October 10, 2025 • 42 mins
From Croatia to South Africa: Chuck's Journey in Hip Surgery | AHF Podcast
Welcome to the AHF Podcast with your host, Joe Schwab! In this episode, we sit down with the trailblazing hip surgeon, Josip 'Chuck' Cakic. 🌍 Chuck shares his inspiring journey from Croatia to South Africa, his deep passion for hip surgery, and his innovative contributions to the field. Learn about his pioneering work in hip arthroscopy, the challenges he faced, and his role in introducing the anterior approach to hip surgery in South Africa. Whether you're an aspiring surgeon or just fascinated by medical innovation, this conversation is packed with insights and inspiration. 🔬💪 Don't miss it! #AnteriorApproach #AnteriorHipFoundation #AHF
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:22):
Hello again and welcome to the AHF Podcast.
I'm your host, Joe Schwab.
My guest today is Josip Cakic.
He goes by Chuck, and he's atrue pioneer in the field of hip
surgery.
Born and raised in Croatia andpracticing in South Africa.
I first met Chuck at this year'sEuropean anterior hip meeting
(00:45):
where I learned not only alittle about his life's journey,
but about his passion for hipsurgery, his sense of humor, and
his gift for being an educator.
Chuck, welcome to the AHFPodcast.
Josip "Chuck" Cakic (01:00):
Hello everybody.
Thank you very much for havingme.
Joseph M. Schwab (01:04):
Chuck, it's a true honor to have you on the
show.
I, I know you have a reallyinteresting story and I would
love if you could start bysharing a little bit about your
story, a little bit about yourbackground being born and raised
in Croatia and eventually endingup in South Africa.
Tell us a little bit about that.
Josip "Chuck" Cakic (01:24):
Well, you know, the, the life is
unpredictable and I'm, I'm, I'ma leading example of that is I.
When I finished my medicalschool and I did start doing
internship in Zagreb, where I'mborn in Croatia, um, and I was
looking, I always wanted to beorthopedic surgeon.
My passion was always orthopedicsurgery, specifically sports
(01:46):
parts of it.
And it happened to be thatduring my medical school I.
Uh, got in touch with a, with aphenomenal person, professor
Kosky, who was, um, one of theVienna school guys, and he
introduced me to hip and intothe, that phenomenal joint that
I believe that is the center ofuniverse, by the way.
(02:08):
And I did some, my firstresearches in a, in a hip as a
student, and I always wanted tobe in a hip.
And I always had kind of ideaabout the hip from looking into
it from the sports side.
But the life is different.
So what happened is that Ifinished my internship and I
couldn't get the job.
They told me that I can get toorthopedic rotation in five to
(02:30):
seven years.
And I said, I'm not gonna be awaiter for so long.
I'm gonna go somewhere else.
And in meantime, that was a kindof a year that was already
starting having, uh, problems informer Yugoslavia and we didn't
know what's gonna happen.
So combination of the factorsbasically.
Was asking to look the otheroptions.
(02:51):
So I looked in Holland and uh,because as a student I was on
exchange in Holland, so I knewpeople in Holland.
But in meantime, my very goodfriend of mine, from my
generation, from my class, he'llend up in South Africa and he
found me and said, listen, youdon't have to know Dutch.
You can come to South Africa.
English is perfectly fine.
So in a period of literally 10days, I decided to go.
(03:16):
I got the visa, I got married,sold my car, bought a ticket,
and arrived to South Africa.
So that was basically allhappening in 10 days.
And, um, and the rest ishistory.
I came here, I looked for thejob, I got the job as soon as I
got the job in, in, in thehospital, uh.
(03:39):
As an intern, because I had torepeat my internship, I went to
orthopedics department and Ispoke to the prof who was a
prof, kin at the time, a guyfrom Munich, German, and he told
me, don't do any shortcuts.
Start from the beginning, becomea part of the team, and go
forward from day one onwards.
(04:01):
And that's what I did.
And I did my internship, I didmy senior house job.
I did necessary exams and Ibecame Registrating Orthopedics
in 1995 and finishedorthopedics.
So that was, that was my, thatwas my trip up become in 1999, I
(04:23):
became specialist.
And when, for the fellowship,through the fellowship, I
learned about more.
I did fellowship in the hiparthroplasty, and that's what.
Put me in touch with doing theresearch, put me in touch with
the cross-linking and with the,the whole idea of cross-linking.
(04:44):
'cause we didn't know what'sgoing on.
I mean, we're talking now 19 90,19 99 going to, in that period
of time.
And I did research even beforeand, and, and that's how I
landed up with the crosslinkingbecause I dunno if the people
now that.
The first crosslinking in theworld was starting in, in South
(05:05):
Africa in 1957 actually.
So, so, and it was published,uh, later on by Dr.
Alala in, uh, one of thebiomechanical researches and
congresses.
And the crosslinking was usedfor sterilization, not for
improving the quality ofpolyethylene,
Joseph M. Schwab (05:24):
Mm-hmm.
Josip "Chuck" Cakic (05:25):
but never actually got onto the worldwide
market for two reasons.
Number one.
A limit commercial limitation ofupper hate and South Africa at
the time.
And secondly, it was a caramelcolor.
It was a very much so color ofthe white coffee.
So nobody want to buy it.
Everybody wants to crystal blwhite specimen not to have
(05:49):
something which looks cock, youknow?
So that was, that was the, and Icame across the patients.
They were having a SANE implantsand they were lasting.
Instead of 5, 7, 10 years, thelast 20, 25, 30 years.
So that was beginning of mythesis and professor of the,
(06:10):
the, the PhD that I did.
But, um, and during the time ofmy, of my, um, fellowship.
I came across of situations whenI was facing the young people
and, and the only option was ahip replacement.
So I was, I, I was not happywith that and start looking
around, start reading little bitand find, you know, actually in
(06:35):
a, in a, some funny articles,newspapers, there's somebody is
doing a hip arthroscopy.
I didn't even know who that is.
I didn't even have a clue what'sgoing on.
I just needed some blo in, in,in UK is doing it.
Okay.
Spoke to some of the localcompanies, says, guys, can you
try to find out what's going on?
Gimme some idea.
(06:55):
And that was 1999.
And I start looking into thatand researching.
And um, that was a beginning of,of the preservation in, in, in,
in practice.
Not in practice, but in, in kindof a, in a cradle first, like in
the beginning.
What, what was what?
(07:17):
We didn't have equipment, wedidn't have anything, and that
company brought me a, someinstrumentation that I believed,
I can't say a hundred percent,that actually was a Dr.
Glicks original set that, thatsomething similar to it.
So my first operation wasbasically taking a piece of bone
out of the trauma into thejoint.
(07:39):
So that was the idea to lookinto the joint post-traumatic.
Was the, uh, and that probablytook about four hours, if I
remember correctly.
I dunno, I'm, maybe I'mexaggerating.
But the problem was that I hadideas, I had a written, written
kind of a guides how to do theprocedure and where to look at
(08:00):
it.
And then I, I'm, I'm, I cameacross, uh, Dr.
Bird's book.
Somebody brought me from, fromthe states, and that was
actually Revelation.
Then I learned how to kind of,that that is possible, that can
be done.
And that's how we start withthat.
(08:22):
And then the problem was thatwhen I finished my fellowship, I
was fired from university.
So I land up on a, on a, withouta job.
So I had to go to privatepractice and that's where my
mentor.
Dr.
Professor Weber, he took meunder the wing and I spent 10
years working with him andeverything.
What I know about the hips Ilearned from him besides
(08:44):
preservation.
But the point is that he was aJohn Charley's direct pupil, and
he was a big hip replacementsurgeon in the country, but he
was the one who actuallyencouraged me to do something
different and to go into thesomething.
Is not gonna be only the hipreplacement.
And he was a guy who supportedme from the beginning and
(09:06):
that's, that was amazing fromsomebody who is a arthroplasty
person to have that kind ofencouragement.
So that helped a lot and thatincludes anterior approach
because this is few years later,I was unhappy with the big cuts.
And that's how I start lookinginto the anterior approach, as
you know.
That was a time in the beginningof the 21st century when
(09:27):
everybody was calling, calling asmall incision, a minimal
invasive procedure or minimalinvasive surgery.
So we was making a small cut,but we were still doing the huge
damages.
So in my tour, going with thehip laproscopy, visiting Dr.
Tomberg, visiting Philip Oal wasstill working in a, in a
(09:49):
Pittsburgh, going to France andvisiting the, the, the anterior
approach guys.
Going to Belgium.
I went through all of thatprocess of learning and seen
learning, getting exposed ofdifferent approaches in
different, different way, how todo the procedures and it, it was
almost going parallel, the hiplaproscopy on one side and
(10:11):
anterior approach on anotherside.
So, so this is how I kind of tryto change the way of looking
into the hip, per se.
That is not only.
Open cut throw, you know,Damond, put something in it must
be must something more into it.
You know, it, it deservesbetter.
If any other joint in the body,we can look for this little
(10:33):
camera.
Why not hip?
You know?
And that's, that's, that's whatI believed in it and I kind of
saw doing it.
And that's it.
That's what, that was mybeginning.
Joseph M. Schwab (10:47):
let, let's focus a little bit on, on the
arthroscopy for just a moment,uh, because I, I'm under the
impression you're the first orone of the first surgeons to
bring hip arthroscopy to SouthAfrica.
Do I have that right?
Josip "Chuck" Cakic (11:03):
Officially, yes.
There was a couple of seniordoctors that were telling me
that they were doing somethinglike that in the, in the
eighties, but they wereunsuccessful to perform any
procedures.
They were trying to put thecamera into the joint as a kind
of experiment or whatever, butthey never managed to do any
actually procedures.
So, um, as, as a, as a, as aprocedure, successful procedure,
(11:26):
yes, I would say I was the firstone in the country.
Joseph M. Schwab (11:29):
So given that hip arthroscopy was, let's say,
virtually non-existent in SouthAfrica at the time, can you walk
us through what it's like to bethe first, uh, what does it take
to introduce a procedure andwhat, what sort of barriers,
either logistical or ortechnological do you run into in
(11:52):
a situation like that?
Josip "Chuck" Cakic (11:56):
So.
Um, number one, I, I, I wasn'tpart of university.
I was, I was, everything.
What I did in my academic, myresearch and everything, I did
everything through the privatepractice.
'cause I had to feed my family,the wife to kids.
You have to work.
So I work in private practiceand.
(12:18):
When I came across of hipLaproscopy, as I said, I asked
one of the local companies oragencies rather, and which
through the work, it's a littlebit different system that I
believe in the rest of theworld.
Because we don't have tenders,we can actually, as a private
doctors, in a private hospital,you can actually choose for each
operation, whatever company youwant.
(12:39):
other words, the hospital perse, can't limit you to be for
that year only for that.
Product, you can actually have avariety.
So there was, there was acompany that brought me the
first arthroscopy set, which Iused it on a cadavers and I
tried to figure it out whatthose notes are telling me.
So this was a beginning, andthen when I got across that
(13:02):
particular patient, the firstpatient I used it.
And it was successful.
I managed to find it.
I managed to make a biggeropening and then put the forceps
inside and to take, take theinstruments.
And this was a combination of,because at that stage in my
private practice, I was mainlydoing from the sports sides, I
was doing shoulders and knees.
So I wasn't, I was verycomfortable with, with 70 degree
(13:24):
lens, which I haven't been usingat that stage, but I was using,
was only 30, but I wascomfortable with arthroscopy as
a procedure.
So it was, that wasn't aproblem.
The problem was obstacles ofgetting into the joint.
So that was the beginning.
The biggest problem is that mostof the procedures in the
beginning, I didn't get paidbecause there were no codes.
(13:46):
There's nothing to be, how youcoded, how are you going to
motivate that to do medicalinsurances?
Joseph M. Schwab (13:52):
Mm-hmm.
Josip "Chuck" Cakic (13:53):
So, so the, that was a big problem.
I was coding the knees andshoulders, so combination of, of
knee, knee codes and theshoulder codes because labrum is
a labrum, a meniscus could belabrum and so and so forth.
You know, ACL could be somethingand osteotomy could be
something, but, and there is acode in South African book that
(14:14):
can be used as the, allow you touse these more similar coding to
what you're doing.
Joseph M. Schwab (14:20):
Mm-hmm.
Josip "Chuck" Cakic (14:21):
Something like that.
So, so I had support from thecompanies obviously because they
wanna sell and they sawsomething, but I didn't have a
support from the institution inbureaucracy.
So that was a problem for the,from gee whiz for a very long
time.
I mean, Dr.
Bird visited me while I had a,still basically was doing all of
(14:42):
that almost.
Philanthropically, like, likenot get paid and try to do
something for, for just becauseI believed in
Joseph M. Schwab (14:50):
Mm-hmm.
Josip "Chuck" Cakic (14:51):
And that was the reason why we started
actually a later on a SouthAfrican ros, uh, hip oscopy
society because in order to getin touch and in order to make,
um.
Communication with the medicalinsurance is if, if you're one
person is a one story.
But if you associateassociation, it's a different
(15:13):
story.
So between 2000, when I started99, 2000 when I started, by
2011, when Sasha was started asa as association, we had
literally nine doctor, eightdoctors that they started.
We're doing to the point, littlebit of arthroscopy.
(15:34):
So we sat together and that's,that's how Sasha started.
But I didn't invent anythingnew.
I actually copied Isha because Iwas introduced to Isha in 2008.
I was one of the first membersin Isha, and I met all of those
phenomenal guys in Paris wheneverything started.
(15:55):
And then in 2010.
Ricky Villa introduced me toboard.
He asked me to come onto theboard, and I became educational
secretary for Isha.
And based on what I was doing inthe sense of education and
organizing fellowships andeverything through Isha in a, in
a first year of my, myeducational board position, I
(16:18):
said, Hmm, let me do that forSouth Africa.
And that's how in 2011 westarted Sasha to have a
documentation to have.
Strength to have a position thatwe can go and negotiate with the
insurances and that we can makeit officially something that is
actually we to these days exist.
(16:38):
And obviously it's proven to beright, that we believe there's
something right.
But that was, those are the,those are the limitated
limitations and mainly, mainlyrelated to money.
That's where the limitationcomes into it.
Joseph M. Schwab (16:51):
When you talk about op opposition from
hospitals and from, uh, thebureaucracy, I think was the
phrase that you used, did yousee any resistance from the
medical community, at least atthe beginning?
And, and if so, what was yourstrategy for building, let's
say, trust and, and credibilitywith your, your fellow surgeons?
Josip "Chuck" Cakic (17:14):
Uh.
In 2004, I did my firstpresentation on the South
African Orthopedic Society Meet,were my results of the 51st
hippies.
And, um, by the time that I cameto the podium, I think there was
a three people left in the inaudience, if that gives you the
(17:37):
best answer.
Joseph M. Schwab (17:41):
What, what types of, were these all trauma
cases that you were presentingor were they, were these more
preservation cases by thispoint?
Josip "Chuck" Cakic (17:50):
There were of hip, oscopy presented all,
all, everything that I puttogether between 2000 and 2004,
I put it together in one paper.
It says, this is what I did,this's, how many cases I did.
So many converted into the hipreplacement.
So many are still happy.
That's what it was, was therewas no big academic science
behind it.
It's just something to intro to,to, to show to the people.
(18:14):
And I must say by that time,Smith, the nephew, which
obviously, uh, mark Philipponand Tom Bird did huge influence
in United States in, in thedevelopment of Laproscopy
Equipment and Oscopy as a name.
So that came through Smit andNephew, which does exist as
individual company in SouthAfrica, not as agency.
(18:35):
Obviously that message camethrough and me being there with,
with Tom Bird and Mark Philipponand being involved in that with
those people, they actually kindof said, Hmm, maybe we can, we
can do something with you.
So I hadn't.
Huge support from, from the,from them in South Africa.
We built digital theater.
(18:56):
They brought me actual hipinstrumentation, which hospital
bought it.
So we had the first unit inSouth Africa that there was a
capable of doing a hipmicroscopy.
And then they start actuallyorganizing the, uh, visitations
education, visit, visitationwith other doctors.
(19:16):
Were coming to my theater and wewill work together.
And in the same way, uh, I was,we were organizing together the
AVA workshops.
So this was a platform thatstarted with, that was basically
all based on communicationbetween the company and myself.
(19:38):
And that was all done through,uh, uh, through them.
Obviously with me being, being aconsultant.
Where the problem is to thisspace 25 years later is that is
no interest in, uh,universities, purely and utterly
that in South Africa there is,universities are so overwhelmed
(19:58):
with the trauma and with otherkind of pathologies that
actually arthroscopy per se.
That takes, as you know,significant time in theater.
It's not like quick knee scope.
It takes.
Si significant time.
It, there's, there's no actualinterest in it at this stage.
We're still trying, I'm stillteaching the guys reg
(20:22):
registrars, the juniorconsultants are coming, but
they're coming to my privatepractice.
So I'm associate with academicsand with the department in a way
that the senior registrars and aconsult is coming to me.
I'm not going to university.
That, and I have obviouslyfellows, so that that is the
(20:42):
arrangement that we have withac, with academics, with the
time the medical insurancesaccepted.
The fact that a oscopy cutsreality and obviously I'm not
strong enough in a way topresent papers and everything
else, is a one man with twohands and not having it.
(21:04):
Backup power, but it helpedknowing Tom Bird and Mark
Philippon and other guys, andRicky Villa and those guys who
actually, uh, published and wehad the documentation and we
could use that to argue and tobasically make back a deal.
So this was, this was, uh, very,very important.
And as you know, in a part ofthe time, that was the FAI was,
(21:27):
um, questioned the United Statesof America by the assurances.
I think that was somewherearound 2008, nine, somewhere in
that times.
Joseph M. Schwab (21:37):
Mm-hmm.
Josip "Chuck" Cakic (21:38):
And then we helped out because we had the
data that we could support it.
And that's what our, what is soimportant to have Isha or Sasha
or whatever you wanna call it,it's organization, a group.
Because you can collect all thedata together and you can
support.
And that's exactly what faria,what we did.
Joseph M. Schwab (21:56):
So these lessons that you learned, sort
of growing hip arthroscopy inSouth Africa, bringing on a new
procedure, um, seeking out maybestate-of-the-art or a new way of
doing something, What lessonsdid you learn from that, that
you began to apply once yourecognized anterior approach was
(22:17):
something that you wanted to?
Learn more about, or maybe also,you know, uh, grow as a practice
in South Africa.
Josip "Chuck" Cakic (22:31):
What I learned with the time, and I
think the best example is thestudy that I did around, on, on,
on the development on, on theDDH where I followed up 108.
Patients that had a hiplaproscopy and what's going on
with them on a later stage.
And 48% of them actually wereconverted to the hip replacement
(22:55):
in a period of five years.
it's maximum five years followup, but some of them were
converted, you know, in a periodof a year, and some of them
managed to survive two or threeyears.
So depends how you are lookinginto, what do you classify
success.
Two years, three years, fiveyears.
What is the success ofHepatectomy?
That's, that's questionable.
That's very individual that wecan put, define it ourselves,
(23:16):
but for the patient is veryindividual.
Um, the bottom line is thatpreservation, there is a limit
in the madness.
And it's the same is a limit inpreservation, but you can't
preserve everything.
So that's why I put being in mymind an aist and.
(23:36):
Wanted to preserve whatever Ican preserve.
It fit perfectly.
My supine position for hiplaproscopy and my supine
position for, uh, anteriorapproach.
So what I learned as a lesson isthat my conversion to the hip
replacement is much less than itwas 10 years ago because I'm not
(23:57):
as aggressive with the hippiesas I used to be.
And what I'm basing at all thatmy.
Maybe 15, 10, 10 years ago, myconsultation was half an hour to
45 minutes.
Now my consultation, firstconsultation is an hour.
I'm spending a much more timewith the patient.
I'm listening what they have tosay.
(24:17):
I'm listening to their symptoms,and I'm making a very careful
decision if I'm going to putthem into the dead basket or
their basket, and I have to havea very, very.
A clear picture what theirexpectations are, that person,
and they are some of them, andthey say, no, doc, I can't do
you because you're doing a scopeand I want you to put this stuff
into my hip and save my hip.
(24:39):
If you can save it, fine.
If you can't save it, we try it.
They are some people like that,but they are people who have
expectations that you cannotgive.
Joseph M. Schwab (24:50):
Yeah.
Josip "Chuck" Cakic (24:50):
And that's the lesson that I learned to
listen to the people and to tryto make at least.
Possible mistakes.
Back to the 5,000 years ago,Hippocrates says, do no harm.
Joseph M. Schwab (25:03):
So as you're learning anterior approach, tell
me a little bit about thatjourney you, you mentioned with
arthroscopy It, was.
Um, learning, uh, you know,through, uh, Tom Bird's book.
Tell me a little bit about howyou sought out your education
for anterior approach.
Josip "Chuck" Cakic (25:24):
It, that journey started almost the same
time as I did at my fellowshipwith NG approach because Prophet
Weiberg was, as I said, he was aCharley guy, and, uh, one of the
first, you know, first twomonths I have to do the charney
wiring, which I wouldn'trecommend to anybody anyway.
The whole process of chandleyis, um, is beautiful.
(25:46):
You, you can put a foot inside.
And it's a beautifulreconstructive procedure, but
it's not, in my mind, it's notfor primary.
So I was looking into how toavoid such a collateral damage,
rather you, and, and we startwith a, with a, with the whole
idea of, of making incisionsmaller and smaller.
And then I brought to ProfWebert Doors book about anterior
(26:08):
approach, which came outsomewhere around 2005.
We looked into that book and welooked into the thing says,
okay, let's try to makeincisions smaller.
Let's try to avoid thesedamages.
Eventually we managed to comedown to making a lateral
approach or, uh, variation oflateral approach through the 10
centimeter cut.
(26:29):
Obviously the depends on thepatient.
You can't do that on a, onelephant, but nevermind.
It was a very much so smaller.
But it, I wasn't happy with thatbecause I then, I started
reading, um, about.
Um, anterior approach as, asbeing anatomically anterior
approach.
So the first patient that Ivisit was in, in Belgium, late
(26:52):
Dr.
Devita, who, who was doing afigure of, of four, and he was,
uh, I believe one of the firstguys in in Belgium who did that.
And I looked at it and it wasfun.
But South Africans are bigpeople.
They are the then figure offour.
You need to have four assistantsto keep that leg in position.
(27:12):
You know, my opinion, it's my, alittle bit of humility, but the
point is that it wasn'tsomething that I was, I was
impressed with anatomy.
I was impressed with theprocedure, but it not
reproducible for me in myenvironment.
Then I went to Switzerland andspent time with Theus Michel,
who was doing his way of doingit.
(27:33):
Which was, uh, kind of, uh,upside down in my mind.
So I said, no, this is not forme.
Then I visit Dr.
Berger, who doing, who was doinga double incision procedure, and
I liked it.
I really liked it because for usin South Africa, trauma is, is,
(27:54):
is a bread and butter, and weknow how to put a femoral nail
down the shaft.
That procedure was based onthat.
Basically you were putting theprosthesis through the separate
incision as a femoral nail, andwe started zebra, we started, we
did, uh, so many cases, but thenwas stopped for whatever reason
globally that procedure wasstopped, but that was a very,
(28:16):
very good idea.
How would.
Go into in, in my practice.
Would that be so successful?
I don't know.
But my patients that I did fornow, thank God they're very good
and they are happy with it.
And then I end up doing it entryapproach French Way.
The company came to me and theyknew, I mean, people talk,
(28:38):
people gossip people, uh, speakaround, so they knew that I'm
experimenting with something.
So the company came, says, wemet somebody in France.
Would you like to go and see theentry approach through the.
This way.
Okay.
Never heard of it.
Let's go.
And that's it.
I married the procedure and I'mstill married.
(29:02):
That's it.
And I, and main reason for me isit's reproducible using a table.
I can put 140 kilo person, I canput a three meter person, I can
put a small little guy.
I did operation with a stump.
I did with amputation.
I did the different operationsand different people.
It's always the same.
(29:22):
And that's what makes, andobviously because hip microscopy
basically on the same table.
Joseph M. Schwab (29:28):
Mm-hmm.
Josip "Chuck" Cakic (29:29):
So I can do both procedures in a bo
identical way of draping,preparing.
Doing everything in the same wayin an at same position.
Joseph M. Schwab (29:40):
And so how did you get connected to the
European anterior hip meeting?
Was it through these connectionsin France or were there
additional connections that thatgot you involved in that
meeting?
Josip "Chuck" Cakic (29:52):
I met the mad guy in 2010 when Ricky Villa
approached me to become a partof Isha board.
The other person who wasapproached was Richard v uh,
Richard, uh, field.
So Richard Field and myself, weknow each other for, since
basically 2010 or nine.
And, um, we stayed very goodfriends, I mean colleagues and
(30:13):
everything else.
So he invited me to come to toLondon this year.
And that was it.
That was, I suppose, uh, also Ithink the Feder Lord had a
certain interest in it orinfluence into it because he
knew that I'm was doing it sincemy first.
My first, uh, uh, anteriorapproach was in December, 2006.
(30:34):
So somewhere there, yeah.
The first private one was inJanuary, 2007, but I did some of
them in a, in a, in a, uh, with,with somebody else and, and I
was visiting in 2006.
The France, actually the firstperson in South Africa who did
it was a few, few months beforeme, was a.
(30:54):
Doctor by name Ybe from CapeTown.
So two of us, we were goingtogether for, for the training
to Paris, and that's how westarted.
Joseph M. Schwab (31:04):
Tell me a little bit about the population
of surgeons in South Africadoing anterior approach.
Is there, is it still relativelysmall?
Is it a growing population?
Um, or has it, uh, you know, hasit blossomed?
Josip "Chuck" Cakic (31:18):
Uh, yeah, I wouldn't say that is blossomed.
Uh, I think it's, uh, uh, it'sa, it's, it's a, again, mea and
he's not represented into, orMEA is, I'm saying MEA is a name
for, for, in my mind that is a,an entry approach with the
table.
That's, that's what I'm talkingabout, is represented in South
(31:41):
Africa with agency, not with theregion company.
So that agency tried to followthe same rules and patterns of
education.
So it's a very strict, verySwiss, if you will.
So you cannot do it on your own.
You have to pass the certainrules.
You have to go and visit, youneed to go for the education,
then you need to do the cadaverworkshop.
(32:02):
Then you need to have a a, somany surgery done with a
consultant, and then you have todo so many surgery yourself.
With a consultant presence.
So it's, it's it's ongoingprocess.
And that in, in, in SouthAfrica, in private sector that
I'm talking about, becauseessentially we have two
universe, we have a privatesector that covers in a region,
(32:23):
about 15 million population outof the 60 with a medical issue,
private medical insurancecenter, and you have a
government system.
In a government system.
Anterior approach was not as.
Seen as as a, as a, as going,as, as, uh, fast as in a
(32:43):
private, but the junior, again,influence of the education,
influence of the meetings,influence of the journals
brought to the, to the, to thesurface that, well, we need to
learn that.
We need to know that that is,that is what is all about.
So yes, in South Africa, wepublished that paper last year.
(33:05):
In 2024, when we look into the,answering the questions of, from
South African Society, there isa, in a region about, uh, 36% of
population of, of South AfricanOrthopedic Society, they are
doing it or they're interestedto convert into the interior
approach.
Approach.
So it, it is, it is a, it is a,in significantly increased
(33:30):
interest in it.
I mean, since London I wasinvolved in, it was in June, so
in last two, three months,whatever, I was involved within
two cadaver workshops.
So altogether that was about 12surgeons.
They were interested in it andanother four surgeons were
coming through my theater forvisitation.
So it is, especially the juniorguys, they are, uh, very much
(33:54):
so.
In line with being educated inanterior approach, and I'm sure
if we repeat the same study inabout two to three years, we
gonna double those.
Joseph M. Schwab (34:05):
Yeah, and it, it sounds like those numbers
are, are very similar to what wesee in Australia, which is
around a third of surgeonseither doing or, or highly
interested in anterior approach.
Um, one of the things that Iget, uh, the benefit of, I guess
when I travel is I get to meet,um, young surgeons who, many of
(34:25):
whom listen to the podcast,which is great and are
interested in what moreexperienced surgeons like
yourself.
Um, have to say about, uh, youknow, advice, sort of life
advice.
And so, you know, you mentionedin your story having multiple
mentors that sounds like werevery influential in your career
(34:47):
and the choices that you made.
Um, for the young surgeons whoare listening and who are
interested in orthopedics, whatadvice would you give to them?
Josip "Chuck" Cakic (34:57):
If I can answer with something else, it's
that when I travel around, I tryto get into, visit somebody like
you in your home, in yourtheater, and I'm trying to learn
from you.
So the message is very, I mean,I, I met Joel Madam many years
ago on the meetings and thingslike that, but um, last time
(35:21):
when he was in South Africa, wespent more time together.
And I thought, you know, what?
If this guy after so many yearscan use a X-ray in theater, for
example, and I'm having a 3000operations and I'm not using it,
why should I not start using it?
Uh, the message is it's neverlate to learn, and it's never
(35:43):
late to change and to adapt andto get better.
So.
Wherever I go, I try to listen.
I try to learn.
I try to change.
I try to make it better.
So I think for the juniors,that's the best message.
Always.
Wherever you go, instead ofgoing twice to the, with the
guys in a pub for a beer, goonce and spend some time with
(36:06):
somebody in theater and try topick up the detail because we
all different and.
Long, long time ago, my proftold me while I was a student,
says, if you want to be good inmedicine, you need to know
English, German, and Italian.
There's a completely different,and Italian and French he met
(36:28):
says, this are completelydifferent cultures and everybody
thinks different, and you pickup the best out of the three and
you're going to put your ownsoup.
And that was the best messagethat I ever heard and to these
days.
I respect American Logic.
I respect English Logic, butthey so much into Italians.
(36:49):
There's so much in the Germans,there's so much in the French
and, and we all have to read,learn from each other, and we
all gonna get better.
Joseph M. Schwab (36:59):
Uh, well, I.
think that's a great message forour young learners, but it
raises a question.
So 3000 hips in you learn to usefluoroscopy.
Are, are there other technology?
Or, uh, innovations that you'relooking for on the horizon,
things that get you excited orthings that concern you.
Josip "Chuck" Cakic (37:21):
Both.
Um, I'm like, like anyorthopedic surgeon, I like toys.
So, so this is, this is, thisis, this is what, what the
companies knows and they'reselling us toys on daily basis,
you know, and even though it'sthe same thing, it's just new.
So we want it.
But the point of the matter isthat we need to be very
cautious.
Uh, uh, are we going to use acomputer, I mean computer, the
(37:45):
robotic surgery to replacesurgery?
That, that, that is somethingthat scares me because I, why do
I have a fellows?
Uh, because I wanna know who'sgonna operate on me.
It's as simple as that.
And, and I don't want DaVinci tooperate on me.
I want somebody else.
I want somebody who has a brainto hands and can make a
(38:06):
decision.
I'm, I'm probably rough, but thepoint of the matter is, is that
my problem is that what ifsomething technically happens
and you need to convert?
And as far as I know, theconversion from robotics into
the manual surgery is not sosimple.
Um, I'm at the moment, very muchso involved into, uh, into the
(38:27):
navigation related to the hiplaproscopy, because navigation
is a tool, is something that canhelp us on our, I mean, using a
map.
Using A GPS, especially if yourmap is in a hand to your
co-driver, which happened to beyour wife, and then you don't
know where you are.
(38:48):
But the point is that the pointis that there is a place for the
new things, but that doesn'tmean that our basic education
and basic training has to beginwith the new technology.
I think that new technology canbe adjuvant through the basic
training.
That is, that is what I, me, um,after so many years of
(39:13):
traditional and uh, um, kind ofexperience, I would, I want to
know if somebody using roboticpH enough, but can you do that
operation in the same mannerwithout the rock?
That's, that's my question.
Preparation of surgery, anythingaround the surgery, fine.
(39:34):
We can use any technology wewant, but when it comes to the
finesse of the hand and eye handcoordination, hmm, that's, I
would like to know that thatsurgeon knows how to switch the
autopilot and go land properly.
Joseph M. Schwab (39:50):
Do you have any final sort of inspiring
message for any of ourlisteners, especially the young
surgeons out there?
Josip "Chuck" Cakic (39:59):
Okay.
I wouldn't be where I am withoutmy family and my, my support.
Uh, that's the first thing.
Don't, don't ever forget who's,who is behind you and who
supports you.
That's, that's the first thingyou can go forward.
Medicine and being a surgeon isnot a job.
(40:20):
It is a life legacy.
That is your life.
That is a 24 settle, and yourpartner has to, I'm extremely
lucky that, that we live as ateam, so I don't have a problem
with that.
We had a crisis like everybodydoes, but that is the most
(40:42):
important.
In my opinion, most importantthing to try, when you go up and
you wanted to improve, you wantto go up the ladder, whatever,
you will never succeed it if youdon't have a support you.
That support gives you theenergy, that support gives you
everything that you can goforward.
And if you go forward, just tryto listen more than talk.
(41:05):
I never learned that, butanyway.
But it's so much to absorb andso much to take it, and, uh,
much less to criticize and muchless to say
Joseph M. Schwab (41:24):
I really wanna, uh, thank you Chuck, for
agreeing to appear and for beingour guest here on the AHF
podcast.
Josip "Chuck" Cakic (41:32):
My absolute pleasure.
Thank you again for having me.
It was absolute pleasure.
Enjoy.
Joseph M. Schwab (41:37):
Thank you for watching this episode of the AHF
podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content and great
conversations just like this.
Please also drop any topic ideasor feedback in the comments
(41:58):
below.
You can find the AHF podcast onApple Podcasts, Spotify, or in
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation.
All one word.
Episodes of the AHF Podcast comeout on Fridays.
(42:19):
I'm your host, Joe Schwab,asking you to keep those hips
happy, healthy, and humble.
Hello again and welcome to the AHF Podcast.
I'm your host, Joe Schwab.
My guest today is Josip Cakic.
He goes by Chuck, and he's atrue pioneer in the field of hip
surgery.
Born and raised in Croatia andpracticing in South Africa.
I first met Chuck at this year'sEuropean anterior hip meeting
(00:45):
where I learned not only alittle about his life's journey,
but about his passion for hipsurgery, his sense of humor, and
his gift for being an educator.
Chuck, welcome to the AHFPodcast.
Josip "Chuck" Cakic (01:00):
Hello everybody.
Thank you very much for havingme.
Joseph M. Schwab (01:04):
Chuck, it's a true honor to have you on the
show.
I, I know you have a reallyinteresting story and I would
love if you could start bysharing a little bit about your
story, a little bit about yourbackground being born and raised
in Croatia and eventually endingup in South Africa.
Tell us a little bit about that.
Josip "Chuck" Cakic (01:24):
Well, you know, the, the life is
unpredictable and I'm, I'm, I'ma leading example of that is I.
When I finished my medicalschool and I did start doing
internship in Zagreb, where I'mborn in Croatia, um, and I was
looking, I always wanted to beorthopedic surgeon.
My passion was always orthopedicsurgery, specifically sports
(01:46):
parts of it.
And it happened to be thatduring my medical school I.
Uh, got in touch with a, with aphenomenal person, professor
Kosky, who was, um, one of theVienna school guys, and he
introduced me to hip and intothe, that phenomenal joint that
I believe that is the center ofuniverse, by the way.
(02:08):
And I did some, my firstresearches in a, in a hip as a
student, and I always wanted tobe in a hip.
And I always had kind of ideaabout the hip from looking into
it from the sports side.
But the life is different.
So what happened is that Ifinished my internship and I
couldn't get the job.
They told me that I can get toorthopedic rotation in five to
(02:30):
seven years.
And I said, I'm not gonna be awaiter for so long.
I'm gonna go somewhere else.
And in meantime, that was a kindof a year that was already
starting having, uh, problems informer Yugoslavia and we didn't
know what's gonna happen.
So combination of the factorsbasically.
Was asking to look the otheroptions.
(02:51):
So I looked in Holland and uh,because as a student I was on
exchange in Holland, so I knewpeople in Holland.
But in meantime, my very goodfriend of mine, from my
generation, from my class, he'llend up in South Africa and he
found me and said, listen, youdon't have to know Dutch.
You can come to South Africa.
English is perfectly fine.
So in a period of literally 10days, I decided to go.
(03:16):
I got the visa, I got married,sold my car, bought a ticket,
and arrived to South Africa.
So that was basically allhappening in 10 days.
And, um, and the rest ishistory.
I came here, I looked for thejob, I got the job as soon as I
got the job in, in, in thehospital, uh.
(03:39):
As an intern, because I had torepeat my internship, I went to
orthopedics department and Ispoke to the prof who was a
prof, kin at the time, a guyfrom Munich, German, and he told
me, don't do any shortcuts.
Start from the beginning, becomea part of the team, and go
forward from day one onwards.
(04:01):
And that's what I did.
And I did my internship, I didmy senior house job.
I did necessary exams and Ibecame Registrating Orthopedics
in 1995 and finishedorthopedics.
So that was, that was my, thatwas my trip up become in 1999, I
(04:23):
became specialist.
And when, for the fellowship,through the fellowship, I
learned about more.
I did fellowship in the hiparthroplasty, and that's what.
Put me in touch with doing theresearch, put me in touch with
the cross-linking and with the,the whole idea of cross-linking.
(04:44):
'cause we didn't know what'sgoing on.
I mean, we're talking now 19 90,19 99 going to, in that period
of time.
And I did research even beforeand, and, and that's how I
landed up with the crosslinkingbecause I dunno if the people
now that.
The first crosslinking in theworld was starting in, in South
(05:05):
Africa in 1957 actually.
So, so, and it was published,uh, later on by Dr.
Alala in, uh, one of thebiomechanical researches and
congresses.
And the crosslinking was usedfor sterilization, not for
improving the quality ofpolyethylene,
Joseph M. Schwab (05:24):
Mm-hmm.
Josip "Chuck" Cakic (05:25):
but never actually got onto the worldwide
market for two reasons.
Number one.
A limit commercial limitation ofupper hate and South Africa at
the time.
And secondly, it was a caramelcolor.
It was a very much so color ofthe white coffee.
So nobody want to buy it.
Everybody wants to crystal blwhite specimen not to have
(05:49):
something which looks cock, youknow?
So that was, that was the, and Icame across the patients.
They were having a SANE implantsand they were lasting.
Instead of 5, 7, 10 years, thelast 20, 25, 30 years.
So that was beginning of mythesis and professor of the,
(06:10):
the, the PhD that I did.
But, um, and during the time ofmy, of my, um, fellowship.
I came across of situations whenI was facing the young people
and, and the only option was ahip replacement.
So I was, I, I was not happywith that and start looking
around, start reading little bitand find, you know, actually in
(06:35):
a, in a, some funny articles,newspapers, there's somebody is
doing a hip arthroscopy.
I didn't even know who that is.
I didn't even have a clue what'sgoing on.
I just needed some blo in, in,in UK is doing it.
Okay.
Spoke to some of the localcompanies, says, guys, can you
try to find out what's going on?
Gimme some idea.
(06:55):
And that was 1999.
And I start looking into thatand researching.
And um, that was a beginning of,of the preservation in, in, in,
in practice.
Not in practice, but in, in kindof a, in a cradle first, like in
the beginning.
What, what was what?
(07:17):
We didn't have equipment, wedidn't have anything, and that
company brought me a, someinstrumentation that I believed,
I can't say a hundred percent,that actually was a Dr.
Glicks original set that, thatsomething similar to it.
So my first operation wasbasically taking a piece of bone
out of the trauma into thejoint.
(07:39):
So that was the idea to lookinto the joint post-traumatic.
Was the, uh, and that probablytook about four hours, if I
remember correctly.
I dunno, I'm, maybe I'mexaggerating.
But the problem was that I hadideas, I had a written, written
kind of a guides how to do theprocedure and where to look at
(08:00):
it.
And then I, I'm, I'm, I cameacross, uh, Dr.
Bird's book.
Somebody brought me from, fromthe states, and that was
actually Revelation.
Then I learned how to kind of,that that is possible, that can
be done.
And that's how we start withthat.
(08:22):
And then the problem was thatwhen I finished my fellowship, I
was fired from university.
So I land up on a, on a, withouta job.
So I had to go to privatepractice and that's where my
mentor.
Dr.
Professor Weber, he took meunder the wing and I spent 10
years working with him andeverything.
What I know about the hips Ilearned from him besides
(08:44):
preservation.
But the point is that he was aJohn Charley's direct pupil, and
he was a big hip replacementsurgeon in the country, but he
was the one who actuallyencouraged me to do something
different and to go into thesomething.
Is not gonna be only the hipreplacement.
And he was a guy who supportedme from the beginning and
(09:06):
that's, that was amazing fromsomebody who is a arthroplasty
person to have that kind ofencouragement.
So that helped a lot and thatincludes anterior approach
because this is few years later,I was unhappy with the big cuts.
And that's how I start lookinginto the anterior approach, as
you know.
That was a time in the beginningof the 21st century when
(09:27):
everybody was calling, calling asmall incision, a minimal
invasive procedure or minimalinvasive surgery.
So we was making a small cut,but we were still doing the huge
damages.
So in my tour, going with thehip laproscopy, visiting Dr.
Tomberg, visiting Philip Oal wasstill working in a, in a
(09:49):
Pittsburgh, going to France andvisiting the, the, the anterior
approach guys.
Going to Belgium.
I went through all of thatprocess of learning and seen
learning, getting exposed ofdifferent approaches in
different, different way, how todo the procedures and it, it was
almost going parallel, the hiplaproscopy on one side and
(10:11):
anterior approach on anotherside.
So, so this is how I kind of tryto change the way of looking
into the hip, per se.
That is not only.
Open cut throw, you know,Damond, put something in it must
be must something more into it.
You know, it, it deservesbetter.
If any other joint in the body,we can look for this little
(10:33):
camera.
Why not hip?
You know?
And that's, that's, that's whatI believed in it and I kind of
saw doing it.
And that's it.
That's what, that was mybeginning.
Joseph M. Schwab (10:47):
let, let's focus a little bit on, on the
arthroscopy for just a moment,uh, because I, I'm under the
impression you're the first orone of the first surgeons to
bring hip arthroscopy to SouthAfrica.
Do I have that right?
Josip "Chuck" Cakic (11:03):
Officially, yes.
There was a couple of seniordoctors that were telling me
that they were doing somethinglike that in the, in the
eighties, but they wereunsuccessful to perform any
procedures.
They were trying to put thecamera into the joint as a kind
of experiment or whatever, butthey never managed to do any
actually procedures.
So, um, as, as a, as a, as aprocedure, successful procedure,
(11:26):
yes, I would say I was the firstone in the country.
Joseph M. Schwab (11:29):
So given that hip arthroscopy was, let's say,
virtually non-existent in SouthAfrica at the time, can you walk
us through what it's like to bethe first, uh, what does it take
to introduce a procedure andwhat, what sort of barriers,
either logistical or ortechnological do you run into in
(11:52):
a situation like that?
Josip "Chuck" Cakic (11:56):
So.
Um, number one, I, I, I wasn'tpart of university.
I was, I was, everything.
What I did in my academic, myresearch and everything, I did
everything through the privatepractice.
'cause I had to feed my family,the wife to kids.
You have to work.
So I work in private practiceand.
(12:18):
When I came across of hipLaproscopy, as I said, I asked
one of the local companies oragencies rather, and which
through the work, it's a littlebit different system that I
believe in the rest of theworld.
Because we don't have tenders,we can actually, as a private
doctors, in a private hospital,you can actually choose for each
operation, whatever company youwant.
(12:39):
other words, the hospital perse, can't limit you to be for
that year only for that.
Product, you can actually have avariety.
So there was, there was acompany that brought me the
first arthroscopy set, which Iused it on a cadavers and I
tried to figure it out whatthose notes are telling me.
So this was a beginning, andthen when I got across that
(13:02):
particular patient, the firstpatient I used it.
And it was successful.
I managed to find it.
I managed to make a biggeropening and then put the forceps
inside and to take, take theinstruments.
And this was a combination of,because at that stage in my
private practice, I was mainlydoing from the sports sides, I
was doing shoulders and knees.
So I wasn't, I was verycomfortable with, with 70 degree
(13:24):
lens, which I haven't been usingat that stage, but I was using,
was only 30, but I wascomfortable with arthroscopy as
a procedure.
So it was, that wasn't aproblem.
The problem was obstacles ofgetting into the joint.
So that was the beginning.
The biggest problem is that mostof the procedures in the
beginning, I didn't get paidbecause there were no codes.
(13:46):
There's nothing to be, how youcoded, how are you going to
motivate that to do medicalinsurances?
Joseph M. Schwab (13:52):
Mm-hmm.
Josip "Chuck" Cakic (13:53):
So, so the, that was a big problem.
I was coding the knees andshoulders, so combination of, of
knee, knee codes and theshoulder codes because labrum is
a labrum, a meniscus could belabrum and so and so forth.
You know, ACL could be somethingand osteotomy could be
something, but, and there is acode in South African book that
(14:14):
can be used as the, allow you touse these more similar coding to
what you're doing.
Joseph M. Schwab (14:20):
Mm-hmm.
Josip "Chuck" Cakic (14:21):
Something like that.
So, so I had support from thecompanies obviously because they
wanna sell and they sawsomething, but I didn't have a
support from the institution inbureaucracy.
So that was a problem for the,from gee whiz for a very long
time.
I mean, Dr.
Bird visited me while I had a,still basically was doing all of
(14:42):
that almost.
Philanthropically, like, likenot get paid and try to do
something for, for just becauseI believed in
Joseph M. Schwab (14:50):
Mm-hmm.
Josip "Chuck" Cakic (14:51):
And that was the reason why we started
actually a later on a SouthAfrican ros, uh, hip oscopy
society because in order to getin touch and in order to make,
um.
Communication with the medicalinsurance is if, if you're one
person is a one story.
But if you associateassociation, it's a different
(15:13):
story.
So between 2000, when I started99, 2000 when I started, by
2011, when Sasha was started asa as association, we had
literally nine doctor, eightdoctors that they started.
We're doing to the point, littlebit of arthroscopy.
(15:34):
So we sat together and that's,that's how Sasha started.
But I didn't invent anythingnew.
I actually copied Isha because Iwas introduced to Isha in 2008.
I was one of the first membersin Isha, and I met all of those
phenomenal guys in Paris wheneverything started.
(15:55):
And then in 2010.
Ricky Villa introduced me toboard.
He asked me to come onto theboard, and I became educational
secretary for Isha.
And based on what I was doing inthe sense of education and
organizing fellowships andeverything through Isha in a, in
a first year of my, myeducational board position, I
(16:18):
said, Hmm, let me do that forSouth Africa.
And that's how in 2011 westarted Sasha to have a
documentation to have.
Strength to have a position thatwe can go and negotiate with the
insurances and that we can makeit officially something that is
actually we to these days exist.
(16:38):
And obviously it's proven to beright, that we believe there's
something right.
But that was, those are the,those are the limitated
limitations and mainly, mainlyrelated to money.
That's where the limitationcomes into it.
Joseph M. Schwab (16:51):
When you talk about op opposition from
hospitals and from, uh, thebureaucracy, I think was the
phrase that you used, did yousee any resistance from the
medical community, at least atthe beginning?
And, and if so, what was yourstrategy for building, let's
say, trust and, and credibilitywith your, your fellow surgeons?
Josip "Chuck" Cakic (17:14):
Uh.
In 2004, I did my firstpresentation on the South
African Orthopedic Society Meet,were my results of the 51st
hippies.
And, um, by the time that I cameto the podium, I think there was
a three people left in the inaudience, if that gives you the
(17:37):
best answer.
Joseph M. Schwab (17:41):
What, what types of, were these all trauma
cases that you were presentingor were they, were these more
preservation cases by thispoint?
Josip "Chuck" Cakic (17:50):
There were of hip, oscopy presented all,
all, everything that I puttogether between 2000 and 2004,
I put it together in one paper.
It says, this is what I did,this's, how many cases I did.
So many converted into the hipreplacement.
So many are still happy.
That's what it was, was therewas no big academic science
behind it.
It's just something to intro to,to, to show to the people.
(18:14):
And I must say by that time,Smith, the nephew, which
obviously, uh, mark Philipponand Tom Bird did huge influence
in United States in, in thedevelopment of Laproscopy
Equipment and Oscopy as a name.
So that came through Smit andNephew, which does exist as
individual company in SouthAfrica, not as agency.
(18:35):
Obviously that message camethrough and me being there with,
with Tom Bird and Mark Philipponand being involved in that with
those people, they actually kindof said, Hmm, maybe we can, we
can do something with you.
So I hadn't.
Huge support from, from the,from them in South Africa.
We built digital theater.
(18:56):
They brought me actual hipinstrumentation, which hospital
bought it.
So we had the first unit inSouth Africa that there was a
capable of doing a hipmicroscopy.
And then they start actuallyorganizing the, uh, visitations
education, visit, visitationwith other doctors.
(19:16):
Were coming to my theater and wewill work together.
And in the same way, uh, I was,we were organizing together the
AVA workshops.
So this was a platform thatstarted with, that was basically
all based on communicationbetween the company and myself.
(19:38):
And that was all done through,uh, uh, through them.
Obviously with me being, being aconsultant.
Where the problem is to thisspace 25 years later is that is
no interest in, uh,universities, purely and utterly
that in South Africa there is,universities are so overwhelmed
(19:58):
with the trauma and with otherkind of pathologies that
actually arthroscopy per se.
That takes, as you know,significant time in theater.
It's not like quick knee scope.
It takes.
Si significant time.
It, there's, there's no actualinterest in it at this stage.
We're still trying, I'm stillteaching the guys reg
(20:22):
registrars, the juniorconsultants are coming, but
they're coming to my privatepractice.
So I'm associate with academicsand with the department in a way
that the senior registrars and aconsult is coming to me.
I'm not going to university.
That, and I have obviouslyfellows, so that that is the
(20:42):
arrangement that we have withac, with academics, with the
time the medical insurancesaccepted.
The fact that a oscopy cutsreality and obviously I'm not
strong enough in a way topresent papers and everything
else, is a one man with twohands and not having it.
(21:04):
Backup power, but it helpedknowing Tom Bird and Mark
Philippon and other guys, andRicky Villa and those guys who
actually, uh, published and wehad the documentation and we
could use that to argue and tobasically make back a deal.
So this was, this was, uh, very,very important.
And as you know, in a part ofthe time, that was the FAI was,
(21:27):
um, questioned the United Statesof America by the assurances.
I think that was somewherearound 2008, nine, somewhere in
that times.
Joseph M. Schwab (21:37):
Mm-hmm.
Josip "Chuck" Cakic (21:38):
And then we helped out because we had the
data that we could support it.
And that's what our, what is soimportant to have Isha or Sasha
or whatever you wanna call it,it's organization, a group.
Because you can collect all thedata together and you can
support.
And that's exactly what faria,what we did.
Joseph M. Schwab (21:56):
So these lessons that you learned, sort
of growing hip arthroscopy inSouth Africa, bringing on a new
procedure, um, seeking out maybestate-of-the-art or a new way of
doing something, What lessonsdid you learn from that, that
you began to apply once yourecognized anterior approach was
(22:17):
something that you wanted to?
Learn more about, or maybe also,you know, uh, grow as a practice
in South Africa.
Josip "Chuck" Cakic (22:31):
What I learned with the time, and I
think the best example is thestudy that I did around, on, on,
on the development on, on theDDH where I followed up 108.
Patients that had a hiplaproscopy and what's going on
with them on a later stage.
And 48% of them actually wereconverted to the hip replacement
(22:55):
in a period of five years.
it's maximum five years followup, but some of them were
converted, you know, in a periodof a year, and some of them
managed to survive two or threeyears.
So depends how you are lookinginto, what do you classify
success.
Two years, three years, fiveyears.
What is the success ofHepatectomy?
That's, that's questionable.
That's very individual that wecan put, define it ourselves,
(23:16):
but for the patient is veryindividual.
Um, the bottom line is thatpreservation, there is a limit
in the madness.
And it's the same is a limit inpreservation, but you can't
preserve everything.
So that's why I put being in mymind an aist and.
(23:36):
Wanted to preserve whatever Ican preserve.
It fit perfectly.
My supine position for hiplaproscopy and my supine
position for, uh, anteriorapproach.
So what I learned as a lesson isthat my conversion to the hip
replacement is much less than itwas 10 years ago because I'm not
(23:57):
as aggressive with the hippiesas I used to be.
And what I'm basing at all thatmy.
Maybe 15, 10, 10 years ago, myconsultation was half an hour to
45 minutes.
Now my consultation, firstconsultation is an hour.
I'm spending a much more timewith the patient.
I'm listening what they have tosay.
(24:17):
I'm listening to their symptoms,and I'm making a very careful
decision if I'm going to putthem into the dead basket or
their basket, and I have to havea very, very.
A clear picture what theirexpectations are, that person,
and they are some of them, andthey say, no, doc, I can't do
you because you're doing a scopeand I want you to put this stuff
into my hip and save my hip.
(24:39):
If you can save it, fine.
If you can't save it, we try it.
They are some people like that,but they are people who have
expectations that you cannotgive.
Joseph M. Schwab (24:50):
Yeah.
Josip "Chuck" Cakic (24:50):
And that's the lesson that I learned to
listen to the people and to tryto make at least.
Possible mistakes.
Back to the 5,000 years ago,Hippocrates says, do no harm.
Joseph M. Schwab (25:03):
So as you're learning anterior approach, tell
me a little bit about thatjourney you, you mentioned with
arthroscopy It, was.
Um, learning, uh, you know,through, uh, Tom Bird's book.
Tell me a little bit about howyou sought out your education
for anterior approach.
Josip "Chuck" Cakic (25:24):
It, that journey started almost the same
time as I did at my fellowshipwith NG approach because Prophet
Weiberg was, as I said, he was aCharley guy, and, uh, one of the
first, you know, first twomonths I have to do the charney
wiring, which I wouldn'trecommend to anybody anyway.
The whole process of chandleyis, um, is beautiful.
(25:46):
You, you can put a foot inside.
And it's a beautifulreconstructive procedure, but
it's not, in my mind, it's notfor primary.
So I was looking into how toavoid such a collateral damage,
rather you, and, and we startwith a, with a, with the whole
idea of, of making incisionsmaller and smaller.
And then I brought to ProfWebert Doors book about anterior
(26:08):
approach, which came outsomewhere around 2005.
We looked into that book and welooked into the thing says,
okay, let's try to makeincisions smaller.
Let's try to avoid thesedamages.
Eventually we managed to comedown to making a lateral
approach or, uh, variation oflateral approach through the 10
centimeter cut.
(26:29):
Obviously the depends on thepatient.
You can't do that on a, onelephant, but nevermind.
It was a very much so smaller.
But it, I wasn't happy with thatbecause I then, I started
reading, um, about.
Um, anterior approach as, asbeing anatomically anterior
approach.
So the first patient that Ivisit was in, in Belgium, late
(26:52):
Dr.
Devita, who, who was doing afigure of, of four, and he was,
uh, I believe one of the firstguys in in Belgium who did that.
And I looked at it and it wasfun.
But South Africans are bigpeople.
They are the then figure offour.
You need to have four assistantsto keep that leg in position.
(27:12):
You know, my opinion, it's my, alittle bit of humility, but the
point is that it wasn'tsomething that I was, I was
impressed with anatomy.
I was impressed with theprocedure, but it not
reproducible for me in myenvironment.
Then I went to Switzerland andspent time with Theus Michel,
who was doing his way of doingit.
(27:33):
Which was, uh, kind of, uh,upside down in my mind.
So I said, no, this is not forme.
Then I visit Dr.
Berger, who doing, who was doinga double incision procedure, and
I liked it.
I really liked it because for usin South Africa, trauma is, is,
(27:54):
is a bread and butter, and weknow how to put a femoral nail
down the shaft.
That procedure was based onthat.
Basically you were putting theprosthesis through the separate
incision as a femoral nail, andwe started zebra, we started, we
did, uh, so many cases, but thenwas stopped for whatever reason
globally that procedure wasstopped, but that was a very,
(28:16):
very good idea.
How would.
Go into in, in my practice.
Would that be so successful?
I don't know.
But my patients that I did fornow, thank God they're very good
and they are happy with it.
And then I end up doing it entryapproach French Way.
The company came to me and theyknew, I mean, people talk,
(28:38):
people gossip people, uh, speakaround, so they knew that I'm
experimenting with something.
So the company came, says, wemet somebody in France.
Would you like to go and see theentry approach through the.
This way.
Okay.
Never heard of it.
Let's go.
And that's it.
I married the procedure and I'mstill married.
(29:02):
That's it.
And I, and main reason for me isit's reproducible using a table.
I can put 140 kilo person, I canput a three meter person, I can
put a small little guy.
I did operation with a stump.
I did with amputation.
I did the different operationsand different people.
It's always the same.
(29:22):
And that's what makes, andobviously because hip microscopy
basically on the same table.
Joseph M. Schwab (29:28):
Mm-hmm.
Josip "Chuck" Cakic (29:29):
So I can do both procedures in a bo
identical way of draping,preparing.
Doing everything in the same wayin an at same position.
Joseph M. Schwab (29:40):
And so how did you get connected to the
European anterior hip meeting?
Was it through these connectionsin France or were there
additional connections that thatgot you involved in that
meeting?
Josip "Chuck" Cakic (29:52):
I met the mad guy in 2010 when Ricky Villa
approached me to become a partof Isha board.
The other person who wasapproached was Richard v uh,
Richard, uh, field.
So Richard Field and myself, weknow each other for, since
basically 2010 or nine.
And, um, we stayed very goodfriends, I mean colleagues and
(30:13):
everything else.
So he invited me to come to toLondon this year.
And that was it.
That was, I suppose, uh, also Ithink the Feder Lord had a
certain interest in it orinfluence into it because he
knew that I'm was doing it sincemy first.
My first, uh, uh, anteriorapproach was in December, 2006.
(30:34):
So somewhere there, yeah.
The first private one was inJanuary, 2007, but I did some of
them in a, in a, in a, uh, with,with somebody else and, and I
was visiting in 2006.
The France, actually the firstperson in South Africa who did
it was a few, few months beforeme, was a.
(30:54):
Doctor by name Ybe from CapeTown.
So two of us, we were goingtogether for, for the training
to Paris, and that's how westarted.
Joseph M. Schwab (31:04):
Tell me a little bit about the population
of surgeons in South Africadoing anterior approach.
Is there, is it still relativelysmall?
Is it a growing population?
Um, or has it, uh, you know, hasit blossomed?
Josip "Chuck" Cakic (31:18):
Uh, yeah, I wouldn't say that is blossomed.
Uh, I think it's, uh, uh, it'sa, it's, it's a, again, mea and
he's not represented into, orMEA is, I'm saying MEA is a name
for, for, in my mind that is a,an entry approach with the
table.
That's, that's what I'm talkingabout, is represented in South
(31:41):
Africa with agency, not with theregion company.
So that agency tried to followthe same rules and patterns of
education.
So it's a very strict, verySwiss, if you will.
So you cannot do it on your own.
You have to pass the certainrules.
You have to go and visit, youneed to go for the education,
then you need to do the cadaverworkshop.
(32:02):
Then you need to have a a, somany surgery done with a
consultant, and then you have todo so many surgery yourself.
With a consultant presence.
So it's, it's it's ongoingprocess.
And that in, in, in SouthAfrica, in private sector that
I'm talking about, becauseessentially we have two
universe, we have a privatesector that covers in a region,
(32:23):
about 15 million population outof the 60 with a medical issue,
private medical insurancecenter, and you have a
government system.
In a government system.
Anterior approach was not as.
Seen as as a, as a, as going,as, as, uh, fast as in a
(32:43):
private, but the junior, again,influence of the education,
influence of the meetings,influence of the journals
brought to the, to the, to thesurface that, well, we need to
learn that.
We need to know that that is,that is what is all about.
So yes, in South Africa, wepublished that paper last year.
(33:05):
In 2024, when we look into the,answering the questions of, from
South African Society, there isa, in a region about, uh, 36% of
population of, of South AfricanOrthopedic Society, they are
doing it or they're interestedto convert into the interior
approach.
Approach.
So it, it is, it is a, it is a,in significantly increased
(33:30):
interest in it.
I mean, since London I wasinvolved in, it was in June, so
in last two, three months,whatever, I was involved within
two cadaver workshops.
So altogether that was about 12surgeons.
They were interested in it andanother four surgeons were
coming through my theater forvisitation.
So it is, especially the juniorguys, they are, uh, very much
(33:54):
so.
In line with being educated inanterior approach, and I'm sure
if we repeat the same study inabout two to three years, we
gonna double those.
Joseph M. Schwab (34:05):
Yeah, and it, it sounds like those numbers
are, are very similar to what wesee in Australia, which is
around a third of surgeonseither doing or, or highly
interested in anterior approach.
Um, one of the things that Iget, uh, the benefit of, I guess
when I travel is I get to meet,um, young surgeons who, many of
(34:25):
whom listen to the podcast,which is great and are
interested in what moreexperienced surgeons like
yourself.
Um, have to say about, uh, youknow, advice, sort of life
advice.
And so, you know, you mentionedin your story having multiple
mentors that sounds like werevery influential in your career
(34:47):
and the choices that you made.
Um, for the young surgeons whoare listening and who are
interested in orthopedics, whatadvice would you give to them?
Josip "Chuck" Cakic (34:57):
If I can answer with something else, it's
that when I travel around, I tryto get into, visit somebody like
you in your home, in yourtheater, and I'm trying to learn
from you.
So the message is very, I mean,I, I met Joel Madam many years
ago on the meetings and thingslike that, but um, last time
(35:21):
when he was in South Africa, wespent more time together.
And I thought, you know, what?
If this guy after so many yearscan use a X-ray in theater, for
example, and I'm having a 3000operations and I'm not using it,
why should I not start using it?
Uh, the message is it's neverlate to learn, and it's never
(35:43):
late to change and to adapt andto get better.
So.
Wherever I go, I try to listen.
I try to learn.
I try to change.
I try to make it better.
So I think for the juniors,that's the best message.
Always.
Wherever you go, instead ofgoing twice to the, with the
guys in a pub for a beer, goonce and spend some time with
(36:06):
somebody in theater and try topick up the detail because we
all different and.
Long, long time ago, my proftold me while I was a student,
says, if you want to be good inmedicine, you need to know
English, German, and Italian.
There's a completely different,and Italian and French he met
(36:28):
says, this are completelydifferent cultures and everybody
thinks different, and you pickup the best out of the three and
you're going to put your ownsoup.
And that was the best messagethat I ever heard and to these
days.
I respect American Logic.
I respect English Logic, butthey so much into Italians.
(36:49):
There's so much in the Germans,there's so much in the French
and, and we all have to read,learn from each other, and we
all gonna get better.
Joseph M. Schwab (36:59):
Uh, well, I.
think that's a great message forour young learners, but it
raises a question.
So 3000 hips in you learn to usefluoroscopy.
Are, are there other technology?
Or, uh, innovations that you'relooking for on the horizon,
things that get you excited orthings that concern you.
Josip "Chuck" Cakic (37:21):
Both.
Um, I'm like, like anyorthopedic surgeon, I like toys.
So, so this is, this is, thisis, this is what, what the
companies knows and they'reselling us toys on daily basis,
you know, and even though it'sthe same thing, it's just new.
So we want it.
But the point of the matter isthat we need to be very
cautious.
Uh, uh, are we going to use acomputer, I mean computer, the
(37:45):
robotic surgery to replacesurgery?
That, that, that is somethingthat scares me because I, why do
I have a fellows?
Uh, because I wanna know who'sgonna operate on me.
It's as simple as that.
And, and I don't want DaVinci tooperate on me.
I want somebody else.
I want somebody who has a brainto hands and can make a
(38:06):
decision.
I'm, I'm probably rough, but thepoint of the matter is, is that
my problem is that what ifsomething technically happens
and you need to convert?
And as far as I know, theconversion from robotics into
the manual surgery is not sosimple.
Um, I'm at the moment, very muchso involved into, uh, into the
(38:27):
navigation related to the hiplaproscopy, because navigation
is a tool, is something that canhelp us on our, I mean, using a
map.
Using A GPS, especially if yourmap is in a hand to your
co-driver, which happened to beyour wife, and then you don't
know where you are.
(38:48):
But the point is that the pointis that there is a place for the
new things, but that doesn'tmean that our basic education
and basic training has to beginwith the new technology.
I think that new technology canbe adjuvant through the basic
training.
That is, that is what I, me, um,after so many years of
(39:13):
traditional and uh, um, kind ofexperience, I would, I want to
know if somebody using roboticpH enough, but can you do that
operation in the same mannerwithout the rock?
That's, that's my question.
Preparation of surgery, anythingaround the surgery, fine.
(39:34):
We can use any technology wewant, but when it comes to the
finesse of the hand and eye handcoordination, hmm, that's, I
would like to know that thatsurgeon knows how to switch the
autopilot and go land properly.
Joseph M. Schwab (39:50):
Do you have any final sort of inspiring
message for any of ourlisteners, especially the young
surgeons out there?
Josip "Chuck" Cakic (39:59):
Okay.
I wouldn't be where I am withoutmy family and my, my support.
Uh, that's the first thing.
Don't, don't ever forget who's,who is behind you and who
supports you.
That's, that's the first thingyou can go forward.
Medicine and being a surgeon isnot a job.
(40:20):
It is a life legacy.
That is your life.
That is a 24 settle, and yourpartner has to, I'm extremely
lucky that, that we live as ateam, so I don't have a problem
with that.
We had a crisis like everybodydoes, but that is the most
(40:42):
important.
In my opinion, most importantthing to try, when you go up and
you wanted to improve, you wantto go up the ladder, whatever,
you will never succeed it if youdon't have a support you.
That support gives you theenergy, that support gives you
everything that you can goforward.
And if you go forward, just tryto listen more than talk.
(41:05):
I never learned that, butanyway.
But it's so much to absorb andso much to take it, and, uh,
much less to criticize and muchless to say
Joseph M. Schwab (41:24):
I really wanna, uh, thank you Chuck, for
agreeing to appear and for beingour guest here on the AHF
podcast.
Josip "Chuck" Cakic (41:32):
My absolute pleasure.
Thank you again for having me.
It was absolute pleasure.
Enjoy.
Joseph M. Schwab (41:37):
Thank you for watching this episode of the AHF
podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content and great
conversations just like this.
Please also drop any topic ideasor feedback in the comments
(41:58):
below.
You can find the AHF podcast onApple Podcasts, Spotify, or in
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation.
All one word.
Episodes of the AHF Podcast comeout on Fridays.
(42:19):
I'm your host, Joe Schwab,asking you to keep those hips
happy, healthy, and humble.
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.
My Favorite Murder with Karen Kilgariff and Georgia Hardstark
My Favorite Murder is a true crime comedy podcast hosted by Karen Kilgariff and Georgia Hardstark. Each week, Karen and Georgia share compelling true crimes and hometown stories from friends and listeners. Since MFM launched in January of 2016, Karen and Georgia have shared their lifelong interest in true crime and have covered stories of infamous serial killers like the Night Stalker, mysterious cold cases, captivating cults, incredible survivor stories and important events from history like the Tulsa race massacre of 1921. My Favorite Murder is part of the Exactly Right podcast network that provides a platform for bold, creative voices to bring to life provocative, entertaining and relatable stories for audiences everywhere. The Exactly Right roster of podcasts covers a variety of topics including historic true crime, comedic interviews and news, science, pop culture and more. Podcasts on the network include Buried Bones with Kate Winkler Dawson and Paul Holes, That's Messed Up: An SVU Podcast, This Podcast Will Kill You, Bananas and more.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com