June 20, 2025 • 29 mins
In this episode of the AHF Podcast, host Joe Schwab continues his in-depth conversation with Professor Justin Cobb, focusing on the specifics of performing hip resurfacing with the H1 ceramic on ceramic implant through an anterior approach. Professor Cobb provides a detailed walkthrough of the setup, techniques, and tools required for the procedure, highlighting the importance of complete capsulotomy and the differences from standard hip replacement surgeries. He also shares his insights on femoral head measurements, the role of fluoroscopy, and advice for dealing with challenging cases. Tune in to learn the nuances of hip resurfacing from a leading expert in the field.
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Episode Transcript
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Joseph M. Schwab (00:24):
Hello everyone and welcome to the AHF podcast.
I'm your host, Joe Schwab.
This week we have part two ofour conversation with Professor
Justin Cobb on hip resurfacing.
We focus our conversation moreon specifically how he performs
hip resurfacing with the H1ceramic on ceramic implant
(00:47):
through an anterior approach.
Let's rejoin the conversation.
I wanna switch gears a littlebit and talk a little bit more
about the practicality of doingone of these hip resurfacings
specifically from an anteriorapproach.
Um, because, you know, as aconcept, we talked about this a
little bit.
(01:08):
Uh, some people find thatanterior approach, uh, is, uh,
maybe more difficult for doing aresurfacing, I think for various
reasons.
Um, but the first question Ihave for you is, can you walk me
through a little bit of theusual equipment that you use,
uh, for one of these anteriorapproach hippers surfacings,
things like table fluoroscopy,any special devices, and
(01:32):
especially anything that mightdiffer from a setup of a
standard anterior total hipreplacement.
Justin Cobb (01:39):
So for a, um, an ordinary person, nothing
different at all from a standardanterior tunnel lip.
I mean, the wonderful thing thatjob matter, I mean, I, I, I
definitely, as I said at thebeginning, I don't feel I've
invented anything here.
There are giants before me inJoel.
Obviously a huge, huge figure.
And in Europe there are several,obviously, huge figures who've,
(02:01):
who've done anterior total hip.
And Indeed and Paul Budha wouldactually call out, um, in the,
in that, um, and in Europe, um,Heinz Barer was doing anterior
resurfacings in the seventies.
Um, so it's not as if there'sanything new there.
All the only, the onlydifference, the only difference
is the amount of capsularrelease.
(02:22):
And if you watch, uh, Fred Loaddoing a, uh, anterior total hip,
um, the capsule is briefly insize in a tiny way, because he's
an amazingly conservativesurgeon, we have to do a
complete release of the capsule.
And the, the big differencebetween resurging replacement is
(02:42):
we're trying to keep the femoralhead and neck alive.
And the reason that I, the, oneof, one of the reasons I think
the anterior approach isattractive is that if we, we do
an ellipsoid.
Capsulotomy.
So we take the capsule offsuperiorly and laterally right
round to the mid coronal planebefore dislocation.
(03:02):
We'll obviously take the wholeof the pubal femoral off
medially.
And then having dislocated, wethen do the posterior
capsulotomy, well away from thefemur joining up, cutting across
the whole of the she femoralligament.
And if you just, you, this is anintracapsular, um, procedure
(03:23):
once you've dislocated, butwe've completely released the
capsule, then the femur femoralhead goes approximately
laterally.
Um, and it, it's honestly notdifficult.
So, so the release, it's just acomplete capsulotomy.
And of course that's not as goodas an incomplete capsulotomy,
but I don't think you can do aresurfacing from the anterior
(03:46):
approach without a completecapsulotomy.
And so we just not, we do that.
Joseph M. Schwab (03:51):
But you have an anterior based capsulectomy
first and then an inside out.
No capsulectomy not You saidnothing.
You, the ellipsoid is not acapsulectomy.
It was,
Justin Cobb (04:02):
No, no.
We go the, the, just to describein words and, and we'll put some
pictures to it.
The anterior radial along thelines, right?
Just beside IOC Capis.
Joseph M. Schwab (04:15):
Yeah.
Justin Cobb (04:15):
I tried to leave cap, iron cap towers on the
capsule there.
We don't, we don't disturb that.
Just right from, from the, thelabrum at the top right down to
the instructionary line.
And then at the top of that, wego round beneath the indirect
head of rectus, right round tothe Midal plane.
And in fact, and then actuallywith a pair of scissors, um,
(04:40):
push and take out the lateralbit of the iseo femoral ligament
from the front there.
And, um, um.
A fellow gild in Atlantadescribes that very nicely.
And Ben do, I think lots ofpeople do.
Everyone, everyone has to dothat.
Um, George Gild in Atlanta, um,describes that nicely.
And then, then you take thewhole of the pub femoral
(05:02):
ligament off right down to thelesser trant.
Joseph M. Schwab (05:06):
Okay.
Justin Cobb (05:07):
And then, then having taken that all off, you
put a lever over the TAL, whichgives you access to the sort of
inferior head and neck junction.
And quite often there's a sortof frenulum of capsule of so
onto the femoral head and neckjunction there, which you take
off.
And having released all of thatwith Ilio Captima, you can then
(05:29):
put a sharp home and your sharplever onto the pubis and lift
up.
And you have a lovely view rightfrom the, uh, super end of the
TAL.
Right round the front of thecaps, right around the front of
the rim and do your rim surgerynow, because forever after, it's
gonna be harder than now.
(05:50):
So we do the rim surgery beforedislocating then.
Um, and, and so do all youranterior, um, head preparation
at that stage.
And then if, if it's a slimwoman, you don't need a table.
Um, we just, if a labor, if aligamentum is intact, either a
(06:11):
ligamentum cutter or just acurved, um, Bovie just to
release the, um, um, uh, andthen the hip, there's no force
involved.
It's a very, you don't have touse force to dislocate the hip.
Joseph M. Schwab (06:25):
Yeah.
And, and you can see that, sobasically at this point, with
the acetabulum exposed, the wayyou described, or with the, with
the joint exposed, the way youdescribed, you can quite easily
see that notch that you're so,you know, careful to
Justin Cobb (06:41):
So in a, in a bloke,
Joseph M. Schwab (06:43):
Yeah,
Justin Cobb (06:43):
in a big bloke, it doesn't matter.
They've got masses of bone.
You can bury a socket in a bigman, it just doesn't matter.
In a slim, in a sorry widthperson in a woman, um, they
haven't got a huge acid pelvicbone there.
And that, that, um, uh, notch,uh, ile pubic recess there
(07:07):
really makes sense when you,when you put the trial
prosthesis against it.
Joseph M. Schwab (07:12):
And
Justin Cobb (07:12):
Um.
Joseph M. Schwab (07:15):
so.
you're, you, you do your rimsurgery, you, you clean your rim
at this point, and then you movetowards the femur before you do
true acetabular
Justin Cobb (07:24):
then so, so, no.
Um, I think it is.
Uh, so what, um, Derek, with,with the approach, what he said
was, do your acetabular surgeryfirst because you ought be as
conservative as you can be.
And so you don't wanna takemasses of pelvis away.
(07:45):
Um, you measure the, the, thehead neck junction with tongs
before you dislocate to confirmwhat sort of size you're in.
Then I personally think you thengo and do your acetabular
surgery, put in your socket,bearing in mind what you know,
you've gotta achieve your head,and then do the head surgery.
(08:07):
If you are very concerned, youcan do the head first.
Um, and.
I, I think for, for, uh, you canchoose, I think there's some
indication of doing one first.
Some for the other first, as Ithink it's true with total hip
arthroplasty actually is somepeople want to know their
version on their femoral stembefore they put their socket in.
(08:28):
I've heard that that proposed.
Joseph M. Schwab (08:31):
Um, so the, um, you know, the size of the
prosthesis you're gonna beputting in as soon as you do
that, the head, neck junctionmeasurement before you've done
any dislocation.
Yeah,
Justin Cobb (08:45):
I mean, from the x-ray, um, what, you know, have
you got a cam, IE somebody witha fat neck and almost a
cylindrical neck?
Um, or have they, are they aaplastic here with a slender
femoral neck and the, the, theslender neck, you've got three
or four choices of femoral headthat will all fit there.
(09:07):
With a guy with a, um, short,very fat neck, you have got very
limited choice.
That's a very narrow fairway.
You really can't, becauseparticularly when the head is,
um, inferior and posterior,that's, that's the really
demanding hip.
And there you haven't got muchchoice.
But actually they are prettymuch all, um, men who've
(09:32):
distorted their femoral head bya lot of exercise in their
teens.
So they've got, they've got alot of pelvic bone, so you can.
You can upsize.
So we, in the planning, wereally pay greater deal
attention there.
But unless you're doing ct, youknow, your 2D plan, it's always
plus or minus the size.
So you have to valid, you haveto measure with the tongs, you
(09:56):
know, what is the size I'm gonnago for here?
Which is really, really what isthe size of the head, neck
junction?
What is the, um, that's whatyou're really measuring there.
Joseph M. Schwab (10:05):
Yeah.
And the, if, if you are, maybe,if your measurement is slightly
in between sizes, how do youdeal with that?
Justin Cobb (10:14):
Well, that's where I think it's, it's worth, um,
that's where you go toacetabulum first.
So you then say, is the, so somepeople occasionally see someone
whose femoral head has reallyground out the acetabulum and
they have quite a big mismatchwith a big socket.
And there it's quite, you know,that's, that, that's the most
difficult thing for a servicing,honestly, because.
(10:36):
You can't really up, you know,you've got a limited
relationship there.
We haven't yet had a problem,but I can, I theoretically that
could be a problem.
Joseph M. Schwab (10:46):
The, because the cups and the head sizes are
matched, right?
Justin Cobb (10:49):
that's right, that's right.
And truly I have, um, from theold days, the old hip
resurfacings had two thicknessesof aceta for every femoral head
because in the very old days,the, it wasn't, um, every two
millimeters, it was every fourmillimeters of femoral head.
So the first, I think from 2000till 2004 or five, it went 46,
(11:15):
50, 54.
Um,
Joseph M. Schwab (11:18):
Wow.
Justin Cobb (11:19):
So that's why there were two thicknesses of VAs
tablum, because that was a bigjump in feral head size.
Joseph M. Schwab (11:24):
Yeah.
Justin Cobb (11:25):
Um, but it, but I haven't used a thick acetabulum.
I, I don't think, I can't thinkof any one for decades, so, so.
You measure the feral head size,go to the ace tabular, and then
choose, are you gonna go to thebigger or smaller?
Joseph M. Schwab (11:42):
sure.
And is trialing part of theprocedure?
Do you do trialing at all foreither the femoral or acetabular
side or, okay.
I.
Justin Cobb (11:49):
Um, both.
Um, on the, on the ace tabularside, it's really about getting
the, um, orientation of the, asof the acetabular component,
right.
Which is important in women, inmen, it really isn't very
important.
They've got masses of bones, itdoesn't matter so much, but in
anyone who's got a bit ofdysplasia, you really want to
get that rotation.
Absolutely right.
(12:10):
Um, on the, on the acetabularside, and are, we've gone over
to reusable instruments, so youhave to know, because you don't
really have control over youranymore, you have to know that
your trial has got a pre fit.
Um, and so the trial is, is apre fit for orientation.
(12:31):
In three ways.
So abduction version androtation of the acetabular
component.
And in fact, once you've setthat on your impactor, then we
don't change that rotation forthe the acetabular component.
We then, and I'll give you alittle video clip showing that,
um, just showing how that works.
Joseph M. Schwab (12:51):
Um, and, and so, um, do you use fluoroscopy
during the procedure as well?
Do you use any imaging
Justin Cobb (12:57):
I do, I don't actually, I do it before
closing.
Um, I don't do it before that,but I mean, just I, um.
It is really interesting.
I'm, I'm, I'm sure you know,there's the, the surgeon who's
doing planned surgery where youare, if you've got a CT based
(13:18):
plan, you feel that's the truth.
I'm achieving my plan.
If you've got, if you've got a2D plan, you know it's a guide,
but in the end, you've gottamake the decision because those
x-rays aren't as accurate as youthought they were.
So you really are making yourmind up about size, but the
angles are pretty much true fromyour, on the acetabulum, but on
(13:39):
the femur, of course, not somuch.
I, I think if you are, if youare used to, and I know there's
a whole group of people who havethe Fluor on the whole time.
Um, I, I, I don't, I think it'san interesting way of doing it,
but it's slightly different fromlooking and feeling, and I'm,
I'm still, I suppose I don'tlike doing more than a couple of
(14:04):
flashes of radiation.
I don't like wearing lead, so wetend to just do a flash at the
end to make sure nothing'smoved.
Um, um, and obviously withcementless, acetabular
components, things can move andso that's why we do it after.
Really, that's risk time for me,I would say.
Joseph M. Schwab (14:24):
that's, that's what you're checking for.
But there would be nothing toprohibit you from doing it
during the procedure if youneeded to
Justin Cobb (14:29):
No,
Joseph M. Schwab (14:30):
uh, for position uhhuh.
Okay.
That's just a level of comfort.
Justin Cobb (14:34):
And that's right.
It's interesting, isn't it?
Joseph M. Schwab (14:36):
yeah.
Do you find, um, so first ofall, do you have, um, a backup
total hip set when you're doingthis?
Or do you, do you ever find thatyou have to bail to a total hip
for one reason or another?
Or has that not been an issue?
Justin Cobb (14:50):
I, I can't remember the last time that happened.
I mean, we have total upsets,um, in the background, but we
don't say is one sterile?
Um, because seems like thatwould be a very unusual day at
the office.
That'd be very unusual.
I mean, you know, this, we'redoing this operation on someone
who's got a healthy femoral headand neck and the instruments.
(15:13):
Um, and again, I'll, um, theywe're very excited about our,
I'll put, I'll send you a coupleof video clips of, of the
femoral neck guide.
Um, the, the huge differencebetween resurfacing surgery and
tu hip arthroplasty is that it'sguidewire based.
And if your guidewire's wrong,you can't correct it like a DHS
(15:36):
If the, if the guidewire's inthe wrong place, you can't
correct it.
And if you think, oh, I'll justcorrect it with the next
instrument, then things go badlyis you just have to change your
mindset and accept all of yourtime is spent making sure that
the position and orientation ofyour guidewire is right and the,
the, the stylists and the jigsreally help that.
(15:57):
So it's easy to know.
Be fine.
And, and you just check, check,check.
There are three checks on thefemoral side, um, before you
start machining bone
Joseph M. Schwab (16:10):
For, for the position of the Guidewire to
make sure it's
Justin Cobb (16:13):
position, position, orientation.
Joseph M. Schwab (16:16):
Okay.
Um, and the, uh, any other, soyou mentioned the, the device
that's used to, to, uh, youknow, position the guidewire for
the femur.
Any other special devices thatare, that you use or that are
needed are, again, are you doingthis on a standard table, on an
orthopedic table?
What,
Justin Cobb (16:34):
So, so I've done both.
Um, and in fact, um, in acouple, in six weeks time, when
you come over, we're gonnapresent a little bit of data on,
on table and no table.
Um, I think in, in, um, women,you just don't need a table if,
but if you're used to it, it is,it's just as easy in a big man.
I think a table is a really bighelp because it, um.
(16:57):
Obviously you don't, unlessyou're using, um, Fred's w
computer guided table with theirnumbers, you don't know the
forces.
You are, you know, thatfinishing the external rotation
on the boot, um, you don't knowthe forces.
You have a good idea, but it's,it's, it's unmeasured.
But in a big muscly man, um, thetable makes it much easier.
(17:22):
And,
Joseph M. Schwab (17:22):
Okay.
Justin Cobb (17:23):
and right now, I'll say for any woman, I would
absolutely say, uh, anteriorapproach is less trauma than a
posterior approach.
But for huge blokes and, and ofcourse the female pelvis, the,
the, the hip is at the front ofthe pelvis, whereas in men, it's
really in the middle.
And for those guys with hugethighs, it's literally in the
(17:47):
middle.
And there's no benefit ofanterior or posterior for those
people.
Really, there isn't.
Um, and for those guys, eitherway, you need big levers.
Because you are in the middle ofa big person.
Um, that, and that we all know,I mean, anyone who does
resurfacing knows that hugeathletes are, are, you know,
(18:07):
they're pretty challenging.
Joseph M. Schwab (18:09):
And that, so how many, uh, um, assistants are
you using, uh, during your case?
How many people would be, wouldyou need to have scrubbed in
apart from yourself?
Justin Cobb (18:18):
Um, I definitely have one person scrubs in either
a gas store or a gule, dependingon, um, how many I, you smile at
that there, you, you need, youneed some something or someone
on the other side of the tableas well.
Um, I think, I think just, um,uh, Chris Corins beautiful bits
(18:41):
of string, they're not quiteenough for, for that.
I mean, Paul Bulley has, has,um, a different device, but you
need some something.
The far side of the table justfor the feal head prep really.
Joseph M. Schwab (18:55):
Yeah.
And when you're, uh, when you'reevaluating the position of your
components, for instance, itseems like there's, um, maybe
naturally is, uh, perhaps theright word, perhaps not
naturally less concern about,um, what their length and offset
is because of the relativelysmall amount of bone you're
(19:16):
taking away.
Is that the philosophy?
Justin Cobb (19:18):
So the length is a really big deal in, in men
because men with cams haveusually worn their hip out by
having a great time and they'vegot really hard bone.
And so if you are not, and whenyou are resurfacing a cam on the
femoral side, you are taking therugby ball and putting a
(19:39):
football on the end of thefemur, um, and lengthen by three
or four millimeters on a.
Joseph M. Schwab (19:48):
Yeah.
Justin Cobb (19:50):
Ream acetabulum out superiorly.
You can distalize the acetabulumtoo.
So, so it is possible tolengthen someone by five or six
millimeters by mistake,lengthen.
And so you have to pay attentionin those cams.
Um, but the offset and theoffsets, the thing that I think
(20:11):
the total people really justdon't agree with because they
spend a lot of time getting theoffset exactly right.
But we frequently reduce theoffset by a centimeter
frequently, uh, or even 12 or 30millimeters because you are
wanting to put, you are doingtop of neck based surgery,
you're putting the femoral headback on the top of the neck and
(20:32):
that rugby ball shaped femoralhead has got a whole lot of bone
beneath the compressive rabbe.
That's very osteoporotic.
You don't wanna resurface that.
So you are, you are reallylateralizing the femoral head.
Putting it, getting a loadthrough the compressive
directly, again, frequentlychanging the offset very
substantially.
(20:53):
And, and suddenly Andy Murray,there are lots of, you know,
alpha level athletes who've hadvery substantial offset
reduction and are none the worstfor it.
So the rules seem to be quitedifferent for resurfacing
replacement in that respect,
Joseph M. Schwab (21:09):
So you re um, offset is not something you, it
sounds like you worry about toomuch, but with
Justin Cobb (21:15):
horizontal.
Joseph M. Schwab (21:16):
Yeah.
Um, as far as length, how do youevaluate for, uh, leg length
during the procedure if you're,if you're waiting and doing
fluoroscopy at the end, is thatwhen you find out or do you do
checks during
Justin Cobb (21:29):
So, um, if I'm doing, if I'm doing male table
based resurfacing, then.
Um, I, I don't pay very much.
I mean, because we planned whatwe're doing and your measure,
your, your napkin ring, which,which is your top head cut,
(21:50):
which of course isn't, it'sgiving you half offset and half
leg lengths.
But in a cam you, it's mainlymedial.
There's often very little or nobone.
You're taking away laterallywith that, um, napkin ring.
You get a, you know, with thatwhat you're doing on the femoral
side and uh, on the acetabularside, you are getting your
(22:12):
acetabulum in at the right depthor orientation.
We are not spending any timeworrying about changing the leg
length very much at all.
Really
Joseph M. Schwab (22:18):
Okay.
Okay.
So really not too many checksfor that, it sounds like.
Interesting.
Um, and do you do, do you everdo any leg length films
afterwards?
If somebody, what?
What would be a typicalcomplaint that you might see for
somebody who has a leg lengthissue?
Or is it just not common
Justin Cobb (22:33):
Well, you can see it on the plane X-ray.
I mean, if, if, if you've doneit, you don't need a leg film to
tell you that, um, you betterstart apologizing.
Um,
Joseph M. Schwab (22:43):
So humility.
That's the approach.
Justin Cobb (22:46):
yeah, well, surgery keeps you humble, Jerry.
You know, it keeps you pretty.
Joseph M. Schwab (22:49):
this is true.
This is true.
Um, so I, I appreciate youwalking me through some of these
questions.
Uh, one, one additional questionfrom a surgical standpoint, if
you were to need to doadditional release, um, to
mobilize the femur, you feellike you've done your full cap.
Uh, you, you've done yourcapsulotomy the way you
(23:10):
described, uh, where normallyyou would expect to have a
mobile femur, you've doublechecked to make sure that that
capsulotomy is as complete as itis normally, but you're just not
getting that mobility and it'sobstructing your view of the
acetabulum say, or your abilityto put the head somewhere safe.
Yeah.
What do you do?
Justin Cobb (23:27):
so Gregor, first of all, in that stiff, short
necked, um, man who's a realheadache, whatever, I would
definitely take out, take downthe top 15 or even 20
millimeters of TFL off the bone,um, and would definitely repair
it afterwards, but I wouldstraightaway do that.
Joseph M. Schwab (23:49):
Okay.
Justin Cobb (23:49):
Um, not, not even think about not doing it in such
a person because that lets theTFL sit down.
So you, you see well beyond theMidal plane before you dislocate
and that, so, and you've made anice, you can push a big swab
down into that.
Um, freeing the, uh, DT eye offthe lateral capsule, making sure
(24:13):
that's all, all free there insuch a person.
And then, and I've definitelyhad this experience and it's
because there's still fibers ofthe issue of femoral ligament
you haven't released, or it'sthe pube femoral you haven't
released.
Um, and you know, when you'vecompletely released the pube
femoral ligament because there'sroom for your fingers there,
(24:37):
there's no tension thereanymore.
So if that is released, it'salmost certainly you haven't
fully released the she offemoral ligament.
Um, because the muscles aren'tthe problem, it's the capsule.
Um, I think that's a, I'd bereally interested to hear what,
um, um, so Paul has donethousands of anterior hip sings.
(25:01):
I'd be, I'd be interested toknow what he says about that.
My experience, which is hundredsor thousands, is that, um, it's
about the capsule.
Whichever approach you use forresurfacing, it's about the
capsule.
Joseph M. Schwab (25:14):
Yeah.
Justin Cobb (25:14):
Um, because that's the uncompliant thing.
The muscles are just so muchmore compliant
Joseph M. Schwab (25:19):
Yeah.
Justin Cobb (25:20):
and we don't, we don't, the T ffl releases the
only muscle release if you do,if you, if you have to.
Joseph M. Schwab (25:25):
Do you release that soft tissue or do you take
a sliver of bone with it?
How do you do your TFL release?
Justin Cobb (25:30):
I just, I just do, so I mean the very top, front
edge of TFL is quite tendernessand if you just take it off
sharply there you have a nicebit of tenderness material to
sew straight back on.
So I haven't taken a piece ofbone off myself.
Um, um, but I think there arelots of ways of doing that.
Joseph M. Schwab (25:52):
Yeah.
So, um, uh, obviously you'relooking forward to the H1 being
released to a broader audienceof surgeons, which is, uh, uh,
it sounds like a lot of years ofdevelopment have gone into that
and a lot of experience.
Um, what do you think is nextfor it?
I mean, is this gonna solve hipresurfacing or do we have more
(26:14):
problems yet to yet to
Justin Cobb (26:16):
I.
think I.
I, I, obviously it's not theonly, um, new resurfacing device
out on the blocks.
There's the resurface, which isalready inducing in Australia,
and the poly motion.
So these are three novelresurfacing without the bronze
of metal and metal.
The problem is not the devices,
Joseph M. Schwab (26:36):
Yeah.
Justin Cobb (26:37):
it's, it's a surgeon.
And, um, getting people's skillsup is, is so we are, I'm
literally spending the wholetime right now trying to get the
technique, the steps ascrystallized as possible.
And it feels like, um, right nowthe steps are the steps.
(27:01):
And if you, if you do completeeach step, and of course you
think you, you may not havecompleted, you think you debut
in completely completed.
That's often a thing, isn't it,in surgery, but it feels like,
um, getting people.
To learn how to do it and, anddeliver it.
That's, it's, no you saying thisis really cool, but nobody else
(27:23):
can do it.
That's not interesting, is it?
Um,
Joseph M. Schwab (27:27):
It's hard for it to catch on if that's the
case.
Yeah,
Justin Cobb (27:30):
Yeah, yeah, yeah, yeah.
But I think the, for a total,for a total hip surgeon who's
doing is very happy with theirarti total hips and is regularly
doing that.
They know if you're doing a Hemiarthroplasty, then you're much
more conservative on the capsuleside.
If you're just doing a hemiarthroplasty, if you're doing a,
a total hip, you are not asconservative as for Hemi
(27:51):
Arthroplasty.
If you're doing a, if you, ifit's, it's perfectly easy to
start preparing Cebul withoutcutting off the head, neck for
hip.
It's perfectly easy to do that,and you do that.
I don't think 97 year oldsshould have hip resurfacings.
Joseph M. Schwab (28:12):
Okay.
Justin Cobb (28:13):
I think that's probably too old.
Joseph M. Schwab (28:15):
Yeah.
Justin Cobb (28:16):
96.
I'm not too sure.
Joseph M. Schwab (28:20):
You have to have a limit somewhere.
Right.
Well, professor Cobb, I reallyappreciate you meeting with us.
I, I, uh, absolutely, uh, adoredour conversation and I
appreciate the way you approach,um, how you think about hip
surgery, how you think abouttrying to conserve around the
hip and, and how you think abouttrying to deliver the best for
(28:44):
your patients.
I really appreciate having you.
Justin Cobb (28:46):
So it's been great, a great honor.
See you soon.
Joseph M. Schwab (28:50):
Thank you for joining me for this episode of
the AHF podcast.
We think of the AHF as a family,so if you can remember to take a
moment to like and subscribe.
You'd be helping us find morepeople just like you to share
our thoughts with.
And as an AHF family member, youcan always drop an idea for a
topic or any feedback you likein the comments below, you can
(29:14):
find the AHF podcast on ApplePodcasts, Spotify, or in any of
your favorite podcast apps, aswell as in video form on YouTube
slash at anterior hipfoundation, all one word.
New episodes of the AHF podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(29:35):
happy, healthy, and maybe evenresurfaced.
Hello everyone and welcome to the AHF podcast.
I'm your host, Joe Schwab.
This week we have part two ofour conversation with Professor
Justin Cobb on hip resurfacing.
We focus our conversation moreon specifically how he performs
hip resurfacing with the H1ceramic on ceramic implant
(00:47):
through an anterior approach.
Let's rejoin the conversation.
I wanna switch gears a littlebit and talk a little bit more
about the practicality of doingone of these hip resurfacings
specifically from an anteriorapproach.
Um, because, you know, as aconcept, we talked about this a
little bit.
(01:08):
Uh, some people find thatanterior approach, uh, is, uh,
maybe more difficult for doing aresurfacing, I think for various
reasons.
Um, but the first question Ihave for you is, can you walk me
through a little bit of theusual equipment that you use,
uh, for one of these anteriorapproach hippers surfacings,
things like table fluoroscopy,any special devices, and
(01:32):
especially anything that mightdiffer from a setup of a
standard anterior total hipreplacement.
Justin Cobb (01:39):
So for a, um, an ordinary person, nothing
different at all from a standardanterior tunnel lip.
I mean, the wonderful thing thatjob matter, I mean, I, I, I
definitely, as I said at thebeginning, I don't feel I've
invented anything here.
There are giants before me inJoel.
Obviously a huge, huge figure.
And in Europe there are several,obviously, huge figures who've,
(02:01):
who've done anterior total hip.
And Indeed and Paul Budha wouldactually call out, um, in the,
in that, um, and in Europe, um,Heinz Barer was doing anterior
resurfacings in the seventies.
Um, so it's not as if there'sanything new there.
All the only, the onlydifference, the only difference
is the amount of capsularrelease.
(02:22):
And if you watch, uh, Fred Loaddoing a, uh, anterior total hip,
um, the capsule is briefly insize in a tiny way, because he's
an amazingly conservativesurgeon, we have to do a
complete release of the capsule.
And the, the big differencebetween resurging replacement is
(02:42):
we're trying to keep the femoralhead and neck alive.
And the reason that I, the, oneof, one of the reasons I think
the anterior approach isattractive is that if we, we do
an ellipsoid.
Capsulotomy.
So we take the capsule offsuperiorly and laterally right
round to the mid coronal planebefore dislocation.
(03:02):
We'll obviously take the wholeof the pubal femoral off
medially.
And then having dislocated, wethen do the posterior
capsulotomy, well away from thefemur joining up, cutting across
the whole of the she femoralligament.
And if you just, you, this is anintracapsular, um, procedure
(03:23):
once you've dislocated, butwe've completely released the
capsule, then the femur femoralhead goes approximately
laterally.
Um, and it, it's honestly notdifficult.
So, so the release, it's just acomplete capsulotomy.
And of course that's not as goodas an incomplete capsulotomy,
but I don't think you can do aresurfacing from the anterior
(03:46):
approach without a completecapsulotomy.
And so we just not, we do that.
Joseph M. Schwab (03:51):
But you have an anterior based capsulectomy
first and then an inside out.
No capsulectomy not You saidnothing.
You, the ellipsoid is not acapsulectomy.
It was,
Justin Cobb (04:02):
No, no.
We go the, the, just to describein words and, and we'll put some
pictures to it.
The anterior radial along thelines, right?
Just beside IOC Capis.
Joseph M. Schwab (04:15):
Yeah.
Justin Cobb (04:15):
I tried to leave cap, iron cap towers on the
capsule there.
We don't, we don't disturb that.
Just right from, from the, thelabrum at the top right down to
the instructionary line.
And then at the top of that, wego round beneath the indirect
head of rectus, right round tothe Midal plane.
And in fact, and then actuallywith a pair of scissors, um,
(04:40):
push and take out the lateralbit of the iseo femoral ligament
from the front there.
And, um, um.
A fellow gild in Atlantadescribes that very nicely.
And Ben do, I think lots ofpeople do.
Everyone, everyone has to dothat.
Um, George Gild in Atlanta, um,describes that nicely.
And then, then you take thewhole of the pub femoral
(05:02):
ligament off right down to thelesser trant.
Joseph M. Schwab (05:06):
Okay.
Justin Cobb (05:07):
And then, then having taken that all off, you
put a lever over the TAL, whichgives you access to the sort of
inferior head and neck junction.
And quite often there's a sortof frenulum of capsule of so
onto the femoral head and neckjunction there, which you take
off.
And having released all of thatwith Ilio Captima, you can then
(05:29):
put a sharp home and your sharplever onto the pubis and lift
up.
And you have a lovely view rightfrom the, uh, super end of the
TAL.
Right round the front of thecaps, right around the front of
the rim and do your rim surgerynow, because forever after, it's
gonna be harder than now.
(05:50):
So we do the rim surgery beforedislocating then.
Um, and, and so do all youranterior, um, head preparation
at that stage.
And then if, if it's a slimwoman, you don't need a table.
Um, we just, if a labor, if aligamentum is intact, either a
(06:11):
ligamentum cutter or just acurved, um, Bovie just to
release the, um, um, uh, andthen the hip, there's no force
involved.
It's a very, you don't have touse force to dislocate the hip.
Joseph M. Schwab (06:25):
Yeah.
And, and you can see that, sobasically at this point, with
the acetabulum exposed, the wayyou described, or with the, with
the joint exposed, the way youdescribed, you can quite easily
see that notch that you're so,you know, careful to
Justin Cobb (06:41):
So in a, in a bloke,
Joseph M. Schwab (06:43):
Yeah,
Justin Cobb (06:43):
in a big bloke, it doesn't matter.
They've got masses of bone.
You can bury a socket in a bigman, it just doesn't matter.
In a slim, in a sorry widthperson in a woman, um, they
haven't got a huge acid pelvicbone there.
And that, that, um, uh, notch,uh, ile pubic recess there
(07:07):
really makes sense when you,when you put the trial
prosthesis against it.
Joseph M. Schwab (07:12):
And
Justin Cobb (07:12):
Um.
Joseph M. Schwab (07:15):
so.
you're, you, you do your rimsurgery, you, you clean your rim
at this point, and then you movetowards the femur before you do
true acetabular
Justin Cobb (07:24):
then so, so, no.
Um, I think it is.
Uh, so what, um, Derek, with,with the approach, what he said
was, do your acetabular surgeryfirst because you ought be as
conservative as you can be.
And so you don't wanna takemasses of pelvis away.
(07:45):
Um, you measure the, the, thehead neck junction with tongs
before you dislocate to confirmwhat sort of size you're in.
Then I personally think you thengo and do your acetabular
surgery, put in your socket,bearing in mind what you know,
you've gotta achieve your head,and then do the head surgery.
(08:07):
If you are very concerned, youcan do the head first.
Um, and.
I, I think for, for, uh, you canchoose, I think there's some
indication of doing one first.
Some for the other first, as Ithink it's true with total hip
arthroplasty actually is somepeople want to know their
version on their femoral stembefore they put their socket in.
(08:28):
I've heard that that proposed.
Joseph M. Schwab (08:31):
Um, so the, um, you know, the size of the
prosthesis you're gonna beputting in as soon as you do
that, the head, neck junctionmeasurement before you've done
any dislocation.
Yeah,
Justin Cobb (08:45):
I mean, from the x-ray, um, what, you know, have
you got a cam, IE somebody witha fat neck and almost a
cylindrical neck?
Um, or have they, are they aaplastic here with a slender
femoral neck and the, the, theslender neck, you've got three
or four choices of femoral headthat will all fit there.
(09:07):
With a guy with a, um, short,very fat neck, you have got very
limited choice.
That's a very narrow fairway.
You really can't, becauseparticularly when the head is,
um, inferior and posterior,that's, that's the really
demanding hip.
And there you haven't got muchchoice.
But actually they are prettymuch all, um, men who've
(09:32):
distorted their femoral head bya lot of exercise in their
teens.
So they've got, they've got alot of pelvic bone, so you can.
You can upsize.
So we, in the planning, wereally pay greater deal
attention there.
But unless you're doing ct, youknow, your 2D plan, it's always
plus or minus the size.
So you have to valid, you haveto measure with the tongs, you
(09:56):
know, what is the size I'm gonnago for here?
Which is really, really what isthe size of the head, neck
junction?
What is the, um, that's whatyou're really measuring there.
Joseph M. Schwab (10:05):
Yeah.
And the, if, if you are, maybe,if your measurement is slightly
in between sizes, how do youdeal with that?
Justin Cobb (10:14):
Well, that's where I think it's, it's worth, um,
that's where you go toacetabulum first.
So you then say, is the, so somepeople occasionally see someone
whose femoral head has reallyground out the acetabulum and
they have quite a big mismatchwith a big socket.
And there it's quite, you know,that's, that, that's the most
difficult thing for a servicing,honestly, because.
(10:36):
You can't really up, you know,you've got a limited
relationship there.
We haven't yet had a problem,but I can, I theoretically that
could be a problem.
Joseph M. Schwab (10:46):
The, because the cups and the head sizes are
matched, right?
Justin Cobb (10:49):
that's right, that's right.
And truly I have, um, from theold days, the old hip
resurfacings had two thicknessesof aceta for every femoral head
because in the very old days,the, it wasn't, um, every two
millimeters, it was every fourmillimeters of femoral head.
So the first, I think from 2000till 2004 or five, it went 46,
(11:15):
50, 54.
Um,
Joseph M. Schwab (11:18):
Wow.
Justin Cobb (11:19):
So that's why there were two thicknesses of VAs
tablum, because that was a bigjump in feral head size.
Joseph M. Schwab (11:24):
Yeah.
Justin Cobb (11:25):
Um, but it, but I haven't used a thick acetabulum.
I, I don't think, I can't thinkof any one for decades, so, so.
You measure the feral head size,go to the ace tabular, and then
choose, are you gonna go to thebigger or smaller?
Joseph M. Schwab (11:42):
sure.
And is trialing part of theprocedure?
Do you do trialing at all foreither the femoral or acetabular
side or, okay.
I.
Justin Cobb (11:49):
Um, both.
Um, on the, on the ace tabularside, it's really about getting
the, um, orientation of the, asof the acetabular component,
right.
Which is important in women, inmen, it really isn't very
important.
They've got masses of bones, itdoesn't matter so much, but in
anyone who's got a bit ofdysplasia, you really want to
get that rotation.
Absolutely right.
(12:10):
Um, on the, on the acetabularside, and are, we've gone over
to reusable instruments, so youhave to know, because you don't
really have control over youranymore, you have to know that
your trial has got a pre fit.
Um, and so the trial is, is apre fit for orientation.
(12:31):
In three ways.
So abduction version androtation of the acetabular
component.
And in fact, once you've setthat on your impactor, then we
don't change that rotation forthe the acetabular component.
We then, and I'll give you alittle video clip showing that,
um, just showing how that works.
Joseph M. Schwab (12:51):
Um, and, and so, um, do you use fluoroscopy
during the procedure as well?
Do you use any imaging
Justin Cobb (12:57):
I do, I don't actually, I do it before
closing.
Um, I don't do it before that,but I mean, just I, um.
It is really interesting.
I'm, I'm, I'm sure you know,there's the, the surgeon who's
doing planned surgery where youare, if you've got a CT based
(13:18):
plan, you feel that's the truth.
I'm achieving my plan.
If you've got, if you've got a2D plan, you know it's a guide,
but in the end, you've gottamake the decision because those
x-rays aren't as accurate as youthought they were.
So you really are making yourmind up about size, but the
angles are pretty much true fromyour, on the acetabulum, but on
(13:39):
the femur, of course, not somuch.
I, I think if you are, if youare used to, and I know there's
a whole group of people who havethe Fluor on the whole time.
Um, I, I, I don't, I think it'san interesting way of doing it,
but it's slightly different fromlooking and feeling, and I'm,
I'm still, I suppose I don'tlike doing more than a couple of
(14:04):
flashes of radiation.
I don't like wearing lead, so wetend to just do a flash at the
end to make sure nothing'smoved.
Um, um, and obviously withcementless, acetabular
components, things can move andso that's why we do it after.
Really, that's risk time for me,I would say.
Joseph M. Schwab (14:24):
that's, that's what you're checking for.
But there would be nothing toprohibit you from doing it
during the procedure if youneeded to
Justin Cobb (14:29):
No,
Joseph M. Schwab (14:30):
uh, for position uhhuh.
Okay.
That's just a level of comfort.
Justin Cobb (14:34):
And that's right.
It's interesting, isn't it?
Joseph M. Schwab (14:36):
yeah.
Do you find, um, so first ofall, do you have, um, a backup
total hip set when you're doingthis?
Or do you, do you ever find thatyou have to bail to a total hip
for one reason or another?
Or has that not been an issue?
Justin Cobb (14:50):
I, I can't remember the last time that happened.
I mean, we have total upsets,um, in the background, but we
don't say is one sterile?
Um, because seems like thatwould be a very unusual day at
the office.
That'd be very unusual.
I mean, you know, this, we'redoing this operation on someone
who's got a healthy femoral headand neck and the instruments.
(15:13):
Um, and again, I'll, um, theywe're very excited about our,
I'll put, I'll send you a coupleof video clips of, of the
femoral neck guide.
Um, the, the huge differencebetween resurfacing surgery and
tu hip arthroplasty is that it'sguidewire based.
And if your guidewire's wrong,you can't correct it like a DHS
(15:36):
If the, if the guidewire's inthe wrong place, you can't
correct it.
And if you think, oh, I'll justcorrect it with the next
instrument, then things go badlyis you just have to change your
mindset and accept all of yourtime is spent making sure that
the position and orientation ofyour guidewire is right and the,
the, the stylists and the jigsreally help that.
(15:57):
So it's easy to know.
Be fine.
And, and you just check, check,check.
There are three checks on thefemoral side, um, before you
start machining bone
Joseph M. Schwab (16:10):
For, for the position of the Guidewire to
make sure it's
Justin Cobb (16:13):
position, position, orientation.
Joseph M. Schwab (16:16):
Okay.
Um, and the, uh, any other, soyou mentioned the, the device
that's used to, to, uh, youknow, position the guidewire for
the femur.
Any other special devices thatare, that you use or that are
needed are, again, are you doingthis on a standard table, on an
orthopedic table?
What,
Justin Cobb (16:34):
So, so I've done both.
Um, and in fact, um, in acouple, in six weeks time, when
you come over, we're gonnapresent a little bit of data on,
on table and no table.
Um, I think in, in, um, women,you just don't need a table if,
but if you're used to it, it is,it's just as easy in a big man.
I think a table is a really bighelp because it, um.
(16:57):
Obviously you don't, unlessyou're using, um, Fred's w
computer guided table with theirnumbers, you don't know the
forces.
You are, you know, thatfinishing the external rotation
on the boot, um, you don't knowthe forces.
You have a good idea, but it's,it's, it's unmeasured.
But in a big muscly man, um, thetable makes it much easier.
(17:22):
And,
Joseph M. Schwab (17:22):
Okay.
Justin Cobb (17:23):
and right now, I'll say for any woman, I would
absolutely say, uh, anteriorapproach is less trauma than a
posterior approach.
But for huge blokes and, and ofcourse the female pelvis, the,
the, the hip is at the front ofthe pelvis, whereas in men, it's
really in the middle.
And for those guys with hugethighs, it's literally in the
(17:47):
middle.
And there's no benefit ofanterior or posterior for those
people.
Really, there isn't.
Um, and for those guys, eitherway, you need big levers.
Because you are in the middle ofa big person.
Um, that, and that we all know,I mean, anyone who does
resurfacing knows that hugeathletes are, are, you know,
(18:07):
they're pretty challenging.
Joseph M. Schwab (18:09):
And that, so how many, uh, um, assistants are
you using, uh, during your case?
How many people would be, wouldyou need to have scrubbed in
apart from yourself?
Justin Cobb (18:18):
Um, I definitely have one person scrubs in either
a gas store or a gule, dependingon, um, how many I, you smile at
that there, you, you need, youneed some something or someone
on the other side of the tableas well.
Um, I think, I think just, um,uh, Chris Corins beautiful bits
(18:41):
of string, they're not quiteenough for, for that.
I mean, Paul Bulley has, has,um, a different device, but you
need some something.
The far side of the table justfor the feal head prep really.
Joseph M. Schwab (18:55):
Yeah.
And when you're, uh, when you'reevaluating the position of your
components, for instance, itseems like there's, um, maybe
naturally is, uh, perhaps theright word, perhaps not
naturally less concern about,um, what their length and offset
is because of the relativelysmall amount of bone you're
(19:16):
taking away.
Is that the philosophy?
Justin Cobb (19:18):
So the length is a really big deal in, in men
because men with cams haveusually worn their hip out by
having a great time and they'vegot really hard bone.
And so if you are not, and whenyou are resurfacing a cam on the
femoral side, you are taking therugby ball and putting a
(19:39):
football on the end of thefemur, um, and lengthen by three
or four millimeters on a.
Joseph M. Schwab (19:48):
Yeah.
Justin Cobb (19:50):
Ream acetabulum out superiorly.
You can distalize the acetabulumtoo.
So, so it is possible tolengthen someone by five or six
millimeters by mistake,lengthen.
And so you have to pay attentionin those cams.
Um, but the offset and theoffsets, the thing that I think
(20:11):
the total people really justdon't agree with because they
spend a lot of time getting theoffset exactly right.
But we frequently reduce theoffset by a centimeter
frequently, uh, or even 12 or 30millimeters because you are
wanting to put, you are doingtop of neck based surgery,
you're putting the femoral headback on the top of the neck and
(20:32):
that rugby ball shaped femoralhead has got a whole lot of bone
beneath the compressive rabbe.
That's very osteoporotic.
You don't wanna resurface that.
So you are, you are reallylateralizing the femoral head.
Putting it, getting a loadthrough the compressive
directly, again, frequentlychanging the offset very
substantially.
(20:53):
And, and suddenly Andy Murray,there are lots of, you know,
alpha level athletes who've hadvery substantial offset
reduction and are none the worstfor it.
So the rules seem to be quitedifferent for resurfacing
replacement in that respect,
Joseph M. Schwab (21:09):
So you re um, offset is not something you, it
sounds like you worry about toomuch, but with
Justin Cobb (21:15):
horizontal.
Joseph M. Schwab (21:16):
Yeah.
Um, as far as length, how do youevaluate for, uh, leg length
during the procedure if you're,if you're waiting and doing
fluoroscopy at the end, is thatwhen you find out or do you do
checks during
Justin Cobb (21:29):
So, um, if I'm doing, if I'm doing male table
based resurfacing, then.
Um, I, I don't pay very much.
I mean, because we planned whatwe're doing and your measure,
your, your napkin ring, which,which is your top head cut,
(21:50):
which of course isn't, it'sgiving you half offset and half
leg lengths.
But in a cam you, it's mainlymedial.
There's often very little or nobone.
You're taking away laterallywith that, um, napkin ring.
You get a, you know, with thatwhat you're doing on the femoral
side and uh, on the acetabularside, you are getting your
(22:12):
acetabulum in at the right depthor orientation.
We are not spending any timeworrying about changing the leg
length very much at all.
Really
Joseph M. Schwab (22:18):
Okay.
Okay.
So really not too many checksfor that, it sounds like.
Interesting.
Um, and do you do, do you everdo any leg length films
afterwards?
If somebody, what?
What would be a typicalcomplaint that you might see for
somebody who has a leg lengthissue?
Or is it just not common
Justin Cobb (22:33):
Well, you can see it on the plane X-ray.
I mean, if, if, if you've doneit, you don't need a leg film to
tell you that, um, you betterstart apologizing.
Um,
Joseph M. Schwab (22:43):
So humility.
That's the approach.
Justin Cobb (22:46):
yeah, well, surgery keeps you humble, Jerry.
You know, it keeps you pretty.
Joseph M. Schwab (22:49):
this is true.
This is true.
Um, so I, I appreciate youwalking me through some of these
questions.
Uh, one, one additional questionfrom a surgical standpoint, if
you were to need to doadditional release, um, to
mobilize the femur, you feellike you've done your full cap.
Uh, you, you've done yourcapsulotomy the way you
(23:10):
described, uh, where normallyyou would expect to have a
mobile femur, you've doublechecked to make sure that that
capsulotomy is as complete as itis normally, but you're just not
getting that mobility and it'sobstructing your view of the
acetabulum say, or your abilityto put the head somewhere safe.
Yeah.
What do you do?
Justin Cobb (23:27):
so Gregor, first of all, in that stiff, short
necked, um, man who's a realheadache, whatever, I would
definitely take out, take downthe top 15 or even 20
millimeters of TFL off the bone,um, and would definitely repair
it afterwards, but I wouldstraightaway do that.
Joseph M. Schwab (23:49):
Okay.
Justin Cobb (23:49):
Um, not, not even think about not doing it in such
a person because that lets theTFL sit down.
So you, you see well beyond theMidal plane before you dislocate
and that, so, and you've made anice, you can push a big swab
down into that.
Um, freeing the, uh, DT eye offthe lateral capsule, making sure
(24:13):
that's all, all free there insuch a person.
And then, and I've definitelyhad this experience and it's
because there's still fibers ofthe issue of femoral ligament
you haven't released, or it'sthe pube femoral you haven't
released.
Um, and you know, when you'vecompletely released the pube
femoral ligament because there'sroom for your fingers there,
(24:37):
there's no tension thereanymore.
So if that is released, it'salmost certainly you haven't
fully released the she offemoral ligament.
Um, because the muscles aren'tthe problem, it's the capsule.
Um, I think that's a, I'd bereally interested to hear what,
um, um, so Paul has donethousands of anterior hip sings.
(25:01):
I'd be, I'd be interested toknow what he says about that.
My experience, which is hundredsor thousands, is that, um, it's
about the capsule.
Whichever approach you use forresurfacing, it's about the
capsule.
Joseph M. Schwab (25:14):
Yeah.
Justin Cobb (25:14):
Um, because that's the uncompliant thing.
The muscles are just so muchmore compliant
Joseph M. Schwab (25:19):
Yeah.
Justin Cobb (25:20):
and we don't, we don't, the T ffl releases the
only muscle release if you do,if you, if you have to.
Joseph M. Schwab (25:25):
Do you release that soft tissue or do you take
a sliver of bone with it?
How do you do your TFL release?
Justin Cobb (25:30):
I just, I just do, so I mean the very top, front
edge of TFL is quite tendernessand if you just take it off
sharply there you have a nicebit of tenderness material to
sew straight back on.
So I haven't taken a piece ofbone off myself.
Um, um, but I think there arelots of ways of doing that.
Joseph M. Schwab (25:52):
Yeah.
So, um, uh, obviously you'relooking forward to the H1 being
released to a broader audienceof surgeons, which is, uh, uh,
it sounds like a lot of years ofdevelopment have gone into that
and a lot of experience.
Um, what do you think is nextfor it?
I mean, is this gonna solve hipresurfacing or do we have more
(26:14):
problems yet to yet to
Justin Cobb (26:16):
I.
think I.
I, I, obviously it's not theonly, um, new resurfacing device
out on the blocks.
There's the resurface, which isalready inducing in Australia,
and the poly motion.
So these are three novelresurfacing without the bronze
of metal and metal.
The problem is not the devices,
Joseph M. Schwab (26:36):
Yeah.
Justin Cobb (26:37):
it's, it's a surgeon.
And, um, getting people's skillsup is, is so we are, I'm
literally spending the wholetime right now trying to get the
technique, the steps ascrystallized as possible.
And it feels like, um, right nowthe steps are the steps.
(27:01):
And if you, if you do completeeach step, and of course you
think you, you may not havecompleted, you think you debut
in completely completed.
That's often a thing, isn't it,in surgery, but it feels like,
um, getting people.
To learn how to do it and, anddeliver it.
That's, it's, no you saying thisis really cool, but nobody else
(27:23):
can do it.
That's not interesting, is it?
Um,
Joseph M. Schwab (27:27):
It's hard for it to catch on if that's the
case.
Yeah,
Justin Cobb (27:30):
Yeah, yeah, yeah, yeah.
But I think the, for a total,for a total hip surgeon who's
doing is very happy with theirarti total hips and is regularly
doing that.
They know if you're doing a Hemiarthroplasty, then you're much
more conservative on the capsuleside.
If you're just doing a hemiarthroplasty, if you're doing a,
a total hip, you are not asconservative as for Hemi
(27:51):
Arthroplasty.
If you're doing a, if you, ifit's, it's perfectly easy to
start preparing Cebul withoutcutting off the head, neck for
hip.
It's perfectly easy to do that,and you do that.
I don't think 97 year oldsshould have hip resurfacings.
Joseph M. Schwab (28:12):
Okay.
Justin Cobb (28:13):
I think that's probably too old.
Joseph M. Schwab (28:15):
Yeah.
Justin Cobb (28:16):
96.
I'm not too sure.
Joseph M. Schwab (28:20):
You have to have a limit somewhere.
Right.
Well, professor Cobb, I reallyappreciate you meeting with us.
I, I, uh, absolutely, uh, adoredour conversation and I
appreciate the way you approach,um, how you think about hip
surgery, how you think abouttrying to conserve around the
hip and, and how you think abouttrying to deliver the best for
(28:44):
your patients.
I really appreciate having you.
Justin Cobb (28:46):
So it's been great, a great honor.
See you soon.
Joseph M. Schwab (28:50):
Thank you for joining me for this episode of
the AHF podcast.
We think of the AHF as a family,so if you can remember to take a
moment to like and subscribe.
You'd be helping us find morepeople just like you to share
our thoughts with.
And as an AHF family member, youcan always drop an idea for a
topic or any feedback you likein the comments below, you can
(29:14):
find the AHF podcast on ApplePodcasts, Spotify, or in any of
your favorite podcast apps, aswell as in video form on YouTube
slash at anterior hipfoundation, all one word.
New episodes of the AHF podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(29:35):
happy, healthy, and maybe evenresurfaced.
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