you know, fortunatelyon our dislocation side, I mean
our rate at the institution foranterior is, you know, like 0.3
some something below a halfpercent.
(13:28):
Are you doing anythingdifferent?
Are you getting standing filmsor?
Joseph M. Schwab (13:32):
No, in my practice it's supine.
Um, I, you know, I'm, uh, a bitof a, a Joel Matta disciple on
this.
You know, he always teaches thefrontal plane of the body is
what's most important.
You know, the, the position.
Uh, supine versus standing isless important than the position
of the frontal plane of the bodywith the pelvis in the position
(13:53):
that you're operating in, sousually supine.
Um,
Bob Sershon (13:57):
so we're on the
Joseph M. Schwab (13:57):
yeah, I mean it's, we're, we're, we're
talking probably like youdescribed, you know, less than
hundredths of tenths of apercent difference probably in
our dislocation rates based onthat.
So, who knows?
Bob Sershon (14:12):
Yeah.
So, um, but it's important toget, you know, to, to really
match these shots and, and, um,if you're not using, uh,
navigation or something likethat, it's hard to get the C-arm
unless you have one of thoselarge, you know, 12 inch or or
larger square, uh, c-arm thatI've seen.
Um, it's hard to get the entirepelvis in there, and then
(14:32):
there's a lot of parallax.
So, uh, that's, that's achallenge if you're not using
something where you can do anoverlay.
Um.
So now you got everything drapedout.
We do that normally.
And then, you know, from thebikini standpoint, the way that
I like to do it, and, andthere's not too many variations
of this'cause it, it's not avery forgiving incision if
(14:53):
you're not in the right spot.
Um, so I'll, I'll put my, mypinky finger right on the a SIS
and then go three finger breathsdistal.
Uh, and that's been the mostreproducible way for me.
I mean, some people just, youknow, put their ring finger, um,
right below a SIS, but, uh, thatthat's how I do it.
And.
Most patients, I mean, theincisions a little bit smaller
(15:16):
probably than 10 centimeters.
But on these larger patients, Igive a larger incision.
Uh, it's you, you just have to,for visualization purposes, in
my opinion.
Um, I tend to not travelmedially to the A SIS, although
I would tell you in a largepatient where you have a really
thick subcutaneous fat layer,you're probably safe to do that.
(15:39):
Without, you know, being at riskof getting into any of the
vessels or anything like that.
So let me get to the next one.
So the approach is prettystandard.
Once you get through the skin,right, you get down to the
fascia, you find your A SIS,that's gonna be your lighthouse.
It's gonna tell you, Hey, thisis where I know I'm at.
(15:59):
It's a reproducible landmark.
And so for anyone taking thesecases on for the first time, I
would say, Hey, make yourincision.
Feel a SIS know where you are interms of space and then get into
your capsule, or sorry, intoyour fashion work your way down
to capsule from there, uh, onceyou get down into the hip, I, I
like to use an inferior tagstitch on the inferior LA image.
(16:22):
It just helps get the capsuleout of the way.
Uh, some people don't do that.
Some people do a completecapsulotomy or a capsulectomy, I
should say.
That's probably dealer's choice.
Are, are you doing anythingdifferent on that in terms of
the, the, uh, capsule.
Joseph M. Schwab (16:36):
No caps.
Capsular management for me is,is a, a stitch on, on both flaps
and I, I do a capsulotomy and I,I use those as retractors
basically.
Bob Sershon (16:45):
Exactly.
Yep.
I mean, it's, it's really niceto use his retractors and it, it
really helps stay outta the way,especially with a bikini, you're
not mastering the middle of theincision.
Um.
Joseph M. Schwab (16:55):
Right.
I.
Bob Sershon (16:56):
Uh, on these large patients, I, I almost never use
fluoro to identify the saddle orwhat I wanna make my neck cut.
Uh, but on these, if I'm notsure, bring in fluoro, um, it,
it is such a useful tool foranterior, especially in, in a
learning curve or your, yourfresh out of fellowship or
something like that.
(17:17):
Um, and if it's a big stiff hip,like this lady was very mobile,
um, but if it's a big stiff hip,uh, make a napkin ring.
Like make it easy on yourself toget that head out.
Uh, and early on, I, I did thaton every case.
And then as I got morecomfortable and just more
confident with doing things, I,I, I moved away from it.
But I don't think you're everreally wrong to do that.
Joseph M. Schwab (17:40):
Are you normally just doing a single cut
on your, on your standardprimaries?
Bob Sershon (17:44):
Normally, yes.
Um, and that's stem.
Yeah.
We can go back to that.
I mean, that's, uh, STEMdependent as well, right?
So.
Some of, some of these implantshave a little bit of a longer
neck built in, uh, naturally.
Uh, like if we're gonna comparevendors, like I, I would say
that, you know, I feel that, youknow, the Z one has a little bit
of a longer neck than Actis.
(18:05):
If you're looking at tripletaper stems, those are the two
that I used here.
So, you know, I might cheat alittle lower if I use Zimmer or
if I, you know, I have to usethe pew, I might go a little bit
higher with a net cut.
Um, but it, that's, that'sagain, deal dealer's choice.
No right or wrong there.
So with reaming, I, I still,even in these large patients,
(18:25):
ream with a straight reamer, um,I haven't used, uh, at least
that I can remember.
Maybe I have, but I, I don'trecall using the offset reamer,
even though I have it availableall the time.
'cause you just don't wanna getin a situation where they have
such large anterior subcutaneousfat on their thigh that it's.
Pushing you completely invertedand vertical, um, which is the
(18:49):
tendency, uh, on these patientswhen you're reaming.
So, uh, do, do you switch overin the larger patients to
offset, or do you use offset allthe time, or you said you
Joseph M. Schwab (18:57):
No, generally.
Generally straight reamer.
Yeah, generally straight reamer.
Mm-hmm.
Bob Sershon (19:02):
Yeah, it's, it's amazing.
I mean, just'cause it'shemispherical, I mean, you, you
get a great ream.
Um, I think you just on thesepatients especially need to be
careful about not reaming outthe anterior wall because that
fat is gonna wanna push youanterior.
Um, it'll also want to have, youhave a tendency to raise the,
(19:23):
uh, the center of the cup aswell.
So, um, I'm, when I'm reamingI'm kind of pushing down in
posterior to, uh, to keep thehip center lower as or as low as
we reasonably can and to notream out the anterior wall.
'cause I do it under directvisualization.
So this picture here is with thelights off the wound, no
headlight on, and you couldstill see in the wounds.
(19:46):
Then you could imagine, turnyour headlight on, put the, or
the operative field lightspointing back in the wound.
Um, and you get actually a, avery reasonable view here.
Uh, I like to, when I'm reaming,uh, under visualization take
out, uh, so if we're gonna saythat towards the head is 12
o'clock, I'll usually have, uh,like a pointed cobra.
(20:09):
I call it the medium, um, rightdown near the TAL.
And I'll take that out becausethat tends to get in the way of
the reamer for me.
And I'll just have that shortythat pointed shorty retractor
that you could see, um, rightover the anterior brim there.
And then something posteriorlyto help me from catching all the
fat and tissue as I'm getting inand out of the wound.
(20:30):
Um, so you know, then when yousend your, you know, your reamer
down, you could use fluoros.
I'm bringing Fluor up here toshow you.
Just the AP pelvis that I alwaysget to make sure that I have
symmetric obterator and that I'mnot in a inlet or outlet view.
I'm matching their, their ap,that we got supine beforehand in
these larger patients.
(20:51):
But if you're not sure howmedial you've reamed or you want
to get more medial, you're notsure of your cup size.
Bring in fluoro ream underfluoro if you don't usually do
that, I mean, a lot of guys, youknow, especially, you know,
really high volume guys can reamunder fluoro really well, um,
without reaming out the walls.
Um, do you ream under fluoro orare you a direct visualization
(21:12):
guy?
Joseph M. Schwab (21:13):
No, I'm a, I'm a ream under fluoro guy, uh,
with a, with a directvisualization double check.
I would say less than half thetime, but, but yeah.
Uh, um, it's, uh, the, it's oneof the benefits that you
mentioned, and I, I think thisis true even in, in
straightforward patients.
But in difficult patients, ifyou're ever not sure what's
going on.
(21:33):
Uh, or you want to double check,bring fluoro in.
It's just super easy.
Right?
And, and it's, whether it's withyour cup or with your stem, or
with your approach, uh, withyour, your cuts.
Yeah.
Just bring fluoro in.
Bob Sershon (21:45):
Yeah.
And the, and the feel on thesepatients is admittedly not as
good in terms of how you feelthe reamer catching and
engaging.
Uh, so what, what I'll do isI'll, you know, on all the cases
we just measure the head we goup.
It's just like, let's say wemeasured a 51 millimeter head.
I'd start at a 51, uh, reamerand, and probably get up to a
53.
(22:06):
Um.
On these patients.
Some people they like to reamvery small to medial eyes and
then get bigger and bigger andbigger.
I think that's probably a littlebit more dangerous under direct
visualization'cause you can'treally see that you're, you're
centered and not ececcentrically reaming.
Um, so I, I would say if younormally start small and go up,
(22:28):
my preference for this casespecifically would be, Hey,
change it up a little bit.
Start with a reamer that reallyfills the acetabulum early on.
And media lies from there.
Um, and then you have youroffset, and again, navigation
or, you know, mixed reality.
What whatever you want to use isgreat for there.
So you get your cup in.
(22:49):
I always have my templates up.
I am crippled if I don't havetemplates.
I, I mean, I.
I rely on it for everything.
Um, just as a double check and,you know, how medial should I
go, how many yield do I wannago?
And these larger patients, um, Iwill personally have, you know,
less of a, uh, hesitation toleave their cup of hair more
(23:14):
lateral just to help with alittle bit of offset.
Um, if I don't wanna lengthenthem and maybe I want to add a
couple millimeters of offsetfor.
Attention purposes.
Um, but, but here, you know, we,we matched it, you know, fairly
close, uh, to our clan.
The cups probably the sides aretoo bigger than what we
templated, but in these largerpatients, depending on where
they put the calibration marker,uh, you could, you could be way
(23:36):
off.
Um, so, so just be aware of thatas well.
This is where I think the, otherthan the wound healing being.
Being better.
Um, this is where I think Bikinireally helps with large patients
and very muscular patients.
(23:57):
Uh, you know, to cook convincedme to switch over to this, uh,
maybe a year or two ago, I can'tremember.
But, um, he said, Bob, one ofthe craziest things is that the
femoral prep is easier and I,it, it just, it never made sense
to me.
I said, I have a horizontalincision that's limiting how
proximal I get.
How can the femur.
(24:17):
Easier.
And it is, and I, I think a lotof it is because of that medial
Mueller that I have there, thewhite handle, uh, on the, on the
image, it allows you to, to pulla little bit more medial and
present the femur laterally,which is probably the more
limiting factor with gettingfemoral exposure to these large
(24:38):
patients.
Um, so I, I find the femur onthese patients to actually not
be very challenging at all.
Um.
Not, I shouldn't say at all tonot be as, as, as challenging,
uh, than, than with a standardincision.
Um, I use all my standardretractors, uh, standard
(24:59):
sequential releases, you know,capsule and a still type, you
know, piriform ish or externalrotators, kind of the normal
trajectory.
All of us.
Uh, follow.
Um.
And then one of the, you know,the big helps here is I, I
usually just do these cases.
Um, like if the fellow's not inthe room, just with my pa she's
on the other side of the table.
(25:20):
And, um, if you're alone indoing these cases, like the
fellow's not there, in my case,just have your tech come and
give a little hip check to addup to the hip a little bit.
Um, you know, right at thedistal thigh that goes.
That is just so helpful for, forbringing the femur, um, into a
more, you know, I guessdistally, abduct, a deducted and
(25:41):
approximately abducted, uh,space.
So, um, then you, you know, youget everything in and you go to
closure and what's amazing.
That I noticed early on is onceyou take the retractors out,
that the picture to the lefthere, maybe, hopefully my mouse
(26:03):
is working.
That's nothing.
We haven't put anything in thereyet.
It, it just, it closes onitself.
Joseph M. Schwab (26:10):
Yeah.
Bob Sershon (26:12):
Yeah.
And it's just amazing in theselarger patients, it's a long,
you know, it's along the linesof tension.
It just closes on itself.
So then, you know, here's, youknow, our running four oh
closure.
Um, and then we'll put onusually either a, you know,
silver impregnate dressing or ajust a tepa tegaderm.
Uh, if we're not really worriedin patients with a really large
(26:33):
panis, I like to put somethingon that's just gonna be.
Super watertight and I couldleave on for two weeks at a
time.
Um, I'll give them another oneof these dressings here and tell
'em, Hey, in two weeks when you,or 10 days when you take that
off, slap another one on, um,just to keep any of the, the,
the bacterial burden underneaththe panis, away from that wound.
(26:58):
Um, what are you doing for your,for your dressings in these
patients?
Joseph M. Schwab (27:02):
So exactly the same.
Um, you know, the question thatI was gonna ask is some people
talk about doing things likevacuum assisted, uh, dressings,
you know, vac dressings over thetop ones that people can go home
with.
Uh, some people, um, somesurgeons that I've talked to
will put, um.
Essentially a, a, a large,almost kind of diaper in the
(27:25):
area over the, uh, over thedressing itself to just act as a
barrier and, and act as, youknow, to prevent, um, any
friction maybe from, uh, movingthe dressing or curling up the
dressing or anything like that.
What I was gonna ask is, do youlet them shower with this?
Yep.
Bob Sershon (27:47):
Yeah, right off the bat.
Um, are you keeping them fromdoing that or
Joseph M. Schwab (27:50):
Not at all.
I, I encourage him to shower.
Bob Sershon (27:54):
Yeah, the, the VAC dressings, um, you know, there's
reasonable data that is showingthat, that it helps in these
higher risk wounds.
So, I, I, I can't argue too muchagainst it.
I just, in my population, forwhatever reason, um, it almost
promoted drainage.
And I, I, I don't, I don't, Ican't explain it.
(28:16):
That's just my experience.
I'm not gonna poo the wound vax.
So, um, so that's, that's one.
The other thing is, you know,the VAX would malfunction and
they'd be beeping and we'd get abunch of calls from patients.
So we, we kind of moved awayfrom that.
What I used to do on thesepatients, which is kind of
cruel, is I'd put'em in a pelvicgirdle
Joseph M. Schwab (28:36):
Oh
Bob Sershon (28:36):
uh.
Yeah.
Yeah.
I, I like a, almost a corset.
Joseph M. Schwab (28:41):
Yeah.
Bob Sershon (28:42):
it, I, that's when I was doing a standard incision.
I'll tell you what, it, itworked, but they, they didn't
like me for it.
Joseph M. Schwab (28:49):
to, to minimize swelling, basically.
Minimize any sort
Bob Sershon (28:52):
well, to hold the panis up
Joseph M. Schwab (28:54):
oh.
Okay.
Bob Sershon (28:54):
to like, to, you know, like you, you see those
cartoons where, you know, yougot this spat guy and you know,
this like good looking womanwalks by and he puts the girdle
on her and he makes his chestbluff up.
It's like, that's.
That's kind of what we weredoing.
And, uh, I, I just, it was, Ifound it.
I, I don't know.
Patients didn't love it.
We'll put it that way.
Joseph M. Schwab (29:14):
you're, you're not using any skin glue on this.
It doesn't look like Right.
It's just the Monocryl and thendressing.
Bob Sershon (29:20):
Uh, no.
We, we did, um, use derma bond.
Joseph M. Schwab (29:23):
Okay.
Bob Sershon (29:24):
We put derma bond on all of it.
Yeah.
Joseph M. Schwab (29:26):
Okay.
All right.
Bob Sershon (29:29):
Fortunately, haven't had any.
On the bikinis, uh, and thelarge patients.
I haven't had any of thoseadhesive reactions.
I, I do worry about that.
Um.
So if people just wanna do thesilver impregnated, they're,
they're fine to do that.
Um, but this is, this is herfour week follow up, right?
So, um, incisions healing.
(29:50):
Well, you know, she's, she'sdoing well.
She was really deconditionedbefore this, so, um, you know,
she's, she's still gettingaround with a cane and things
like that.
But just'cause she's gassed and,uh, no hip pain, right?
I mean, doing really well.
Super thankful.
Um, and that's, you know.
That's how you get through it.
(31:20):
Then you get, you know, caseslike this.
Um, and this, this poor woman, Imean, you know, she's 50, you
know, 52, um, horrific hip.
That clearly has been a problemfor a long time.
And, uh, I, I said, when did youfirst.
(31:42):
Try to get a hip replacement.
Like, how long have you beenliving like this?
'cause she, she came in in awheelchair and, uh, oh.
For a decade.
You know, no one would touch mefor a decade.
Yeah.
Um.
Just'cause she, they kepttelling her, you're too young,
or You're too heavy, you're tooyoung, you're too heavy.
And, uh, and just a total shameand lost like prime decade of
(32:03):
her life to this.
Uh, but these are really toughcases because the joint, you
could see, I, I should havetaken the templates off here,
but, uh, the, the joints almostauto fused.
Um.
Really no range of motion.
When she tries to stand up towalk, she's leaning forward like
30, 40 degrees.
(32:24):
'cause she's got such a terribleflexion contracture and now her
back's affected.
And, um, you know, and then shehad one of these not super
mobile panes to go on top of it.
Um, which, you know, just, justthat makes it so, so much more
difficult, um, in, in anysituation.
(32:44):
So for her.
You know, we just did much ofthe same.
So, so this is just showinghere.
Okay.
You get him on your back, you,you try to reproduce as best he
can.
The, the AP view.
Um, and she started, which Iwanna show you, and I'm curious
of your thoughts on this.
You know, she started over aninch short and, uh, I mean,
(33:05):
what, what's your threshold herefor, for lengthening when it's
been about a decade with a hip?
Probably not this bad, butdefinitely shortening.
Joseph M. Schwab (33:15):
Yeah, boy, it, it depends on a number of
factors, but if this was a atrue, if this was a pediatric
situation, I, I would probablyaim to make up only about a half
to two thirds of it.
But if it's been over the last10 years and she had, or you
feel confident she had sort of ademonstrably normal hip before
(33:36):
that, I, I think this is onethat you could probably get all
the way back.
Um.
And obviously, I mean, it looksto me like she's in fixed
external rotation too, right?
So, yes.
So that can.
I, I have found that that can,um, affect a little bit the
(33:57):
measurement of, uh, of leglength, at least with the, the
line, uh, you know, using lines,um, just because you're, you're
catching a different, uh,profile of the lesser tro
canner, um, you know, dependingon what, uh, what landmarks
you're using.
So this is one I would say I'mprepared to make her even.
(34:18):
I'm prepared to not make herexactly even, but to give her
back at least two thirds.
Um, but I'm prepared to use alot of fluoroscopy and any tools
that I can get, um, to, to helpme understand exactly how much
length I've given her back.
Bob Sershon (34:34):
Yeah.
Yeah.
And that's, and this also, youknow, the, the external
rotation, uh, really screws upany ability to measure offset.
Um, which, so you, you.
You go, okay, let's get herclose to the other side.
At least you got a fairlynormal, uh, left side hip here.
So, um, yeah, so that was ourgoal was to make up as, as much
(34:56):
of it as we could, so long assoft tissue tension, um, allows,
because what I don't like doing,uh, having, having done it once
or twice is the hip's hard toreduce, and you pull manual
traction and then you lock itand you do one or two clicks of
fine traction.
You push the hip in.
That's just that, that's tootight.
(35:18):
Like, like I, I, I probably inmy mind, shouldn't have done
that, uh, trying to chase leglanes on people.
Um, so now I just, I go untilit's a little bit difficult to
reduce and I, I leave it there.
Um, but whatever they get iswhat I get.
So.
So here you go on those, this isone of those, you know,
(35:38):
fluoroscopy showing you gettingdown there, um, you know, trying
to Alize and, and this was apatient where, and maybe these
are a little bit differentfluoroscopic views from bringing
the fluoro in and out.
But I, I brought this up becauseI specifically remember on this
patient just wailing as hard asI could to get that cup seated.
(36:00):
And taking it out reaming,taking it out, reaming, and it
just kept sticking.
Um, so I probably, I feel likeyou can't see the airball here,
you know, but I feel like thatcup should have been, you know,
two, three millimeters.
Even more medial based on thefluoro shot.
And maybe it's some opticsplaying into here with different
(36:23):
fluoro shots, but, um, that'ssomething that you gotta pay
attention to as well.
There's nothing behind the cup,there's nothing stuck.
But I felt that I was justgetting such a good press fit
here, um, that I, I wascomfortable leaving it not, not
putting any screws.
Is that
Joseph M. Schwab (36:39):
line to line or do you ream?
Uh, one under two under.
Bob Sershon (36:42):
one, one under every, every time.
Yeah.
Yeah.
Joseph M. Schwab (36:47):
as far as the, the, the surface of your, uh,
acetabular component, highfriction acetabular component.
Like a, a grip or a a, a TM orsomething like that.
Something high friction.
Bob Sershon (37:00):
PPS.
Joseph M. Schwab (37:02):
PPS.
Bob Sershon (37:03):
Yeah.
Yeah.
So, um, and again, I could haveone line to line on this and,
uh, you know, really.
Uh, you know, went to town,hitting it down.
But once you get the bite, and Ifeel you're shaking the whole
pelvis on this large patient andthe cup's not moving, all right.
Like, you, you, you're done.
Stop, stop wasting time.
(37:24):
Like, get out of there.
Um, so, you know, and then theseare her.
Joseph M. Schwab (37:29):
is better, right?
Bob Sershon (37:31):
exactly.
Um, and then you could see here,like I, I still, I bring this up
'cause I still don't see.
A big radiolucent line aroundthe cup here.
I mean, I see one in zone two.
Um, but, but you know, not downhere.
So I don't know, maybe it wasfloral playing tricks on me,
but, uh, uh, but, but, but thepoint, the point is here is, you
(37:51):
know, she, this lady crippled, Imean, totally crippled for, uh,
better part of a decade.
No one will touch her.
You come, you do all the steps Ishowed you on the prior one, um,
and then, you know, four weeksout you get a completely
different looking x-ray andthey're so thankful and grateful
for it.
Um.
But to your point earlier, Imade up about two thirds of
this.
(38:12):
Um, she's still got a little bitmore external rotation, as you
could see compared to her, herother side, uh, and clinically
was a little bit short still, soshe might need a lift, but I
could not, that's the longestball I could get on there.
Um, I I, I probably could havedone the trick where you pull
the manual, lock it, do a coupleclicks of fine and gotten one
(38:34):
more ball.
Uh, but at that point.
Not, not worth it.
Not worth it in my opinion, so,
Joseph M. Schwab (38:41):
Interesting.
Yeah.
This, this is one where ratherthan doing more, um, a lift is
probably gonna be.
Uh, reasonable for you and shemight not even notice the
difference.
I don't know.
How far out has she noticed?
Bob Sershon (38:53):
she didn't notice at all.
Joseph M. Schwab (38:55):
Yeah,
Bob Sershon (38:55):
Like by we, we saw her back at four weeks.
I asked my pa, um, who sees allmy four weeks, I said, and I
said, Annie, did she noticedthat?
She goes, oh my God, no.
She's just happy she could walk,
Joseph M. Schwab (39:05):
I was about to say, especially if she was in a
wheelchair for that long.
It's, those are, those are folkswho don't notice leg length
discrepancies that much.
Bob Sershon (39:13):
Yeah.
And I don't know if she came inon a walker or cane.
I can't, I, I, I should havelooked at that.
Um, but it was like asubstantial over four weeks
already, um, increase in, inquality of life there.
So,
Joseph M. Schwab (39:26):
That's, that's amazing.
That's great.
Bob Sershon (39:28):
yep.
Yeah.
So, uh, so that's, that's thebikini there.
And we didn't do anythingspecial.
Just, you know, a, well, a aeland.
Dermabond seen his last case.
So, um, if we got time, this isthe, you
Joseph M. Schwab (39:41):
We got time for this for sure.
Bob Sershon (39:44):
yeah.
Joseph M. Schwab (39:45):
Another standard primary.
Bob Sershon (39:48):
Yeah.
Yeah.
This is one of the cases that,uh, I was gonna present there,
um, at, at a HF, um, which, youknow, the, the time thing, I
totally understood that.
I mean, you've got, you know,Aldo and your acid medias up
there given like a.
Unbelievable, you know, chorus,and I'm sitting there going, I,
(40:08):
these guys are, are justanimals.
Totally unreal at what they'redoing.
Um, so I just, you know, I, Icould tackle this stuff, but
they're just total wizards.
It, it, it's just incredible.
So, um, but uh, yeah, so, sothis lady, uh, she had DDH, uh,
had a primary hip done in PuertoRico.
(40:31):
20 ish years earlier was subYeah.
Subsequently revised, uh, abouta decade before this.
To a, um, uh, for, foracetabular loosening.
Uh, it was one of the implantswhere the, the back coating had
come apart and, uh, clearly hada loose cup and then, you know,
(40:52):
had a, a revision and then thatcame loose and was repeat
revision.
Um, which in those settings, I'malways worried about some
subclinical infection, uh,versus.
Metabolic disease, like do theyhave p acnes or, um,
pseudomonas?
Do they have some like slowgrowing indolent bug in there?
Uh, so anyway.
(41:13):
She had a revision.
Um, that, that actually I did.
Okay.
So I brought this up.
This was my, my public shamingfor myself.
Um, and, uh, so we, we did this.
I got.
Great fixation, like one ofthose hips where you're going, I
don't even really need to putscrews in here, but I'm going to
(41:34):
'cause it's a revision.
So, you know, I don't follow theprinciples that, you know, I,
you know, kind of always tell myfellows of, you know, you want
inferior fixation, superiorfixation.
So she, she, you know, goes andhas one of, not a fall, but what
I think is worse than a fall,which is one of these like hard
stumbles where they plant reallyhard, um.
(41:58):
And felt like immediate pain.
Uh, went to the er, got x-ray,ct, um, you know, didn't, didn't
show anything, and thenliterally walks into the four
week visit like this on a cane.
Joseph M. Schwab (42:12):
Wow.
Bob Sershon (42:13):
and we're going, what happened?
Like how, how did we go fromlike very robust, great fixation
to this hard stumble?
And then so, you know, reallyshe had no pain.
She was probably doing a littlebit too much and, you know,
fell, stumbled, caused, youknow, what I thought was an
acute discontinuity, but it wasreally just a fracture through
the anterior column.
(42:34):
And, um, and, and here we arenow, right?
So.
You've got, uh, you know thislady.
BMI 40, multiple priorsurgeries, complete absence of
the anterior column, cups in thepelvis, tenting the vessels, um,
and, and that, and this has allbeen done anterior, by the way,
(42:55):
the most recent surgery.
So, so now here you are fourweeks out.
I mean.
Your decision is go back inthrough that, which of course we
did.
Um, or, you know, if you're notcomfortable with it, go through
the back, through her priorincisions.
So, you know, the, the planningon this one.
Um, and these, these are allthe, you know, the pearls.
And this is from her caseactually.
(43:15):
I, I said let's, let's, youknow, take some pictures and
show people this, this complexreconstruction.
So.
Um, so, you know, the pearls, I,you just do your normal
incision.
I, I usually go two fingerbreaths, ladder lateral to the a
SIS, even even in the obese.
Um, and then you want to justextend that.
So if the A SIS is right herelabeled, you know, you could see
(43:37):
I came pretty far proximal rightalong the crest right there.
Uh, and right off the bat onthese cases, I'll, I'll go ahead
and, and find TFL.
You know, small cuff, you couldprobably see about a centimeter
of a cup of tissue there.
Um, that, that, I'll leave, I'llpeel it off, off the outer
column right away.
Um, I don't know if, if, if yougo to it right away or if you
(44:00):
wait, I mean, what's yourpreference on these?
Joseph M. Schwab (44:03):
So, um, definitely right away if I'm
planning on doing significant,uh, femoral work, I feel like
the TFL uh, peeling that offgives you a better, uh, femoral
mobility.
Um, but, uh, for a large up andin like this, I would say I
might wait and, um, but chancesare pretty good that you're
gonna do some sort of.
(44:24):
Ensile, uh, maneuver in order toto, to get good access for what
you want to do.
Bob Sershon (44:30):
Yep.
Yeah.
Um, and I knew I was gonna do acage on it.
So for me, just right off thebat, I mean, to enhance femoral.
Mobilization, um, as well, justto get it outta the way.
Let that femur fall.
Posteriorly, uh, that reallyhelped.
I mean, I didn't even need aposterior retractor for the
case.
The femur was just floating outof the way.
It was, it was beautiful.
(44:51):
Um, and then, you know, so, soyou elevate, you know, indirect
erectus, do all your capsularreleases.
I mean, she had already had allthis done.
Um.
Posterior pocket for the ion ifyou need it.
So let's say you're going in thefirst time, you can peel off
some of that posterior scartissue, posterior capsule to
allow the ion to kind of tuckback behind the posterior, um,
(45:12):
acetabulum.
Um, what I'll normally do then,so I do all this before I even.
Dislocate the hip.
Uh, I like to knock the head offinto the cup.
I mean, there's a milliondifferent ways to skin the cat,
but, you know, two, three clicksof fine traction normally is
enough, and you could just hitthat thing off into the cup,
pull it out, you know, rightaway.
(45:33):
Um, what I don't do until afterI've done that the majority of
the time is in, uh, is releasedthe inferior capsule, um, you
know, pubic, femoral, whateveryou wanna call it.
It, it just, because I, I don'tknow how mobile the femurs gonna
be till I try to tuck it backbehind the posterior acetabulum.
(45:54):
And, uh, I've had some caseswhere I haven't had to release
any of it and I've had otherswhere I can't even get the
trion, um, outta the socketbecause it's so tight
inferiorly.
And that is just such a greattrick, um, that you know.
Nobody showed me, right?
I mean, I just started doingthese on my own.
(46:15):
Um, these like bigger anteriorrevisions.
So, uh, you know, that, that'sone thing that I tell everyone.
If you're gonna do that, maybewait until you knock the head
off and you're trying to get thetruing outta the way just to see
what kind of room do you need.
Um.
And, uh, you know, of course,uh, you know, fluoro is your, is
is your tool, uh, throughout allof this.
If you're lost, you need to knowyour landmarks.
(46:37):
Where, where am I in a revisionsetting?
Not a common question you getfrom the fellows.
Um, and, uh, you know, one ofthe actually great articles that
I found, um, this is probablyjust from a couple years ago.
It was, you know, from the guysoutta Utah, you know, Lucas, uh,
Jeremy, those guys out therejust goes over.
(46:58):
This exact technique.
Uh, they've got pictures likethis, uh, in the article.
It, it is super helpful.
I, I gave this to our fellows.
Um, I think I found this be likeright before the case.
Uh, and even I got a couplepearls out of it.
So it was, it was super helpful.
It was this half cup cageconstruct from the front.
(47:19):
Um.
So anyway, we, we get in there,we do that, you know, we do that
exposure that I showed you.
Um, getting that cup out of thepelvis can be a challenge.
Um, this is one where, you know,you could have vascular on
standby, uh, and maybe that'snot a bad idea.
Uh, you could get a CT Angio twoif you, you know, you really
(47:40):
think that that's acutely up andin there.
Maybe you got the vessels.
Um, and you know, for yourreconstruction, even though it's
a bigger patient, I think theprinciples all were remain the
same.
You know, again, anile exposureso that you could really see the
inferior part of the acetabulumcome all the way up over your,
over your anterior acetabulum.
I mean, she had nothing there,so there was really nothing to
(48:02):
release.
Um, and, and do yourreconstruction that way.
And you know, this time, youknow, we got a couple screws.
You know, in inferiorly, whetheror not that would've saved her
the first time.
I don't, I don't know.
I mean, it, it seemed like shejust had a, basically a pelvic
fracture that knocked the wholeconstruct loose.
But, um, and then after you getthis in, I actually really like
(48:25):
using fluoro, uh, for like a,even a trial cage to see where
the trial's gonna sit.
Um, and the other nice partabout a cage, at least for me in
this situation, is it candistalize.
Your joint line.
Right.
So, um, that allowed me toactually put a full cup in here,
distalize it.
(48:45):
I think I got a 40 head in her.
Um, and, and it, it ended upworking out, you know, pretty
well.
I think this is her x-ray, uh,over a year out at this point.
Joseph M. Schwab (48:57):
Very nice.
Bob Sershon (48:58):
Right.
Yeah.
And, and this is, she actuallylost a ton of weight.
I, I saw her, it was like, Iknow you, but, uh, like, you
know, I, I know you, but if, if,if I, if I hadn't, you know,
she, she lost like, she's likeBMI of 30 or like close to 30.
So she's one of these patientsthat actually.
You know, it became way moreactive and, and made healthier
(49:21):
and, and lost weight.
You know, it was just kind of a,a, you know, kind of an
inspirational story for, forothers that are in her
situation.
Um, and yeah, I mean,
Joseph M. Schwab (49:31):
nothing to do with the stem on that one,
right?
You, you were able to maintainthe original stem.
Bob Sershon (49:37):
Yeah.
Well, thank God, you know, thatthat adds,
Joseph M. Schwab (49:42):
Um, did you have to go up and into the inner
table of the pelvis at all?
Were you up and into the innertable or were you not?
Bob Sershon (49:49):
I didn't need to.
Um, I mean, this is a, this is agood case though.
If you don't wanna use a cupcage, uh, you, you can go in the
inner table, put an augmentthere.
Uh, I mean, that's probablywhat, I don't wanna speak for
him, but I mean, that's probablywhat Aldo would've done, um, you
know, running this, run this byhim.
What, what, what would you havedone with, uh, you know, this
(50:11):
big old defect?
Joseph M. Schwab (50:12):
I mean, I, I think it's, uh, I, I, so I think
a cup cage, you know,potentially, uh, if you're, if
you have the opportunity to planfor it, like a custom tri flange
would also be a possibility.
But since this kind of happenedacutely, you want to get in
there as quickly as possible.
And, and maybe you don't havethe time to have something
custom made.
But I, I think this is a greatapplication, um, of a cup cage,
(50:35):
uh, and clearly.
You know, at being a year outand seeing her post-op films,
that's what she needed.
Right.
Uh, I mean, that worked outreally, really well.
Bob Sershon (50:45):
Yeah.
Yep.
Um, so, you know, she's, she'sdoing fine now.
No worse for the wear and, andhopefully this construct, you
know, I always worry about, youknow, Mayo's got good data on
cementing cups.
Um.
Uh, in, into revisionconstructs.
Uh, but I, I worry long term.
I mean, she's, I think I saidshe's in her fifties.
(51:07):
You know, how, how long doesthat cemented cup really, uh,
really last?
Um, I don't know.
I, I, I'm assuming at some pointshe'll, she'll knock it loose.
Uh, but that's hopefully not ahorrific revision because now
you've got ingrowth of your, youknow, your, um, porous metal
shell and your, your cage isn'tgoing anywhere.
(51:28):
So.
Joseph M. Schwab (51:28):
I mean, if she just needs another cup cemented
in, that's not the end of theworld.
Um,
Bob Sershon (51:33):
That's a win.
That's a win.
Joseph M. Schwab (51:35):
that is a win.
And this, so her original, um,I'm gonna come back to just us,
but her original, um, revisionsurgery done by you, that was an
anterior approach, but that wasa traditional.
Incision that you used, right?
For that, uh, for that revision.
And you chose to do that for herrevision specifically.
Bob Sershon (51:57):
yes.
I tried to do all of my, um,revision acetabular work from
the front.
Uh, I just, I, I feel at thispoint it's easier for me.
Um, the, the femur falls out ofthe way.
You get a great view ofeverything.
Um, you can use fluoro, which isa huge, huge plus compared from
(52:22):
the back where you're takingplain films.
Um.
Uh, yeah, I mean, I, I, I, Ipretty much do it.
All the exceptions are.
Like, let's say it's a headlinerexchange on someone that's had a
prior posterior, they've got aton of aversion built into their
cup, their STEM's a little bitverted.
I start going, Hmm, I mean, ourdata, you know, bill Hamilton
(52:43):
and our institution publishedsaying that, that the
dislocation rate's about thesame regardless of approach
after a headliner.
So those are ones where I'llstill go through the back, but
anything where I'm swapping outparts at this point, I, I really
try to go through the front foreverything.
Joseph M. Schwab (52:59):
And as far as using the traditional incision
for that original, um, uh,revision as opposed to a bikini
incision, do you ever use thebikini incision for revision?
If you're just focusing onacetabular work, does that
dissuade you from that?
Wh where, what are your thoughtsthere?
Bob Sershon (53:16):
I, this specific case basically made me say I'm
probably not doing bikinis fromthe front for on a revision.
Right.
I, I don't.
I don't foresee a scenario whereI would've been happy with
myself.
Uh, haven't done that throughthe front, even though I thought
her first case was a prettystraightforward revision.
(53:36):
It's just, you know, things,things happen.
Um, so
Joseph M. Schwab (53:41):
She's definitely made it a lot farther
on this second revision than shedid on the first revision, it
sounds like.
So the, the proof is in thepudding.
That's great.
Um, well Bob, hey.
Thank you so much.
So first of all, uh, uh, thanksfor being a good sport and, uh,
coming and joining us at the aHF annual meeting.
And thanks for being an evenbetter sport and coming and
(54:01):
giving your talk.
Hopefully we gave it the, thetime and attention to do it
justice.
And, and I think what I wouldimpart to our listeners is that
if they've got, um, super obese,morbidly obese patients, they
should be sending'em to you atthe Anderson clinic.
Isn't that, that's that.
Bob Sershon (54:20):
Yeah.
Yeah.
Joseph M. Schwab (54:21):
No.
But hopeful.
Yeah, hopefully they walk awayfrom this with, uh, uh, an
understanding of what's possibleand, um, and, you know,
hopefully, um, if they have anyquestions about, uh, your
thoughts on a patient and whatmight be reasonable, uh, that
they could reach out to you and.
And that's one of the things weencourage as part of the
(54:43):
Anterior Hip Foundation is sortof that, uh, collegiality in, in
answering questions.
I'm sure, uh, I'm sure pa uh,uh, providers out there watching
or, or listening to this wouldappreciate that
Bob Sershon (54:54):
Oh yeah.
I mean that, that's one of theawesome things that I found at
the meeting.
I've already abused thatprivilege on multiple guys,
Laura, at the meeting.
So, um, it's, it's great.
Joseph M. Schwab (55:05):
It was great to have you as part of the
meeting.
It's great to have you as, uh, aguest on the A HF podcast and,
uh, thank you very much for yourpresentation today.
Super impressive stuff and Ilook forward to seeing more from
you in the future.
Bob Sershon (55:19):
Thank you.
Appreciate it.
Joseph M. Schwab (55:23):
Well, thank you for joining me for this
episode of the A HF podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on.
And keep sharing great contentjust like this.
Please also drop any topic ideasor feedback in the comments
below.
You can find the ahf podcast onApple Podcasts, Spotify, or in
(55:47):
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation.
All one word.
episodes of the A HF Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
happy, healthy, and not tooobese.
Hello, and welcome to another episode of
the A HF podcast.
I'm your host, Joe Schwab.
My guest today is Dr.
Robert Shan at the AndersonOrthopedic Clinic, and he's here
to give us another cut for timeepisode.
Dr.
Shan, welcome to the A HFpodcast.
Why don't you tell our listenersa little bit about your
(00:46):
practice, your training, andwhat you're gonna talk about
today?
Bob Sershon (00:51):
Yeah, I appreciate it.
Thanks for having me on.
Um, yeah, so Bob Shan AndersonClinic, uh, Anderson Clinic
trained actually, um, fellowshipback in 20 18, 20 19, joined the
practice right after that.
COVID hit, which was, uh,interesting being first year in
practice having that stuffhappen.
(01:12):
But, uh, it actually was endedup being great for me because a
lot of the other places shutdown and a bunch of revision
volume and all the complex stuffthat couldn't wait started to
come in right away.
So, um.
Things, they couldn't wait.
They had to go.
That was still medicallynecessary.
So it built a pretty quickpractice through that.
And, uh, over time, you know,when you do enough complex
(01:32):
stuff, you kind of get known asthe guy in the area that's doing
that.
So, um, a lot of the, uh, moredifficult cases, more complex
revisions, seeing things likethat started to stroll through.
So, um, now, you know, we're,we're.
Out in Alexandria, Virginia, uh,really over the, uh, entire
Northern Virginia area rightoutside of DC And, uh, my
(01:53):
practice is only hip and kneereplacements.
Uh, we're very subspecialized atthe Anderson Clinic.
Basically, all of our partnersare fellowship trained one way
or the other, and just stick totheir subspecialty.
So you won't see me doing anyankles or wrists or anything
like that.
Uh, never did, never will.
So, uh, probably terrible ofthose now.
Um, but, uh, yeah.
(02:14):
Yeah, that's it.
We got great fellowship, do someresearch, um, you know, real
proud of everything theinstitution's done so far and,
you know, good talking aboutsome, uh, big people on big
cases.
Joseph M. Schwab (02:26):
Well, and we had you invited, you came and,
and were part of the a HF uh,uh, annual meeting this past
year in Nashville, and you arepart of the revision session.
And we're intending to give thistalk, uh, as a part of that
session that, uh, session wasso, uh, popular and had so much,
uh, involvement from, uh, ouraudience and so much discussion
(02:48):
back and forth that we literallylost time for your talk.
And so, uh, for better or forworse, you get to be the second
in our, uh, cut for time series,uh, here on the a HF podcast,
and you're gonna be talking tous about.
Uh, doing anterior approach inthe super morbidly obese
patient.
Is that correct?
Bob Sershon (03:07):
Uh, that's, that's right.
And then we got, uh, one morecase that just to add on, um, if
we have time revision, uh,morbidly obese patient.
Joseph M. Schwab (03:16):
Let's, uh, let's get to it.
The floor is yours.
Bob Sershon (03:20):
Great.
Great.
So, um, here we go.
These are my disclosures, youknow, um, involved with Zimmer
Biome and day care, so.
High BMI, total hips, we knowhigher wound complications.
It's not just from the front,from the back as well.
Higher rates of PJI, higherrevision rates.
Really just any complicationessentially.
(03:40):
You name it.
We found that it's, it's higherwith higher BMI.
Um, and then, you know,unfortunately on the flip side,
a lot of these patients aredoing it to, to lose weight and,
you know, they, they reallydon't afterwards.
And, uh, you know.
Reasons why, who knows?
Lifestyle life choices.
It's just been too long forthem.
Uh, that's something I used totalk to people in clinic about,
(04:02):
and Joe, I don't know if, if, ifyou talk to people in clinic
about that afterwards, but, uh,I, I've stopped discouraging,
um, them saying, Hey, you'reprobably not gonna lose weight
after this.
I give'em a chance.
Uh, in my opinion, I Do.
You do the same or.
Joseph M. Schwab (04:16):
Yeah, I, you know, it's, I, the weight
discussion's always interesting,but it's, it's not likely that
unless they gained a whole bunchof weight in the, you know, two
years or so before they, uh, gottheir hip replacement because
their hip was bothering them.
It's unlikely they're gonna loseit afterwards, but I, I don't
usually mention it.
I encourage'em to be as activeas they want to be.
Bob Sershon (04:36):
Yeah.
Yeah.
And I, and that's the route togo of it.
You know, in the back of my mindI just say, all right, we're
doing this for pain relief andhopefully better function if the
weight comes.
That's a huge plus.
So.
Uh, you know, where that goes,you know, in, in our world
unfortunately is, you know,harder surgery, arguably worse
outcomes and not necessarilypatient reported outcomes,
right?
'cause they get, they getsubstantial relief from that
(04:57):
aspect, but we're talkingcomplications.
Um, and then is it worth therisk?
I mean, you have a lot ofinstitutions on bundled
programs.
Um.
Yeah, some people get dinged forhaving complications at their
institutions, readmissions,reoperations.
And so some people just won'teven take these patients on and
they've drawn these hard cutoffsthat makes access for them
(05:17):
pretty hard.
So, uh, we don't have that, uh,at our institution and we, we
take all comers and we try toindividualize it because the
risk is really gonna be sharedright between the patient and
the surgeon.
So, um, it's not our hip that'sgetting infected, it's, it's
their hip and they have to livewith that.
And that's, that's a tough thingto live with.
So.
Um, we, we just do shareddecision making and, and if we
(05:38):
feel like their pain andfunction are significantly, uh,
impacting their life, then we goahead with the replacement
knowing that hey, they, theymight have a complication that
somewhat of normal weight didn'thave.
Um, we're just verystraightforward about that.
So, you know, dealing with thispopulation and preoperative
planning is so important.
So, um, you have, you know, theexam mobility, I'm not just
(06:02):
talking about their mobilitywalking in the room, I'm talking
about the mobility of theirpanis, right?
So you have some people thathave a very mobile panis.
Um, it, it moves, it gets out ofthe way easy.
Uh, you know, some people youlooked underneath.
I got a little bit of what we'llcall some funky stuff, and
that's something that you, youreally wanna, you know, uh, pay
(06:24):
attention to because you don'twant fungal infections and
things like that.
Those are notoriously hard totreat.
So that's someone where you maysay, oh man, I actually have to
go through the back on this one.
Uh, just to avoid any type oflocal, um, contamination, uh,
booty check, right?
I, I teller fellows do bootycheck where, where do they store
their fat?
'cause some people actually fromthe front.
(06:47):
All their fat is storedposteriorly and, and actually,
you know, they may be morbidlyobese and have large bellies,
but maybe it's mobile.
You tape it outta the way.
Um, they don't really have muchin the way of soft tissue in the
front, and it's really not thatmuch more difficult of a case to
do so where they store theirfat.
Really, um, uh, important for,for DA and then leg lengths.
(07:10):
You know, I, I tell the, youknow, the fellows, Hey, we wanna
be close.
Like we, we wanna, leg lengthsare one of the biggest things
for litigation and patientsatisfaction.
Um, but you know, if you have togive them a few more millimeters
of offset or length in order togive yourself a, a stable hip in
this population, feel free toplan to do that.
(07:31):
Um, in terms of implants.
You know, you could use whateveryou want.
It's dealer's choice.
I think all the data at thispoint though, um, from both
anterior posterior is pointingtowards these triple tapered
stems with a collar, uh, thecup.
I like to use a cup that you canget a large head and a smaller
cup.
So, um, almost every company atthis point now, you can get a 36
(07:51):
head or larger to size 50, uh,which is, which is great.
Um, some companies are alreadyat a 52, you're starting to get
a 40 head in there.
Um, that's, that's definitelypositive.
If you can't, uh, consider dualmobility, maybe this is a
population at increased risk ordislocation.
Um, whether or not that's alsotrue from the front, that's
probably debatable, but, uh, itis something that you want to
(08:13):
keep in mind.
Uh, constrained line.
I mean, I think that's justoverkill on a first timer.
Um, automated impact or, I, Ilove using these things, you
know, whether you're using.
You know, we could do brandedby, by company, you know,
concise or hammer one of thesethings.
Uh, I think it saves a ton oftime.
It gives you consistentimpacting all the way through
(08:34):
for me, it really helps mecontrol the version, uh, of the
STEM as it's getting sent on theway down.
Um, which is, which is great.
Then also your other technology.
These are larger people.
So you know, if you're doingthis off table with no fluoro, I
would say that that's a hardtask.
Um, it's hard to feel theirmalleoli, everything's draped
out.
(08:55):
Uh, I, I prefer in, in mypractice to use some sort of
navigation, um, ai, roboticplatform, mixed reality,
whatever people want to use.
Then have offset ready.
And by offset I'm talking offsetreamers, offset insertion
handles, offset broaches, offsetinsertion.
Anything that you can do to haveoffset, even the hand table, if
(09:15):
you're using a table, uh, youknow, they have the standard
hook and the high offset hooks.
So these are all things thatyou're gonna wanna have ready,
maybe not necessarily used, butat least have ready, um, when
you're, when you're planning forthe surgery.
Joseph M. Schwab (09:30):
Do.
Any challenges with the, do yousee any challenges with the
automated impactor in, in theselarge individuals?
I know, uh, or is it, is thatjust taken care of by the
offset, um, you know, broachhandles and things like that?
Bob Sershon (09:45):
I, I only use the, the straight impact, or I, I
haven't used the offset.
I, I've had it ready inpreparation of, Hey, they're
just too big.
I can't get this out of the way.
But I, I've personally not runinto the issue.
Um, I, I don't know, have, haveyou.
Joseph M. Schwab (10:00):
No, I, I mean, I, it's, it's interesting that
you mention that, right?
Because, um, you know,originally when I first started,
uh, well over a decade ago.
I, I think I was using offset oneverybody just'cause I thought
that was, would be easier.
And I've gotten to the pointwhere I just, I rarely use
offset even in the more obese,uh, patients.
(10:20):
And, uh, with something as bigas a, as some of these automated
impactors are, it seems to befar enough away from the
patient, even in obesesituations that it hasn't, I
haven't noticed it beingproblematic.
Bob Sershon (10:34):
Yeah, I'm, I'm right with you on that.
I think they do have offset.
Articulations or handles thatyou could pop in there if you
need.
Um, but I do wonder how muchpower is, is lost through that.
Um, but, uh, may, maybe I'llgive it a whirl one day, but,
but for now, I just haven'tneeded it.
So, um, so here we go.
You know, 55-year-old femalecoming in, BMI 55.
(10:57):
Uh, she traveled two hours forsurgery because nobody locally
was able to take care of her,whether or not it was from
cutoffs or they just couldn'thandle the case.
It, you know, that's debatableproblem's been going on for
years.
Um, you know, really these, thispa this population usually comes
to you trying extensivenon-operative treatment.
Um, most of these patients, atleast that I've seen it.
(11:19):
Has some type of intraarticularsteroid injection, which, which
for me is really just diagnosticis, is it really coming from
their hip?
Um, especially when they don'thave, you know, severe erosive
bone, bone arthritis, like I'llshow you on the next case.
Um, so, and we do all thatplanning and here we go.
So here's, here's the, uh.
Intraoperative views.
I'm trying to give you all ofthe same patient here so that we
(11:40):
can see.
But you know, even with her onthe table, she has such a large
panis that it is completely overthe operative site, even with
Lang supine.
Um, the uh.
The center, you know, leg holderthere if you will, um, between
the legs you could barely see.
It's kind of poking its way out.
But she's one of these peoplethat has a large mobile panis.
(12:03):
Um, and so you would say, Hey,this actually isn't that
terribly difficult of a caseonce you take the outta the way
and you let the fat fallposteriorly as well as you could
see.
I mean, it's hanging down therepretty low.
Um.
Pre-op fluoro views are, youknow, you just wanna match
(12:24):
exactly what you got.
Pre-op uh, there's, there's beendebate back and forth about
standing versus supine viewsand, you know, functional range
of motion and all of these, all,all of these other factors.
What, what we found at ourinstitution.
We tried doing standing viewsfor a while.
Um.
With patients like, like this,they're morbidly obese.
(12:47):
You, the pan is hanging so lowthat you have a really hard
time, at least we did gettingquality x-rays and then
reproducing their standing filmsupine.
You were doing all these crazythings with fluoro.
Um, so we actually.
After trying standing, went backto supine films on everyone.
(13:07):
All of our surgeons, uh, at theclinic, for the most part,
they're, uh, are doing da andthat's how we positioned during
surgery.
Um, so, so we've continuedgetting, getting supine and just
matching supine.
And, uh, you know, fortunatelyon our dislocation side, I mean
our rate at the institution foranterior is, you know, like 0.3
some something below a halfpercent.
(13:28):
Are you doing anythingdifferent?
Are you getting standing filmsor?
Joseph M. Schwab (13:32):
No, in my practice it's supine.
Um, I, you know, I'm, uh, a bitof a, a Joel Matta disciple on
this.
You know, he always teaches thefrontal plane of the body is
what's most important.
You know, the, the position.
Uh, supine versus standing isless important than the position
of the frontal plane of the bodywith the pelvis in the position
(13:53):
that you're operating in, sousually supine.
Um,
Bob Sershon (13:57):
so we're on the
Joseph M. Schwab (13:57):
yeah, I mean it's, we're, we're, we're
talking probably like youdescribed, you know, less than
hundredths of tenths of apercent difference probably in
our dislocation rates based onthat.
So, who knows?
Bob Sershon (14:12):
Yeah.
So, um, but it's important toget, you know, to, to really
match these shots and, and, um,if you're not using, uh,
navigation or something likethat, it's hard to get the C-arm
unless you have one of thoselarge, you know, 12 inch or or
larger square, uh, c-arm thatI've seen.
Um, it's hard to get the entirepelvis in there, and then
(14:32):
there's a lot of parallax.
So, uh, that's, that's achallenge if you're not using
something where you can do anoverlay.
Um.
So now you got everything drapedout.
We do that normally.
And then, you know, from thebikini standpoint, the way that
I like to do it, and, andthere's not too many variations
of this'cause it, it's not avery forgiving incision if
(14:53):
you're not in the right spot.
Um, so I'll, I'll put my, mypinky finger right on the a SIS
and then go three finger breathsdistal.
Uh, and that's been the mostreproducible way for me.
I mean, some people just, youknow, put their ring finger, um,
right below a SIS, but, uh, thatthat's how I do it.
And.
Most patients, I mean, theincisions a little bit smaller
(15:16):
probably than 10 centimeters.
But on these larger patients, Igive a larger incision.
Uh, it's you, you just have to,for visualization purposes, in
my opinion.
Um, I tend to not travelmedially to the A SIS, although
I would tell you in a largepatient where you have a really
thick subcutaneous fat layer,you're probably safe to do that.
(15:39):
Without, you know, being at riskof getting into any of the
vessels or anything like that.
So let me get to the next one.
So the approach is prettystandard.
Once you get through the skin,right, you get down to the
fascia, you find your A SIS,that's gonna be your lighthouse.
It's gonna tell you, Hey, thisis where I know I'm at.
(15:59):
It's a reproducible landmark.
And so for anyone taking thesecases on for the first time, I
would say, Hey, make yourincision.
Feel a SIS know where you are interms of space and then get into
your capsule, or sorry, intoyour fashion work your way down
to capsule from there, uh, onceyou get down into the hip, I, I
like to use an inferior tagstitch on the inferior LA image.
(16:22):
It just helps get the capsuleout of the way.
Uh, some people don't do that.
Some people do a completecapsulotomy or a capsulectomy, I
should say.
That's probably dealer's choice.
Are, are you doing anythingdifferent on that in terms of
the, the, uh, capsule.
Joseph M. Schwab (16:36):
No caps.
Capsular management for me is,is a, a stitch on, on both flaps
and I, I do a capsulotomy and I,I use those as retractors
basically.
Bob Sershon (16:45):
Exactly.
Yep.
I mean, it's, it's really niceto use his retractors and it, it
really helps stay outta the way,especially with a bikini, you're
not mastering the middle of theincision.
Um.
Joseph M. Schwab (16:55):
Right.
I.
Bob Sershon (16:56):
Uh, on these large patients, I, I almost never use
fluoro to identify the saddle orwhat I wanna make my neck cut.
Uh, but on these, if I'm notsure, bring in fluoro, um, it,
it is such a useful tool foranterior, especially in, in a
learning curve or your, yourfresh out of fellowship or
something like that.
(17:17):
Um, and if it's a big stiff hip,like this lady was very mobile,
um, but if it's a big stiff hip,uh, make a napkin ring.
Like make it easy on yourself toget that head out.
Uh, and early on, I, I did thaton every case.
And then as I got morecomfortable and just more
confident with doing things, I,I, I moved away from it.
But I don't think you're everreally wrong to do that.
Joseph M. Schwab (17:40):
Are you normally just doing a single cut
on your, on your standardprimaries?
Bob Sershon (17:44):
Normally, yes.
Um, and that's stem.
Yeah.
We can go back to that.
I mean, that's, uh, STEMdependent as well, right?
So.
Some of, some of these implantshave a little bit of a longer
neck built in, uh, naturally.
Uh, like if we're gonna comparevendors, like I, I would say
that, you know, I feel that, youknow, the Z one has a little bit
of a longer neck than Actis.
(18:05):
If you're looking at tripletaper stems, those are the two
that I used here.
So, you know, I might cheat alittle lower if I use Zimmer or
if I, you know, I have to usethe pew, I might go a little bit
higher with a net cut.
Um, but it, that's, that'sagain, deal dealer's choice.
No right or wrong there.
So with reaming, I, I still,even in these large patients,
(18:25):
ream with a straight reamer, um,I haven't used, uh, at least
that I can remember.
Maybe I have, but I, I don'trecall using the offset reamer,
even though I have it availableall the time.
'cause you just don't wanna getin a situation where they have
such large anterior subcutaneousfat on their thigh that it's.
Pushing you completely invertedand vertical, um, which is the
(18:49):
tendency, uh, on these patientswhen you're reaming.
So, uh, do, do you switch overin the larger patients to
offset, or do you use offset allthe time, or you said you
Joseph M. Schwab (18:57):
No, generally.
Generally straight reamer.
Yeah, generally straight reamer.
Mm-hmm.
Bob Sershon (19:02):
Yeah, it's, it's amazing.
I mean, just'cause it'shemispherical, I mean, you, you
get a great ream.
Um, I think you just on thesepatients especially need to be
careful about not reaming outthe anterior wall because that
fat is gonna wanna push youanterior.
Um, it'll also want to have, youhave a tendency to raise the,
(19:23):
uh, the center of the cup aswell.
So, um, I'm, when I'm reamingI'm kind of pushing down in
posterior to, uh, to keep thehip center lower as or as low as
we reasonably can and to notream out the anterior wall.
'cause I do it under directvisualization.
So this picture here is with thelights off the wound, no
headlight on, and you couldstill see in the wounds.
(19:46):
Then you could imagine, turnyour headlight on, put the, or
the operative field lightspointing back in the wound.
Um, and you get actually a, avery reasonable view here.
Uh, I like to, when I'm reaming,uh, under visualization take
out, uh, so if we're gonna saythat towards the head is 12
o'clock, I'll usually have, uh,like a pointed cobra.
(20:09):
I call it the medium, um, rightdown near the TAL.
And I'll take that out becausethat tends to get in the way of
the reamer for me.
And I'll just have that shortythat pointed shorty retractor
that you could see, um, rightover the anterior brim there.
And then something posteriorlyto help me from catching all the
fat and tissue as I'm getting inand out of the wound.
(20:30):
Um, so you know, then when yousend your, you know, your reamer
down, you could use fluoros.
I'm bringing Fluor up here toshow you.
Just the AP pelvis that I alwaysget to make sure that I have
symmetric obterator and that I'mnot in a inlet or outlet view.
I'm matching their, their ap,that we got supine beforehand in
these larger patients.
(20:51):
But if you're not sure howmedial you've reamed or you want
to get more medial, you're notsure of your cup size.
Bring in fluoro ream underfluoro if you don't usually do
that, I mean, a lot of guys, youknow, especially, you know,
really high volume guys can reamunder fluoro really well, um,
without reaming out the walls.
Um, do you ream under fluoro orare you a direct visualization
(21:12):
guy?
Joseph M. Schwab (21:13):
No, I'm a, I'm a ream under fluoro guy, uh,
with a, with a directvisualization double check.
I would say less than half thetime, but, but yeah.
Uh, um, it's, uh, the, it's oneof the benefits that you
mentioned, and I, I think thisis true even in, in
straightforward patients.
But in difficult patients, ifyou're ever not sure what's
going on.
(21:33):
Uh, or you want to double check,bring fluoro in.
It's just super easy.
Right?
And, and it's, whether it's withyour cup or with your stem, or
with your approach, uh, withyour, your cuts.
Yeah.
Just bring fluoro in.
Bob Sershon (21:45):
Yeah.
And the, and the feel on thesepatients is admittedly not as
good in terms of how you feelthe reamer catching and
engaging.
Uh, so what, what I'll do isI'll, you know, on all the cases
we just measure the head we goup.
It's just like, let's say wemeasured a 51 millimeter head.
I'd start at a 51, uh, reamerand, and probably get up to a
53.
(22:06):
Um.
On these patients.
Some people they like to reamvery small to medial eyes and
then get bigger and bigger andbigger.
I think that's probably a littlebit more dangerous under direct
visualization'cause you can'treally see that you're, you're
centered and not ececcentrically reaming.
Um, so I, I would say if younormally start small and go up,
(22:28):
my preference for this casespecifically would be, Hey,
change it up a little bit.
Start with a reamer that reallyfills the acetabulum early on.
And media lies from there.
Um, and then you have youroffset, and again, navigation
or, you know, mixed reality.
What whatever you want to use isgreat for there.
So you get your cup in.
(22:49):
I always have my templates up.
I am crippled if I don't havetemplates.
I, I mean, I.
I rely on it for everything.
Um, just as a double check and,you know, how medial should I
go, how many yield do I wannago?
And these larger patients, um, Iwill personally have, you know,
less of a, uh, hesitation toleave their cup of hair more
(23:14):
lateral just to help with alittle bit of offset.
Um, if I don't wanna lengthenthem and maybe I want to add a
couple millimeters of offsetfor.
Attention purposes.
Um, but, but here, you know, we,we matched it, you know, fairly
close, uh, to our clan.
The cups probably the sides aretoo bigger than what we
templated, but in these largerpatients, depending on where
they put the calibration marker,uh, you could, you could be way
(23:36):
off.
Um, so, so just be aware of thatas well.
This is where I think the, otherthan the wound healing being.
Being better.
Um, this is where I think Bikinireally helps with large patients
and very muscular patients.
(23:57):
Uh, you know, to cook convincedme to switch over to this, uh,
maybe a year or two ago, I can'tremember.
But, um, he said, Bob, one ofthe craziest things is that the
femoral prep is easier and I,it, it just, it never made sense
to me.
I said, I have a horizontalincision that's limiting how
proximal I get.
How can the femur.
(24:17):
Easier.
And it is, and I, I think a lotof it is because of that medial
Mueller that I have there, thewhite handle, uh, on the, on the
image, it allows you to, to pulla little bit more medial and
present the femur laterally,which is probably the more
limiting factor with gettingfemoral exposure to these large
(24:38):
patients.
Um, so I, I find the femur onthese patients to actually not
be very challenging at all.
Um.
Not, I shouldn't say at all tonot be as, as, as challenging,
uh, than, than with a standardincision.
Um, I use all my standardretractors, uh, standard
(24:59):
sequential releases, you know,capsule and a still type, you
know, piriform ish or externalrotators, kind of the normal
trajectory.
All of us.
Uh, follow.
Um.
And then one of the, you know,the big helps here is I, I
usually just do these cases.
Um, like if the fellow's not inthe room, just with my pa she's
on the other side of the table.
(25:20):
And, um, if you're alone indoing these cases, like the
fellow's not there, in my case,just have your tech come and
give a little hip check to addup to the hip a little bit.
Um, you know, right at thedistal thigh that goes.
That is just so helpful for, forbringing the femur, um, into a
more, you know, I guessdistally, abduct, a deducted and
(25:41):
approximately abducted, uh,space.
So, um, then you, you know, youget everything in and you go to
closure and what's amazing.
That I noticed early on is onceyou take the retractors out,
that the picture to the lefthere, maybe, hopefully my mouse
(26:03):
is working.
That's nothing.
We haven't put anything in thereyet.
It, it just, it closes onitself.
Joseph M. Schwab (26:10):
Yeah.
Bob Sershon (26:12):
Yeah.
And it's just amazing in theselarger patients, it's a long,
you know, it's along the linesof tension.
It just closes on itself.
So then, you know, here's, youknow, our running four oh
closure.
Um, and then we'll put onusually either a, you know,
silver impregnate dressing or ajust a tepa tegaderm.
Uh, if we're not really worriedin patients with a really large
(26:33):
panis, I like to put somethingon that's just gonna be.
Super watertight and I couldleave on for two weeks at a
time.
Um, I'll give them another oneof these dressings here and tell
'em, Hey, in two weeks when you,or 10 days when you take that
off, slap another one on, um,just to keep any of the, the,
the bacterial burden underneaththe panis, away from that wound.
(26:58):
Um, what are you doing for your,for your dressings in these
patients?
Joseph M. Schwab (27:02):
So exactly the same.
Um, you know, the question thatI was gonna ask is some people
talk about doing things likevacuum assisted, uh, dressings,
you know, vac dressings over thetop ones that people can go home
with.
Uh, some people, um, somesurgeons that I've talked to
will put, um.
Essentially a, a, a large,almost kind of diaper in the
(27:25):
area over the, uh, over thedressing itself to just act as a
barrier and, and act as, youknow, to prevent, um, any
friction maybe from, uh, movingthe dressing or curling up the
dressing or anything like that.
What I was gonna ask is, do youlet them shower with this?
Yep.
Bob Sershon (27:47):
Yeah, right off the bat.
Um, are you keeping them fromdoing that or
Joseph M. Schwab (27:50):
Not at all.
I, I encourage him to shower.
Bob Sershon (27:54):
Yeah, the, the VAC dressings, um, you know, there's
reasonable data that is showingthat, that it helps in these
higher risk wounds.
So, I, I, I can't argue too muchagainst it.
I just, in my population, forwhatever reason, um, it almost
promoted drainage.
And I, I, I don't, I don't, Ican't explain it.
(28:16):
That's just my experience.
I'm not gonna poo the wound vax.
So, um, so that's, that's one.
The other thing is, you know,the VAX would malfunction and
they'd be beeping and we'd get abunch of calls from patients.
So we, we kind of moved awayfrom that.
What I used to do on thesepatients, which is kind of
cruel, is I'd put'em in a pelvicgirdle
Joseph M. Schwab (28:36):
Oh
Bob Sershon (28:36):
uh.
Yeah.
Yeah.
I, I like a, almost a corset.
Joseph M. Schwab (28:41):
Yeah.
Bob Sershon (28:42):
it, I, that's when I was doing a standard incision.
I'll tell you what, it, itworked, but they, they didn't
like me for it.
Joseph M. Schwab (28:49):
to, to minimize swelling, basically.
Minimize any sort
Bob Sershon (28:52):
well, to hold the panis up
Joseph M. Schwab (28:54):
oh.
Okay.
Bob Sershon (28:54):
to like, to, you know, like you, you see those
cartoons where, you know, yougot this spat guy and you know,
this like good looking womanwalks by and he puts the girdle
on her and he makes his chestbluff up.
It's like, that's.
That's kind of what we weredoing.
And, uh, I, I just, it was, Ifound it.
I, I don't know.
Patients didn't love it.
We'll put it that way.
Joseph M. Schwab (29:14):
you're, you're not using any skin glue on this.
It doesn't look like Right.
It's just the Monocryl and thendressing.
Bob Sershon (29:20):
Uh, no.
We, we did, um, use derma bond.
Joseph M. Schwab (29:23):
Okay.
Bob Sershon (29:24):
We put derma bond on all of it.
Yeah.
Joseph M. Schwab (29:26):
Okay.
All right.
Bob Sershon (29:29):
Fortunately, haven't had any.
On the bikinis, uh, and thelarge patients.
I haven't had any of thoseadhesive reactions.
I, I do worry about that.
Um.
So if people just wanna do thesilver impregnated, they're,
they're fine to do that.
Um, but this is, this is herfour week follow up, right?
So, um, incisions healing.
(29:50):
Well, you know, she's, she'sdoing well.
She was really deconditionedbefore this, so, um, you know,
she's, she's still gettingaround with a cane and things
like that.
But just'cause she's gassed and,uh, no hip pain, right?
I mean, doing really well.
Super thankful.
Um, and that's, you know.
That's how you get through it.
(31:20):
Then you get, you know, caseslike this.
Um, and this, this poor woman, Imean, you know, she's 50, you
know, 52, um, horrific hip.
That clearly has been a problemfor a long time.
And, uh, I, I said, when did youfirst.
(31:42):
Try to get a hip replacement.
Like, how long have you beenliving like this?
'cause she, she came in in awheelchair and, uh, oh.
For a decade.
You know, no one would touch mefor a decade.
Yeah.
Um.
Just'cause she, they kepttelling her, you're too young,
or You're too heavy, you're tooyoung, you're too heavy.
And, uh, and just a total shameand lost like prime decade of
(32:03):
her life to this.
Uh, but these are really toughcases because the joint, you
could see, I, I should havetaken the templates off here,
but, uh, the, the joints almostauto fused.
Um.
Really no range of motion.
When she tries to stand up towalk, she's leaning forward like
30, 40 degrees.
(32:24):
'cause she's got such a terribleflexion contracture and now her
back's affected.
And, um, you know, and then shehad one of these not super
mobile panes to go on top of it.
Um, which, you know, just, justthat makes it so, so much more
difficult, um, in, in anysituation.
(32:44):
So for her.
You know, we just did much ofthe same.
So, so this is just showinghere.
Okay.
You get him on your back, you,you try to reproduce as best he
can.
The, the AP view.
Um, and she started, which Iwanna show you, and I'm curious
of your thoughts on this.
You know, she started over aninch short and, uh, I mean,
(33:05):
what, what's your threshold herefor, for lengthening when it's
been about a decade with a hip?
Probably not this bad, butdefinitely shortening.
Joseph M. Schwab (33:15):
Yeah, boy, it, it depends on a number of
factors, but if this was a atrue, if this was a pediatric
situation, I, I would probablyaim to make up only about a half
to two thirds of it.
But if it's been over the last10 years and she had, or you
feel confident she had sort of ademonstrably normal hip before
(33:36):
that, I, I think this is onethat you could probably get all
the way back.
Um.
And obviously, I mean, it looksto me like she's in fixed
external rotation too, right?
So, yes.
So that can.
I, I have found that that can,um, affect a little bit the
(33:57):
measurement of, uh, of leglength, at least with the, the
line, uh, you know, using lines,um, just because you're, you're
catching a different, uh,profile of the lesser tro
canner, um, you know, dependingon what, uh, what landmarks
you're using.
So this is one I would say I'mprepared to make her even.
(34:18):
I'm prepared to not make herexactly even, but to give her
back at least two thirds.
Um, but I'm prepared to use alot of fluoroscopy and any tools
that I can get, um, to, to helpme understand exactly how much
length I've given her back.
Bob Sershon (34:34):
Yeah.
Yeah.
And that's, and this also, youknow, the, the external
rotation, uh, really screws upany ability to measure offset.
Um, which, so you, you.
You go, okay, let's get herclose to the other side.
At least you got a fairlynormal, uh, left side hip here.
So, um, yeah, so that was ourgoal was to make up as, as much
(34:56):
of it as we could, so long assoft tissue tension, um, allows,
because what I don't like doing,uh, having, having done it once
or twice is the hip's hard toreduce, and you pull manual
traction and then you lock itand you do one or two clicks of
fine traction.
You push the hip in.
That's just that, that's tootight.
(35:18):
Like, like I, I, I probably inmy mind, shouldn't have done
that, uh, trying to chase leglanes on people.
Um, so now I just, I go untilit's a little bit difficult to
reduce and I, I leave it there.
Um, but whatever they get iswhat I get.
So.
So here you go on those, this isone of those, you know,
(35:38):
fluoroscopy showing you gettingdown there, um, you know, trying
to Alize and, and this was apatient where, and maybe these
are a little bit differentfluoroscopic views from bringing
the fluoro in and out.
But I, I brought this up becauseI specifically remember on this
patient just wailing as hard asI could to get that cup seated.
(36:00):
And taking it out reaming,taking it out, reaming, and it
just kept sticking.
Um, so I probably, I feel likeyou can't see the airball here,
you know, but I feel like thatcup should have been, you know,
two, three millimeters.
Even more medial based on thefluoro shot.
And maybe it's some opticsplaying into here with different
(36:23):
fluoro shots, but, um, that'ssomething that you gotta pay
attention to as well.
There's nothing behind the cup,there's nothing stuck.
But I felt that I was justgetting such a good press fit
here, um, that I, I wascomfortable leaving it not, not
putting any screws.
Is that
Joseph M. Schwab (36:39):
line to line or do you ream?
Uh, one under two under.
Bob Sershon (36:42):
one, one under every, every time.
Yeah.
Yeah.
Joseph M. Schwab (36:47):
as far as the, the, the surface of your, uh,
acetabular component, highfriction acetabular component.
Like a, a grip or a a, a TM orsomething like that.
Something high friction.
Bob Sershon (37:00):
PPS.
Joseph M. Schwab (37:02):
PPS.
Bob Sershon (37:03):
Yeah.
Yeah.
So, um, and again, I could haveone line to line on this and,
uh, you know, really.
Uh, you know, went to town,hitting it down.
But once you get the bite, and Ifeel you're shaking the whole
pelvis on this large patient andthe cup's not moving, all right.
Like, you, you, you're done.
Stop, stop wasting time.
(37:24):
Like, get out of there.
Um, so, you know, and then theseare her.
Joseph M. Schwab (37:29):
is better, right?
Bob Sershon (37:31):
exactly.
Um, and then you could see here,like I, I still, I bring this up
'cause I still don't see.
A big radiolucent line aroundthe cup here.
I mean, I see one in zone two.
Um, but, but you know, not downhere.
So I don't know, maybe it wasfloral playing tricks on me,
but, uh, uh, but, but, but thepoint, the point is here is, you
(37:51):
know, she, this lady crippled, Imean, totally crippled for, uh,
better part of a decade.
No one will touch her.
You come, you do all the steps Ishowed you on the prior one, um,
and then, you know, four weeksout you get a completely
different looking x-ray andthey're so thankful and grateful
for it.
Um.
But to your point earlier, Imade up about two thirds of
this.
(38:12):
Um, she's still got a little bitmore external rotation, as you
could see compared to her, herother side, uh, and clinically
was a little bit short still, soshe might need a lift, but I
could not, that's the longestball I could get on there.
Um, I I, I probably could havedone the trick where you pull
the manual, lock it, do a coupleclicks of fine and gotten one
(38:34):
more ball.
Uh, but at that point.
Not, not worth it.
Not worth it in my opinion, so,
Joseph M. Schwab (38:41):
Interesting.
Yeah.
This, this is one where ratherthan doing more, um, a lift is
probably gonna be.
Uh, reasonable for you and shemight not even notice the
difference.
I don't know.
How far out has she noticed?
Bob Sershon (38:53):
she didn't notice at all.
Joseph M. Schwab (38:55):
Yeah,
Bob Sershon (38:55):
Like by we, we saw her back at four weeks.
I asked my pa, um, who sees allmy four weeks, I said, and I
said, Annie, did she noticedthat?
She goes, oh my God, no.
She's just happy she could walk,
Joseph M. Schwab (39:05):
I was about to say, especially if she was in a
wheelchair for that long.
It's, those are, those are folkswho don't notice leg length
discrepancies that much.
Bob Sershon (39:13):
Yeah.
And I don't know if she came inon a walker or cane.
I can't, I, I, I should havelooked at that.
Um, but it was like asubstantial over four weeks
already, um, increase in, inquality of life there.
So,
Joseph M. Schwab (39:26):
That's, that's amazing.
That's great.
Bob Sershon (39:28):
yep.
Yeah.
So, uh, so that's, that's thebikini there.
And we didn't do anythingspecial.
Just, you know, a, well, a aeland.
Dermabond seen his last case.
So, um, if we got time, this isthe, you
Joseph M. Schwab (39:41):
We got time for this for sure.
Bob Sershon (39:44):
yeah.
Joseph M. Schwab (39:45):
Another standard primary.
Bob Sershon (39:48):
Yeah.
Yeah.
This is one of the cases that,uh, I was gonna present there,
um, at, at a HF, um, which, youknow, the, the time thing, I
totally understood that.
I mean, you've got, you know,Aldo and your acid medias up
there given like a.
Unbelievable, you know, chorus,and I'm sitting there going, I,
(40:08):
these guys are, are justanimals.
Totally unreal at what they'redoing.
Um, so I just, you know, I, Icould tackle this stuff, but
they're just total wizards.
It, it, it's just incredible.
So, um, but uh, yeah, so, sothis lady, uh, she had DDH, uh,
had a primary hip done in PuertoRico.
(40:31):
20 ish years earlier was subYeah.
Subsequently revised, uh, abouta decade before this.
To a, um, uh, for, foracetabular loosening.
Uh, it was one of the implantswhere the, the back coating had
come apart and, uh, clearly hada loose cup and then, you know,
(40:52):
had a, a revision and then thatcame loose and was repeat
revision.
Um, which in those settings, I'malways worried about some
subclinical infection, uh,versus.
Metabolic disease, like do theyhave p acnes or, um,
pseudomonas?
Do they have some like slowgrowing indolent bug in there?
Uh, so anyway.
(41:13):
She had a revision.
Um, that, that actually I did.
Okay.
So I brought this up.
This was my, my public shamingfor myself.
Um, and, uh, so we, we did this.
I got.
Great fixation, like one ofthose hips where you're going, I
don't even really need to putscrews in here, but I'm going to
(41:34):
'cause it's a revision.
So, you know, I don't follow theprinciples that, you know, I,
you know, kind of always tell myfellows of, you know, you want
inferior fixation, superiorfixation.
So she, she, you know, goes andhas one of, not a fall, but what
I think is worse than a fall,which is one of these like hard
stumbles where they plant reallyhard, um.
(41:58):
And felt like immediate pain.
Uh, went to the er, got x-ray,ct, um, you know, didn't, didn't
show anything, and thenliterally walks into the four
week visit like this on a cane.
Joseph M. Schwab (42:12):
Wow.
Bob Sershon (42:13):
and we're going, what happened?
Like how, how did we go fromlike very robust, great fixation
to this hard stumble?
And then so, you know, reallyshe had no pain.
She was probably doing a littlebit too much and, you know,
fell, stumbled, caused, youknow, what I thought was an
acute discontinuity, but it wasreally just a fracture through
the anterior column.
(42:34):
And, um, and, and here we arenow, right?
So.
You've got, uh, you know thislady.
BMI 40, multiple priorsurgeries, complete absence of
the anterior column, cups in thepelvis, tenting the vessels, um,
and, and that, and this has allbeen done anterior, by the way,
(42:55):
the most recent surgery.
So, so now here you are fourweeks out.
I mean.
Your decision is go back inthrough that, which of course we
did.
Um, or, you know, if you're notcomfortable with it, go through
the back, through her priorincisions.
So, you know, the, the planningon this one.
Um, and these, these are allthe, you know, the pearls.
And this is from her caseactually.
(43:15):
I, I said let's, let's, youknow, take some pictures and
show people this, this complexreconstruction.
So.
Um, so, you know, the pearls, I,you just do your normal
incision.
I, I usually go two fingerbreaths, ladder lateral to the a
SIS, even even in the obese.
Um, and then you want to justextend that.
So if the A SIS is right herelabeled, you know, you could see
(43:37):
I came pretty far proximal rightalong the crest right there.
Uh, and right off the bat onthese cases, I'll, I'll go ahead
and, and find TFL.
You know, small cuff, you couldprobably see about a centimeter
of a cup of tissue there.
Um, that, that, I'll leave, I'llpeel it off, off the outer
column right away.
Um, I don't know if, if, if yougo to it right away or if you
(44:00):
wait, I mean, what's yourpreference on these?
Joseph M. Schwab (44:03):
So, um, definitely right away if I'm
planning on doing significant,uh, femoral work, I feel like
the TFL uh, peeling that offgives you a better, uh, femoral
mobility.
Um, but, uh, for a large up andin like this, I would say I
might wait and, um, but chancesare pretty good that you're
gonna do some sort of.
(44:24):
Ensile, uh, maneuver in order toto, to get good access for what
you want to do.
Bob Sershon (44:30):
Yep.
Yeah.
Um, and I knew I was gonna do acage on it.
So for me, just right off thebat, I mean, to enhance femoral.
Mobilization, um, as well, justto get it outta the way.
Let that femur fall.
Posteriorly, uh, that reallyhelped.
I mean, I didn't even need aposterior retractor for the
case.
The femur was just floating outof the way.
It was, it was beautiful.
(44:51):
Um, and then, you know, so, soyou elevate, you know, indirect
erectus, do all your capsularreleases.
I mean, she had already had allthis done.
Um.
Posterior pocket for the ion ifyou need it.
So let's say you're going in thefirst time, you can peel off
some of that posterior scartissue, posterior capsule to
allow the ion to kind of tuckback behind the posterior, um,
(45:12):
acetabulum.
Um, what I'll normally do then,so I do all this before I even.
Dislocate the hip.
Uh, I like to knock the head offinto the cup.
I mean, there's a milliondifferent ways to skin the cat,
but, you know, two, three clicksof fine traction normally is
enough, and you could just hitthat thing off into the cup,
pull it out, you know, rightaway.
(45:33):
Um, what I don't do until afterI've done that the majority of
the time is in, uh, is releasedthe inferior capsule, um, you
know, pubic, femoral, whateveryou wanna call it.
It, it just, because I, I don'tknow how mobile the femurs gonna
be till I try to tuck it backbehind the posterior acetabulum.
(45:54):
And, uh, I've had some caseswhere I haven't had to release
any of it and I've had otherswhere I can't even get the
trion, um, outta the socketbecause it's so tight
inferiorly.
And that is just such a greattrick, um, that you know.
Nobody showed me, right?
I mean, I just started doingthese on my own.
(46:15):
Um, these like bigger anteriorrevisions.
So, uh, you know, that, that'sone thing that I tell everyone.
If you're gonna do that, maybewait until you knock the head
off and you're trying to get thetruing outta the way just to see
what kind of room do you need.
Um.
And, uh, you know, of course,uh, you know, fluoro is your, is
is your tool, uh, throughout allof this.
If you're lost, you need to knowyour landmarks.
(46:37):
Where, where am I in a revisionsetting?
Not a common question you getfrom the fellows.
Um, and, uh, you know, one ofthe actually great articles that
I found, um, this is probablyjust from a couple years ago.
It was, you know, from the guysoutta Utah, you know, Lucas, uh,
Jeremy, those guys out therejust goes over.
(46:58):
This exact technique.
Uh, they've got pictures likethis, uh, in the article.
It, it is super helpful.
I, I gave this to our fellows.
Um, I think I found this be likeright before the case.
Uh, and even I got a couplepearls out of it.
So it was, it was super helpful.
It was this half cup cageconstruct from the front.
(47:19):
Um.
So anyway, we, we get in there,we do that, you know, we do that
exposure that I showed you.
Um, getting that cup out of thepelvis can be a challenge.
Um, this is one where, you know,you could have vascular on
standby, uh, and maybe that'snot a bad idea.
Uh, you could get a CT Angio twoif you, you know, you really
(47:40):
think that that's acutely up andin there.
Maybe you got the vessels.
Um, and you know, for yourreconstruction, even though it's
a bigger patient, I think theprinciples all were remain the
same.
You know, again, anile exposureso that you could really see the
inferior part of the acetabulumcome all the way up over your,
over your anterior acetabulum.
I mean, she had nothing there,so there was really nothing to
(48:02):
release.
Um, and, and do yourreconstruction that way.
And you know, this time, youknow, we got a couple screws.
You know, in inferiorly, whetheror not that would've saved her
the first time.
I don't, I don't know.
I mean, it, it seemed like shejust had a, basically a pelvic
fracture that knocked the wholeconstruct loose.
But, um, and then after you getthis in, I actually really like
(48:25):
using fluoro, uh, for like a,even a trial cage to see where
the trial's gonna sit.
Um, and the other nice partabout a cage, at least for me in
this situation, is it candistalize.
Your joint line.
Right.
So, um, that allowed me toactually put a full cup in here,
distalize it.
(48:45):
I think I got a 40 head in her.
Um, and, and it, it ended upworking out, you know, pretty
well.
I think this is her x-ray, uh,over a year out at this point.
Joseph M. Schwab (48:57):
Very nice.
Bob Sershon (48:58):
Right.
Yeah.
And, and this is, she actuallylost a ton of weight.
I, I saw her, it was like, Iknow you, but, uh, like, you
know, I, I know you, but if, if,if I, if I hadn't, you know,
she, she lost like, she's likeBMI of 30 or like close to 30.
So she's one of these patientsthat actually.
You know, it became way moreactive and, and made healthier
(49:21):
and, and lost weight.
You know, it was just kind of a,a, you know, kind of an
inspirational story for, forothers that are in her
situation.
Um, and yeah, I mean,
Joseph M. Schwab (49:31):
nothing to do with the stem on that one,
right?
You, you were able to maintainthe original stem.
Bob Sershon (49:37):
Yeah.
Well, thank God, you know, thatthat adds,
Joseph M. Schwab (49:42):
Um, did you have to go up and into the inner
table of the pelvis at all?
Were you up and into the innertable or were you not?
Bob Sershon (49:49):
I didn't need to.
Um, I mean, this is a, this is agood case though.
If you don't wanna use a cupcage, uh, you, you can go in the
inner table, put an augmentthere.
Uh, I mean, that's probablywhat, I don't wanna speak for
him, but I mean, that's probablywhat Aldo would've done, um, you
know, running this, run this byhim.
What, what, what would you havedone with, uh, you know, this
(50:11):
big old defect?
Joseph M. Schwab (50:12):
I mean, I, I think it's, uh, I, I, so I think
a cup cage, you know,potentially, uh, if you're, if
you have the opportunity to planfor it, like a custom tri flange
would also be a possibility.
But since this kind of happenedacutely, you want to get in
there as quickly as possible.
And, and maybe you don't havethe time to have something
custom made.
But I, I think this is a greatapplication, um, of a cup cage,
(50:35):
uh, and clearly.
You know, at being a year outand seeing her post-op films,
that's what she needed.
Right.
Uh, I mean, that worked outreally, really well.
Bob Sershon (50:45):
Yeah.
Yep.
Um, so, you know, she's, she'sdoing fine now.
No worse for the wear and, andhopefully this construct, you
know, I always worry about, youknow, Mayo's got good data on
cementing cups.
Um.
Uh, in, into revisionconstructs.
Uh, but I, I worry long term.
I mean, she's, I think I saidshe's in her fifties.
(51:07):
You know, how, how long doesthat cemented cup really, uh,
really last?
Um, I don't know.
I, I, I'm assuming at some pointshe'll, she'll knock it loose.
Uh, but that's hopefully not ahorrific revision because now
you've got ingrowth of your, youknow, your, um, porous metal
shell and your, your cage isn'tgoing anywhere.
(51:28):
So.
Joseph M. Schwab (51:28):
I mean, if she just needs another cup cemented
in, that's not the end of theworld.
Um,
Bob Sershon (51:33):
That's a win.
That's a win.
Joseph M. Schwab (51:35):
that is a win.
And this, so her original, um,I'm gonna come back to just us,
but her original, um, revisionsurgery done by you, that was an
anterior approach, but that wasa traditional.
Incision that you used, right?
For that, uh, for that revision.
And you chose to do that for herrevision specifically.
Bob Sershon (51:57):
yes.
I tried to do all of my, um,revision acetabular work from
the front.
Uh, I just, I, I feel at thispoint it's easier for me.
Um, the, the femur falls out ofthe way.
You get a great view ofeverything.
Um, you can use fluoro, which isa huge, huge plus compared from
(52:22):
the back where you're takingplain films.
Um.
Uh, yeah, I mean, I, I, I, Ipretty much do it.
All the exceptions are.
Like, let's say it's a headlinerexchange on someone that's had a
prior posterior, they've got aton of aversion built into their
cup, their STEM's a little bitverted.
I start going, Hmm, I mean, ourdata, you know, bill Hamilton
(52:43):
and our institution publishedsaying that, that the
dislocation rate's about thesame regardless of approach
after a headliner.
So those are ones where I'llstill go through the back, but
anything where I'm swapping outparts at this point, I, I really
try to go through the front foreverything.
Joseph M. Schwab (52:59):
And as far as using the traditional incision
for that original, um, uh,revision as opposed to a bikini
incision, do you ever use thebikini incision for revision?
If you're just focusing onacetabular work, does that
dissuade you from that?
Wh where, what are your thoughtsthere?
Bob Sershon (53:16):
I, this specific case basically made me say I'm
probably not doing bikinis fromthe front for on a revision.
Right.
I, I don't.
I don't foresee a scenario whereI would've been happy with
myself.
Uh, haven't done that throughthe front, even though I thought
her first case was a prettystraightforward revision.
(53:36):
It's just, you know, things,things happen.
Um, so
Joseph M. Schwab (53:41):
She's definitely made it a lot farther
on this second revision than shedid on the first revision, it
sounds like.
So the, the proof is in thepudding.
That's great.
Um, well Bob, hey.
Thank you so much.
So first of all, uh, uh, thanksfor being a good sport and, uh,
coming and joining us at the aHF annual meeting.
And thanks for being an evenbetter sport and coming and
(54:01):
giving your talk.
Hopefully we gave it the, thetime and attention to do it
justice.
And, and I think what I wouldimpart to our listeners is that
if they've got, um, super obese,morbidly obese patients, they
should be sending'em to you atthe Anderson clinic.
Isn't that, that's that.
Bob Sershon (54:20):
Yeah.
Yeah.
Joseph M. Schwab (54:21):
No.
But hopeful.
Yeah, hopefully they walk awayfrom this with, uh, uh, an
understanding of what's possibleand, um, and, you know,
hopefully, um, if they have anyquestions about, uh, your
thoughts on a patient and whatmight be reasonable, uh, that
they could reach out to you and.
And that's one of the things weencourage as part of the
(54:43):
Anterior Hip Foundation is sortof that, uh, collegiality in, in
answering questions.
I'm sure, uh, I'm sure pa uh,uh, providers out there watching
or, or listening to this wouldappreciate that
Bob Sershon (54:54):
Oh yeah.
I mean that, that's one of theawesome things that I found at
the meeting.
I've already abused thatprivilege on multiple guys,
Laura, at the meeting.
So, um, it's, it's great.
Joseph M. Schwab (55:05):
It was great to have you as part of the
meeting.
It's great to have you as, uh, aguest on the A HF podcast and,
uh, thank you very much for yourpresentation today.
Super impressive stuff and Ilook forward to seeing more from
you in the future.
Bob Sershon (55:19):
Thank you.
Appreciate it.
Joseph M. Schwab (55:23):
Well, thank you for joining me for this
episode of the A HF podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on.
And keep sharing great contentjust like this.
Please also drop any topic ideasor feedback in the comments
below.
You can find the ahf podcast onApple Podcasts, Spotify, or in
(55:47):
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation.
All one word.
episodes of the A HF Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
happy, healthy, and not tooobese.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
NFL Daily with Gregg Rosenthal
Gregg Rosenthal and a rotating crew of elite NFL Media co-hosts, including Patrick Claybon, Colleen Wolfe, Steve Wyche, Nick Shook and Jourdan Rodrigue of The Athletic get you caught up daily on all the NFL news and analysis you need to be smarter and funnier than your friends.