December 13, 2024 • 23 mins
In part two of our series, we continue our discussion with Australian hip surgeons Dr. Patrick Weinrauch, Dr. Ilan Freedman, Dr. Jit Balakumar, and orthopedic sales rep Joe Scerri. We delve into the challenges and controversies of Direct Anterior Approach (DAA) hip surgeries in Australia, discuss the impact of patient education via the internet, and explore the role of industry in advancing surgical techniques.
Meet our guests:
Mr. Patrick Weinrauch - https://brisbanehipclinic.com.au/about-us/a-prof-weinrauch-orthopaedic-surgeon.html
Mr. Jit Balakumar - https://jitbalakumar.com.au/
Mr. Ilan Freedman - https://melbournehipsurgeon.com.au/
Joe Scerri - https://au.linkedin.com/in/joe-scerri-45a003254
Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:07):
Welcome to part two of examining the
anterior approach from downunder.
Let's get back to ourconversation with Australian hip
surgeons, Patrick Weinrauch,Ilan Freedman and Jit Balakumar,
as well as orthopedic sales repJoe Scerri.
Which, which just raises my nextquestion, and you started this
(00:28):
conversation here a bit, Jit, sowhat do you guys see as the
biggest challenges orcontroversies about DAA, within
the landscape of Australia?
Jit Balakumar (00:39):
The biggest controversy, it's what you've
said already.
I think the, creme de la cremein orthopedics for most, hip
surgeons is arthroplasty.
you have a winning surgery.
very predictable outcome.
Patients are usually lowmaintenance.
So that's what most people wantto do.
And so I think you have to becareful.
(01:00):
There's the private practiceaspect and we've all seen
LinkedIn videos, YouTube videosof patients walking day one post
op 20 steps of stairs.
And, is the marketing, right?
And.
I think this it's no, it's notdissimilar to what my senior
colleagues did with yellowpages.
So we shouldn't criticize peoplefor that.
(01:22):
with it comes some risks becausewe all get complications and we
all have problems.
So when you put yourself outthere, it can also be the sword
you die by.
let's look at the data.
The data shows anterior andposterior approach is.
It's exactly the same inoutcomes at six months, and
there's double the rate ofdislocations with posterior
(01:44):
approach, almost three times theincreased rate of infection,
twice the rate of fracture andloosening, early loosening in
the anterior approach.
so there's, trade offs and Ithink we have to be cognizant
when you do it.
But I agree with Dr Mattacompletely.
I think the market is thecurrent market is very astute.
(02:05):
They know what they want theyare all on social media.
Pat does a lot of resurfacings.
I have so many patients comingin saying, look, I want a
resurfacing.
And I said, where did you hearabout this?
I go, I'm on a Facebook website.
I'm a runner.
I'm a marathon runner.
I've heard that you've got to beloading your proximal
metaphyseal bone if you want torun long distances.
(02:29):
And, I said, look, you're,absolutely right.
look, I'm going to send you toone of my partners.
But the market is way more wellequipped to actually know and
have the knowledge Then we givethem credit for I think gone is
the paternalistic era But you'vegot to play a role in this and
say look I think Um in my hands,this is what the best approach
(02:51):
is.
So I think it's Dr Matta'sabsolutely right the market's
driving it and that's what'sgoing to organically grow it.
Joseph M. Schwab (02:58):
Do you think we're moving the paternalism out
of the clinic room and onto theinternet when we're engaging
with patients, that way?
is that, we're ceding thatinformation a little bit, to our
patients, ahead of time.
Ilan Freedman (03:12):
Yeah, it can be a bit difficult.
Patients come in now, asking forspecific bearing surfaces or
asking you about what particularpolyethylenes or which, which
exact metal have you used.
So it's, I guess it's the, theside effect of having all this
information on hand.
patients can access all of thatvery easily, and many of them
do.
So come in with good questions,but sometimes come with
(03:33):
questions which, They don'treally know what to do with the
answers, they come in asking,what metal is it?
And you tell them and they lookstunned.
yeah, but people are coming in,very informed and they read your
bio, they read your results.
In some cases, they've read yourpapers.
So I guess that's the realitynow.
Patrick Weinrauch (03:54):
I don't, mind, patients being well
informed, I think that, I thinkit's, I think that it's good
that they've we instinctively, Ithink sometimes they may be a
little over informed, but,there's a, good balance there.
And, and I think, I think it'snice to be able to have a really
(04:14):
robust sort of education of apatient prior to their surgery.
so I I don't, shy away from, apatient comes in and my heart
doesn't sink when they come inwith their, with their ream of
papers, it's like, Yeah,sometimes it can be a bit
tricky, our role is, as aresponsible professional is to
(04:35):
guide them, right?
And we're there to be able toeducate them and to be able to
put, what they've read intocontext and balance because
we're the subject matter expertsand, if they're relatively well
read, then it's actually quiteeasy to direct them there and to
be able to, give them aframework to be able to
(04:57):
understand what they're reading.
And I suppose my, comment,bringing it back to anterior
approach is, that, historically,I think when, anterior approach
first came into Australia in anynumbers.
There was very much a, it wasreally marketed hard.
(05:18):
That wasn't necessarily just, infact, that probably wasn't so
much surgeons who are drivingthat.
That was industry.
So industry was driving anteriorreally hard because there was
one company in particular thatwas linking, anterior approach
and, this is the implant andthis is the table.
And so it was like a package andthis, and from a surgeon's
(05:38):
perspective, that was theeasiest conduit to be able to
get education in the space aswell.
So it was a very successfulmarketing strategy, to be able
to, educate surgeons, educatethe community and build
awareness around it allsimultaneously.
And so that particular company,which was really a minnow in
(05:59):
Australia at the time has reallyboomed, right?
So it's a very successfulcompany now in Australia for
that reason.
I think we've seen a bit of acorrection now over the last
sort of eight years where prettymuch all of the companies have
got an anterior offering now.
So instrumentation platforms andthings like that.
(06:19):
And so, we're now starting tosee a bit of diversity, amongst
the ways in which we are doingsurgery.
For instance, whether it's beingput on a traction table or not
on a traction table, there'squite a, I'm not sure what the,
we can't capture that on theAustralian registry.
My instinct is it's probablystill dominated by table use,
(06:43):
but then there's a quite a bigcomponent which are doing it off
traction tables as well now,which is pretty much, and, very
much being implant agnostic nowas well.
Joseph M. Schwab (06:56):
Would you say that the industry based
education, that you're talkingabout, was that a primary driver
towards adoption of, of anteriorapproach or were people getting
their surgical, education onthis technique, it mostly in
other ways.
Patrick Weinrauch (07:13):
So in Australia, like when I went
through My residency, we call itregistrar, but residency, the,
there was really no exposure toanterior approaches.
So this is a technique that I'vetaken up post, qualification
fellowship.
(07:35):
and We're very reliant onindustry support to be able to
get that education, right?
and this of course you do usnowadays if you can find a place
to go and do fellowship, right?
Where you can learn thosetechniques in your fellowship,
but you know a post fellowshiporthopedic surgeon requires
(07:55):
Industry support.
The industry is still veryinvolved here in Australia in,
surgeon education, not just ananterior approach, but in all
aspects,
Jit Balakumar (08:05):
I run two fellowships, and my, all my
fellows, they start theirpractice.
I have a local fellow andinternational fellow their
practice almost instantlyexplodes because of anterior
approach.
Um, look, obviously, I learnedslightly differently, but I
remember that actually the firstanterior approach I saw was with
a guy in Box Hill Hospital,public hospital, and, there was
(08:29):
two of them actually there.
One guy who did it on the table.
Supine and another guy who didit in the lateral position
anteriorly and I was blown awayby it.
No one talked about it.
There was no marketing, buttheir recovery was very
different to the rest of the,unit.
And then when I went to my,equivalent rural rotation, I
convinced my boss there to do itanteriorly.
(08:50):
We had a ASR head, with an ASRcup with a Zweimuller stem, and,
it was, a disaster, and I shouldnever have convinced my boss to
do that, But I would say, look,I echo Pat's points.
It's, changed very much in theindustry has really been, people
(09:10):
are very quick to criticizeindustry.
They have improved patientoutcomes dramatically by
championing high qualityeducation, right?
And, they, the smaller startupcompanies use it as a point of
difference.
The larger companies try to getahead with it.
And now, fellowships that areattached to an anterior, because
(09:32):
they can see the, the return oninvestment and how they can
monetize it.
On the flip side, think everyhospital, I'm sure it's the same
in Queensland and in Australia,in Victoria to be credentialed.
So they classify anterior hips,robotic surgery as a tier B
credentialing.
So not the standard that youfinish in your training program.
(09:54):
And to be credentialed, theyexpect you to have done either a
fellowship.
Or have done at least 30 caseswith someone who's an
experienced anterior hip surgeonand then be supervised by their
local, whoever the hospitalrepresentative is.
there's some very robustcredentialing process and I
again tell trainees, look,you've got to be careful.
(10:16):
When you first start, you don'twant to be, you've got to slay a
few dragons to get your princessand we don't want to go through
that process, right?
don't want to be slayingdragons.
That's not the process withthis.
And, I think that's industry hasdone that amazingly here.
Joseph M. Schwab (10:32):
Joe, as the representative of industry in
this conversation, what do you,what have you seen in the
landscape of anterior approachin Australia?
What has been most striking toyou?
Joe Scerri (10:44):
I think I'd like to answer that question a little
bit historically, and that is ina lot of the points that the
guys are making, certainlyfellowships are really
important.
and I've done a number at,Wrightington and various places
like that over the years.
in France and, so forth and theyhave been, as has been mentioned
(11:06):
in terms of the return oninvestment, excellent because
quite often they're with a highvolume surgeon who happens to be
using obviously, the implantthat is manufactured by the
company that sponsors it.
And then they come back as adevotee and, it becomes a nice
circular return.
Everybody wins.
And, and that's been aworthwhile investment.
(11:29):
And as far as I know.
continue to do that.
then you've got the existingfellowships.
the one that, that you'vementioned Jit when Jit does the
anterior approach, the peoplethat become, proficient at that,
have to learn somewhere.
So if they decide that's forthem in their private practice,
(11:49):
then they'll continue to dothat.
So that goes on.
And then you've got.
people like Pat who, dovisitations from various
companies.
and I think that there areselected people around the
country who, perform directanterior where there are medical
companies that will send,surgeons to those, to those
(12:13):
surgeons because it enables themto be trained on the anterior
approach, but at the same time,presumably.
If they like the implant at thetime, then they go back and that
becomes part of their privatepractice.
And I think that's where, onehand, rubs the other and
everybody wins as well.
And, then there are other thingsthat, I'd like to get involved
(12:35):
in.
And that is, we're not bigenough to be able to sponsor
those things, but certainlythings like, cadaver workshops,
where, you know, that can belearned on that approach.
think, those go on as well, butI think the combination of
fellowships, visitations, Andcertain workshops are probably
the collection of things thatsurgeons are getting exposed to
(12:57):
when registrars and seniorfellows.
Joseph M. Schwab (12:59):
has the landscape for visitations in
Australia, has it begun toinclude things like reverse site
visits where a mentor will comeand spend time with a surgeon as
they're starting to do theircases?
And has there been anyintroduction of, virtual
visitations, using, augmentedreality, virtual reality, those
(13:23):
sorts of things?
Jit Balakumar (13:24):
I've got to say something about that, though.
Look, I do have a problem withvisitations.
And I think Pat and I were withJ and J at this stage where they
were trying to develop this minifellowship and and reverse
visitations.
I do think, the.
One of our all of our pet,interest is adult education,
right?
And adults are very differentlyeducated based on who you are.
(13:47):
There are some who can just dothat and they'll come back and
I'm sure Pat, you probablytaught a lot of people how to do
resurfacings, but there are someyou would never let do a
resurfacing afterwards just bywatching you.
And some of these things requirea lot more.
So you want the expert noviceright at the end of that And
that's not what you're getting.
(14:07):
I don't think with anteriorwho've never had it before.
So it's probably different forthe next group of trainees, but
I think that was one of thedownfalls of the anterior early
on was was high fidelitytraining on cadavers.
Then you came and saw someone,but they weren't the expert
novice.
They weren't the airline pilothas done 10, 000 hours on the
simulator, right?
(14:28):
They were essentially stillgoing through their learning
curve.
And hopefully that, so I do havea problem with visitations and
reverse visitations for certainsurgeries.
And I think anterior approach isone of them.
it has its place at a certainstage, not early on in their
learning curve.
But it looked at everyone'sdifferent.
There are some people who areexceptionally talented.
(14:50):
And they'll be able to do thatvery easily, right?
Patrick Weinrauch (14:53):
I see, I see people at various points in
their learning journey, and theymight come up and visit to be
able to, see a bunch of casesbeing done just to be able to
know, actually, is this a, isthis really a thing, is this
something that's, that I wouldeven contemplate bringing into
(15:14):
my practice or is this somethingthat, it doesn't stack up for me
and then they see it and theycan make their decision, right?
And and then they might go offand they might start learning a
bit more and they might go andsee another guy.
And the, what, I tended to,observe.
in that space, though, is that,they would sit in a, like a pre
(15:39):
learning space or a learningspace, but they would never
actually start.
It would be like the conversionon that, that, that conversion
into starting doing their owncases was a bit of a rocky, a
bit of a rocky, road.
a transition and that's where,having a high quality long
fellowship, I think, has thebenefit because there's a lot
(16:01):
more, there's a lot more sort ofguidance in that transition zone
and to try to bridge that with areverse visitation is sometimes
difficult because it's so it'sone day, we've only got a couple
of cases.
Yes, it is.
You have got an expert surgeonwith you, but it's not like
doing it for over a period ofmonths, right?
And, reverse visitations for, usare, they're difficult because,
(16:28):
you've got to get licensure, andaccreditation in the receiving
facility.
and and it's very, very timeconsuming as well.
if it's just something, If it'sjust a guy down the road, that's
pretty easy.
But if it's like we're a bigcountry, right?
So to fly, three or four hoursto go into a reverse visitation
(16:51):
is like a two day process,right?
Could we use technology to beable to help that?
I think, absolutely.
There's a space for that, right?
So having the remote.
expert with, like we've talkedabout, like Google Glass or,
equivalent sort of devices wherethe remote expert can see what
(17:14):
the, surgeon is doing.
is that a bridging tool?
The answer is yes.
is it?
I suppose if we rated things onthe scale of minimum better
best, is it the best?
The answer is no.
I think a fellowship with Jitwould be the, that would be the
gold standard.
but is there a person in theirlearning journey in whom you
(17:36):
don't necessarily need to goexpend that much?
do you need to have best everytime?
The answer is there are peoplein their learning journey at all
different stages.
And for some, that might beenough.
And we're seeing, for instance,like new surgeons coming out now
who have done some anteriorthrough their primary training.
(17:58):
So they've actually hadexperience in this, but they're,
junior consultants and they justneed that little bit of a high
handholding or and then so maybea visitation and a reverse
visitation is all that, right?
So that's, a different person.
Joseph M. Schwab (18:13):
So Patrick, you, raised this question in my
mind and you had mentioned thisbefore.
is there a role in this type ofeducation, especially anterior
approach or other more complexprocedures, For a no fly list.
are there people that we shouldjust be able to say you should
move on me Just do somethingelse Or is this a situation
(18:37):
where you enough time enoughdedication enough resources?
And we're gonna get you to whereyou need to be
Jit Balakumar (18:44):
Oh, look, 100%.
I think I'm going to step inthere and say it.
I, I have one of my mentors usedto say to me, can't fly like an
eagle when you're a duck, right?
And it's a horrible expression,but it's, but look, it's a very,
I think we all know ourabilities and, watch some of my
(19:05):
senior surgeons who are mastersurgeons are beautiful.
And I just sit there thinking,Oh, am I ever going to be like
that?
And I think we're all pushingourselves to be better and
better.
we know some of us haveawareness, some of us don't, but
I definitely think there is.
There is a higher level ofmanual dexterity and manual,
(19:28):
intensity and awareness that youneed to do to be able to do
that, right?
It's a more technicallydemanding operation and makes it
fun for us.
We need.
a new level of challenge.
but the flip side, it's got lotsof, I guess benefits.
I am going to speak to withtechnology and training.
I went through a lot of thingsto try to enable this to be
(19:51):
better.
So I went on augmented reality,virtual reality with, as a group
called Fundamental Surgery inthe UK, who've got, haptic
feedback.
So you can feel the incision,feel the osteotomes, feel the
broaching.
And, I'm one of those people washappy to accept that my initial
belief about Covid wascompletely wrong.
(20:11):
I'm always very happy to acceptand go back and say what I did
was wrong.
And I can say that all of thoseenabling technologies, which I
thought was going to be great,wasn't so good.
And I think it comes down tosomething very simple.
I think what Patrick said,hopefully it seeps into training
enough that it may be that thesevisitations and reverse
visitations is all that'srequired hopefully in the
(20:33):
future, nothing at all.
that they've done enoughtraining that they don't need to
do it.
Patrick Weinrauch (20:38):
The real question though is who is the,
who was the gatekeeper on that,right?
So if, interesting um, a traineeor so if they're a trainee,
that's easy, right?
Because there's a, there's astandard that you need to
achieve, for you to be able topass that unit.
And, if you haven't achieved it,then you require, Retraining,
(21:01):
right?
So that's easy.
What?
What happens when you've got theticket?
got your ticket, haven't you?
and so the real question is, whois the arbitrator of, of the
gate as you who is thegatekeeper?
And, is that the educator?
(21:23):
because, if someone comes tovisit me, I can't tell them not
to.
It's like I can give them somereally sage like advice saying
watch out and maybe you mightconsider a little bit of
additional training.
but then, I think the otherthing is that most.
(21:43):
Companies now are quite investedin trying to make sure that
their implants are, in Australiaanyway, because of our National
Joint Replacement Registry,picking up the trends of
revisions and failures, industryhas a, a stake in ensuring that
(22:06):
their implants are beingmaintained.
Placed in by, surgeons who havegot a low revision rate and so
it's in their interest to makesure that we're up to scratch.
and so sometimes I might have aindustry come to me and say,
listen, we've got the surgeonwho's struggling a little bit
and these are the, parts thathe's finding hard.
(22:29):
He or she is finding hard.
do you mind if we can bring themalong so you can like
specifically nail there and howto deliver the femur for
instance, right?
and so that's, where they comeback to be able to learn that
one particular step.
Joseph M. Schwab (22:45):
Join me next week for the final part of our
round table discussion,examining the anterior approach
from down under.
We finish our conversation withguests Patrick Weinrauch, Jit
Balakumar, Ilan Freedman and JoeScerri.
Don't forget to check our shownotes for information about each
of their practices.
Make sure to like and subscribeso we can keep this type of
(23:06):
content coming.
And until next week, this is JoeSchwab reminding you to keep
those hips happy and healthy.
Welcome to part two of examining the
anterior approach from downunder.
Let's get back to ourconversation with Australian hip
surgeons, Patrick Weinrauch,Ilan Freedman and Jit Balakumar,
as well as orthopedic sales repJoe Scerri.
Which, which just raises my nextquestion, and you started this
(00:28):
conversation here a bit, Jit, sowhat do you guys see as the
biggest challenges orcontroversies about DAA, within
the landscape of Australia?
Jit Balakumar (00:39):
The biggest controversy, it's what you've
said already.
I think the, creme de la cremein orthopedics for most, hip
surgeons is arthroplasty.
you have a winning surgery.
very predictable outcome.
Patients are usually lowmaintenance.
So that's what most people wantto do.
And so I think you have to becareful.
(01:00):
There's the private practiceaspect and we've all seen
LinkedIn videos, YouTube videosof patients walking day one post
op 20 steps of stairs.
And, is the marketing, right?
And.
I think this it's no, it's notdissimilar to what my senior
colleagues did with yellowpages.
So we shouldn't criticize peoplefor that.
(01:22):
with it comes some risks becausewe all get complications and we
all have problems.
So when you put yourself outthere, it can also be the sword
you die by.
let's look at the data.
The data shows anterior andposterior approach is.
It's exactly the same inoutcomes at six months, and
there's double the rate ofdislocations with posterior
(01:44):
approach, almost three times theincreased rate of infection,
twice the rate of fracture andloosening, early loosening in
the anterior approach.
so there's, trade offs and Ithink we have to be cognizant
when you do it.
But I agree with Dr Mattacompletely.
I think the market is thecurrent market is very astute.
(02:05):
They know what they want theyare all on social media.
Pat does a lot of resurfacings.
I have so many patients comingin saying, look, I want a
resurfacing.
And I said, where did you hearabout this?
I go, I'm on a Facebook website.
I'm a runner.
I'm a marathon runner.
I've heard that you've got to beloading your proximal
metaphyseal bone if you want torun long distances.
(02:29):
And, I said, look, you're,absolutely right.
look, I'm going to send you toone of my partners.
But the market is way more wellequipped to actually know and
have the knowledge Then we givethem credit for I think gone is
the paternalistic era But you'vegot to play a role in this and
say look I think Um in my hands,this is what the best approach
(02:51):
is.
So I think it's Dr Matta'sabsolutely right the market's
driving it and that's what'sgoing to organically grow it.
Joseph M. Schwab (02:58):
Do you think we're moving the paternalism out
of the clinic room and onto theinternet when we're engaging
with patients, that way?
is that, we're ceding thatinformation a little bit, to our
patients, ahead of time.
Ilan Freedman (03:12):
Yeah, it can be a bit difficult.
Patients come in now, asking forspecific bearing surfaces or
asking you about what particularpolyethylenes or which, which
exact metal have you used.
So it's, I guess it's the, theside effect of having all this
information on hand.
patients can access all of thatvery easily, and many of them
do.
So come in with good questions,but sometimes come with
(03:33):
questions which, They don'treally know what to do with the
answers, they come in asking,what metal is it?
And you tell them and they lookstunned.
yeah, but people are coming in,very informed and they read your
bio, they read your results.
In some cases, they've read yourpapers.
So I guess that's the realitynow.
Patrick Weinrauch (03:54):
I don't, mind, patients being well
informed, I think that, I thinkit's, I think that it's good
that they've we instinctively, Ithink sometimes they may be a
little over informed, but,there's a, good balance there.
And, and I think, I think it'snice to be able to have a really
(04:14):
robust sort of education of apatient prior to their surgery.
so I I don't, shy away from, apatient comes in and my heart
doesn't sink when they come inwith their, with their ream of
papers, it's like, Yeah,sometimes it can be a bit
tricky, our role is, as aresponsible professional is to
(04:35):
guide them, right?
And we're there to be able toeducate them and to be able to
put, what they've read intocontext and balance because
we're the subject matter expertsand, if they're relatively well
read, then it's actually quiteeasy to direct them there and to
be able to, give them aframework to be able to
(04:57):
understand what they're reading.
And I suppose my, comment,bringing it back to anterior
approach is, that, historically,I think when, anterior approach
first came into Australia in anynumbers.
There was very much a, it wasreally marketed hard.
(05:18):
That wasn't necessarily just, infact, that probably wasn't so
much surgeons who are drivingthat.
That was industry.
So industry was driving anteriorreally hard because there was
one company in particular thatwas linking, anterior approach
and, this is the implant andthis is the table.
And so it was like a package andthis, and from a surgeon's
(05:38):
perspective, that was theeasiest conduit to be able to
get education in the space aswell.
So it was a very successfulmarketing strategy, to be able
to, educate surgeons, educatethe community and build
awareness around it allsimultaneously.
And so that particular company,which was really a minnow in
(05:59):
Australia at the time has reallyboomed, right?
So it's a very successfulcompany now in Australia for
that reason.
I think we've seen a bit of acorrection now over the last
sort of eight years where prettymuch all of the companies have
got an anterior offering now.
So instrumentation platforms andthings like that.
(06:19):
And so, we're now starting tosee a bit of diversity, amongst
the ways in which we are doingsurgery.
For instance, whether it's beingput on a traction table or not
on a traction table, there'squite a, I'm not sure what the,
we can't capture that on theAustralian registry.
My instinct is it's probablystill dominated by table use,
(06:43):
but then there's a quite a bigcomponent which are doing it off
traction tables as well now,which is pretty much, and, very
much being implant agnostic nowas well.
Joseph M. Schwab (06:56):
Would you say that the industry based
education, that you're talkingabout, was that a primary driver
towards adoption of, of anteriorapproach or were people getting
their surgical, education onthis technique, it mostly in
other ways.
Patrick Weinrauch (07:13):
So in Australia, like when I went
through My residency, we call itregistrar, but residency, the,
there was really no exposure toanterior approaches.
So this is a technique that I'vetaken up post, qualification
fellowship.
(07:35):
and We're very reliant onindustry support to be able to
get that education, right?
and this of course you do usnowadays if you can find a place
to go and do fellowship, right?
Where you can learn thosetechniques in your fellowship,
but you know a post fellowshiporthopedic surgeon requires
(07:55):
Industry support.
The industry is still veryinvolved here in Australia in,
surgeon education, not just ananterior approach, but in all
aspects,
Jit Balakumar (08:05):
I run two fellowships, and my, all my
fellows, they start theirpractice.
I have a local fellow andinternational fellow their
practice almost instantlyexplodes because of anterior
approach.
Um, look, obviously, I learnedslightly differently, but I
remember that actually the firstanterior approach I saw was with
a guy in Box Hill Hospital,public hospital, and, there was
(08:29):
two of them actually there.
One guy who did it on the table.
Supine and another guy who didit in the lateral position
anteriorly and I was blown awayby it.
No one talked about it.
There was no marketing, buttheir recovery was very
different to the rest of the,unit.
And then when I went to my,equivalent rural rotation, I
convinced my boss there to do itanteriorly.
(08:50):
We had a ASR head, with an ASRcup with a Zweimuller stem, and,
it was, a disaster, and I shouldnever have convinced my boss to
do that, But I would say, look,I echo Pat's points.
It's, changed very much in theindustry has really been, people
(09:10):
are very quick to criticizeindustry.
They have improved patientoutcomes dramatically by
championing high qualityeducation, right?
And, they, the smaller startupcompanies use it as a point of
difference.
The larger companies try to getahead with it.
And now, fellowships that areattached to an anterior, because
(09:32):
they can see the, the return oninvestment and how they can
monetize it.
On the flip side, think everyhospital, I'm sure it's the same
in Queensland and in Australia,in Victoria to be credentialed.
So they classify anterior hips,robotic surgery as a tier B
credentialing.
So not the standard that youfinish in your training program.
(09:54):
And to be credentialed, theyexpect you to have done either a
fellowship.
Or have done at least 30 caseswith someone who's an
experienced anterior hip surgeonand then be supervised by their
local, whoever the hospitalrepresentative is.
there's some very robustcredentialing process and I
again tell trainees, look,you've got to be careful.
(10:16):
When you first start, you don'twant to be, you've got to slay a
few dragons to get your princessand we don't want to go through
that process, right?
don't want to be slayingdragons.
That's not the process withthis.
And, I think that's industry hasdone that amazingly here.
Joseph M. Schwab (10:32):
Joe, as the representative of industry in
this conversation, what do you,what have you seen in the
landscape of anterior approachin Australia?
What has been most striking toyou?
Joe Scerri (10:44):
I think I'd like to answer that question a little
bit historically, and that is ina lot of the points that the
guys are making, certainlyfellowships are really
important.
and I've done a number at,Wrightington and various places
like that over the years.
in France and, so forth and theyhave been, as has been mentioned
(11:06):
in terms of the return oninvestment, excellent because
quite often they're with a highvolume surgeon who happens to be
using obviously, the implantthat is manufactured by the
company that sponsors it.
And then they come back as adevotee and, it becomes a nice
circular return.
Everybody wins.
And, and that's been aworthwhile investment.
(11:29):
And as far as I know.
continue to do that.
then you've got the existingfellowships.
the one that, that you'vementioned Jit when Jit does the
anterior approach, the peoplethat become, proficient at that,
have to learn somewhere.
So if they decide that's forthem in their private practice,
(11:49):
then they'll continue to dothat.
So that goes on.
And then you've got.
people like Pat who, dovisitations from various
companies.
and I think that there areselected people around the
country who, perform directanterior where there are medical
companies that will send,surgeons to those, to those
(12:13):
surgeons because it enables themto be trained on the anterior
approach, but at the same time,presumably.
If they like the implant at thetime, then they go back and that
becomes part of their privatepractice.
And I think that's where, onehand, rubs the other and
everybody wins as well.
And, then there are other thingsthat, I'd like to get involved
(12:35):
in.
And that is, we're not bigenough to be able to sponsor
those things, but certainlythings like, cadaver workshops,
where, you know, that can belearned on that approach.
think, those go on as well, butI think the combination of
fellowships, visitations, Andcertain workshops are probably
the collection of things thatsurgeons are getting exposed to
(12:57):
when registrars and seniorfellows.
Joseph M. Schwab (12:59):
has the landscape for visitations in
Australia, has it begun toinclude things like reverse site
visits where a mentor will comeand spend time with a surgeon as
they're starting to do theircases?
And has there been anyintroduction of, virtual
visitations, using, augmentedreality, virtual reality, those
(13:23):
sorts of things?
Jit Balakumar (13:24):
I've got to say something about that, though.
Look, I do have a problem withvisitations.
And I think Pat and I were withJ and J at this stage where they
were trying to develop this minifellowship and and reverse
visitations.
I do think, the.
One of our all of our pet,interest is adult education,
right?
And adults are very differentlyeducated based on who you are.
(13:47):
There are some who can just dothat and they'll come back and
I'm sure Pat, you probablytaught a lot of people how to do
resurfacings, but there are someyou would never let do a
resurfacing afterwards just bywatching you.
And some of these things requirea lot more.
So you want the expert noviceright at the end of that And
that's not what you're getting.
(14:07):
I don't think with anteriorwho've never had it before.
So it's probably different forthe next group of trainees, but
I think that was one of thedownfalls of the anterior early
on was was high fidelitytraining on cadavers.
Then you came and saw someone,but they weren't the expert
novice.
They weren't the airline pilothas done 10, 000 hours on the
simulator, right?
(14:28):
They were essentially stillgoing through their learning
curve.
And hopefully that, so I do havea problem with visitations and
reverse visitations for certainsurgeries.
And I think anterior approach isone of them.
it has its place at a certainstage, not early on in their
learning curve.
But it looked at everyone'sdifferent.
There are some people who areexceptionally talented.
(14:50):
And they'll be able to do thatvery easily, right?
Patrick Weinrauch (14:53):
I see, I see people at various points in
their learning journey, and theymight come up and visit to be
able to, see a bunch of casesbeing done just to be able to
know, actually, is this a, isthis really a thing, is this
something that's, that I wouldeven contemplate bringing into
(15:14):
my practice or is this somethingthat, it doesn't stack up for me
and then they see it and theycan make their decision, right?
And and then they might go offand they might start learning a
bit more and they might go andsee another guy.
And the, what, I tended to,observe.
in that space, though, is that,they would sit in a, like a pre
(15:39):
learning space or a learningspace, but they would never
actually start.
It would be like the conversionon that, that, that conversion
into starting doing their owncases was a bit of a rocky, a
bit of a rocky, road.
a transition and that's where,having a high quality long
fellowship, I think, has thebenefit because there's a lot
(16:01):
more, there's a lot more sort ofguidance in that transition zone
and to try to bridge that with areverse visitation is sometimes
difficult because it's so it'sone day, we've only got a couple
of cases.
Yes, it is.
You have got an expert surgeonwith you, but it's not like
doing it for over a period ofmonths, right?
And, reverse visitations for, usare, they're difficult because,
(16:28):
you've got to get licensure, andaccreditation in the receiving
facility.
and and it's very, very timeconsuming as well.
if it's just something, If it'sjust a guy down the road, that's
pretty easy.
But if it's like we're a bigcountry, right?
So to fly, three or four hoursto go into a reverse visitation
(16:51):
is like a two day process,right?
Could we use technology to beable to help that?
I think, absolutely.
There's a space for that, right?
So having the remote.
expert with, like we've talkedabout, like Google Glass or,
equivalent sort of devices wherethe remote expert can see what
(17:14):
the, surgeon is doing.
is that a bridging tool?
The answer is yes.
is it?
I suppose if we rated things onthe scale of minimum better
best, is it the best?
The answer is no.
I think a fellowship with Jitwould be the, that would be the
gold standard.
but is there a person in theirlearning journey in whom you
(17:36):
don't necessarily need to goexpend that much?
do you need to have best everytime?
The answer is there are peoplein their learning journey at all
different stages.
And for some, that might beenough.
And we're seeing, for instance,like new surgeons coming out now
who have done some anteriorthrough their primary training.
(17:58):
So they've actually hadexperience in this, but they're,
junior consultants and they justneed that little bit of a high
handholding or and then so maybea visitation and a reverse
visitation is all that, right?
So that's, a different person.
Joseph M. Schwab (18:13):
So Patrick, you, raised this question in my
mind and you had mentioned thisbefore.
is there a role in this type ofeducation, especially anterior
approach or other more complexprocedures, For a no fly list.
are there people that we shouldjust be able to say you should
move on me Just do somethingelse Or is this a situation
(18:37):
where you enough time enoughdedication enough resources?
And we're gonna get you to whereyou need to be
Jit Balakumar (18:44):
Oh, look, 100%.
I think I'm going to step inthere and say it.
I, I have one of my mentors usedto say to me, can't fly like an
eagle when you're a duck, right?
And it's a horrible expression,but it's, but look, it's a very,
I think we all know ourabilities and, watch some of my
(19:05):
senior surgeons who are mastersurgeons are beautiful.
And I just sit there thinking,Oh, am I ever going to be like
that?
And I think we're all pushingourselves to be better and
better.
we know some of us haveawareness, some of us don't, but
I definitely think there is.
There is a higher level ofmanual dexterity and manual,
(19:28):
intensity and awareness that youneed to do to be able to do
that, right?
It's a more technicallydemanding operation and makes it
fun for us.
We need.
a new level of challenge.
but the flip side, it's got lotsof, I guess benefits.
I am going to speak to withtechnology and training.
I went through a lot of thingsto try to enable this to be
(19:51):
better.
So I went on augmented reality,virtual reality with, as a group
called Fundamental Surgery inthe UK, who've got, haptic
feedback.
So you can feel the incision,feel the osteotomes, feel the
broaching.
And, I'm one of those people washappy to accept that my initial
belief about Covid wascompletely wrong.
(20:11):
I'm always very happy to acceptand go back and say what I did
was wrong.
And I can say that all of thoseenabling technologies, which I
thought was going to be great,wasn't so good.
And I think it comes down tosomething very simple.
I think what Patrick said,hopefully it seeps into training
enough that it may be that thesevisitations and reverse
visitations is all that'srequired hopefully in the
(20:33):
future, nothing at all.
that they've done enoughtraining that they don't need to
do it.
Patrick Weinrauch (20:38):
The real question though is who is the,
who was the gatekeeper on that,right?
So if, interesting um, a traineeor so if they're a trainee,
that's easy, right?
Because there's a, there's astandard that you need to
achieve, for you to be able topass that unit.
And, if you haven't achieved it,then you require, Retraining,
(21:01):
right?
So that's easy.
What?
What happens when you've got theticket?
got your ticket, haven't you?
and so the real question is, whois the arbitrator of, of the
gate as you who is thegatekeeper?
And, is that the educator?
(21:23):
because, if someone comes tovisit me, I can't tell them not
to.
It's like I can give them somereally sage like advice saying
watch out and maybe you mightconsider a little bit of
additional training.
but then, I think the otherthing is that most.
(21:43):
Companies now are quite investedin trying to make sure that
their implants are, in Australiaanyway, because of our National
Joint Replacement Registry,picking up the trends of
revisions and failures, industryhas a, a stake in ensuring that
(22:06):
their implants are beingmaintained.
Placed in by, surgeons who havegot a low revision rate and so
it's in their interest to makesure that we're up to scratch.
and so sometimes I might have aindustry come to me and say,
listen, we've got the surgeonwho's struggling a little bit
and these are the, parts thathe's finding hard.
(22:29):
He or she is finding hard.
do you mind if we can bring themalong so you can like
specifically nail there and howto deliver the femur for
instance, right?
and so that's, where they comeback to be able to learn that
one particular step.
Joseph M. Schwab (22:45):
Join me next week for the final part of our
round table discussion,examining the anterior approach
from down under.
We finish our conversation withguests Patrick Weinrauch, Jit
Balakumar, Ilan Freedman and JoeScerri.
Don't forget to check our shownotes for information about each
of their practices.
Make sure to like and subscribeso we can keep this type of
(23:06):
content coming.
And until next week, this is JoeSchwab reminding you to keep
those hips happy and healthy.
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