October 24, 2025 • 41 mins
Transforming Hip Surgery from 2D to 3D: Insights on Anterior Approach and Advanced Tools 🦾👨⚕️
In this episode of the AHF Podcast, host Joe Schwab discusses the revolution in anterior approach total hip replacement surgery with Dr. George Haidukewych from Orlando Health and Dr. Brad Waddell from the Carrell Clinic. The conversation explores the impact of 2D and 3D preoperative planning tools on shaping implant choices, enhancing accuracy in complex cases, and guiding intraoperative execution. Key technologies discussed include Smith+Nephew's CORIOGRAPH◊ pre-op planning, RI.Hip Solutions, CATALYSTEM◊ primary hip system, and the CORI◊ Surgical System. This episode highlights how precise planning and cutting-edge tools contribute to better patient outcomes and streamlined surgical procedures.
This episode is sponsored by Smith+Nephew. Learn more at smith-nephew.com
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:23):
Hello and welcome again to the AHF
Podcast.
I'm your host, Joe Schwab.
Today we're joined by twoleaders in hip replacement
surgery, Dr.
George Haidukewych from OrlandoHealth, and Dr.
Brad Waddell from the CarrellClinic.
We'll discuss how preoperativeplanning with 2D and 3D tools is
(00:44):
transforming anterior approach.
It's shaping implant choices,improving accuracy in complex
cases, and guidingintraoperative execution.
Whether you're experienced inhip arthroplasty or just getting
started, you'll find valuableinsights in this conversation.
Dr.
Haidukewych, Dr.
(01:05):
Waddell, thank you for joiningus today.
before we dive into thetechnical details, how did each
of you come to adopt anteriorapproach in your practice?
What sparked your interest inthe technique?
George Haidukewych (01:18):
I've done all the approaches over the last
30 years and over the last fivehave.
Move to almost all directanterior for several reasons.
First and foremost, just lookingat the data of how well patients
recover.
I think it's really a patientdriven, they want the approach,
they want to get back toactivities the patients are
operating on are younger,they're more active, and I think
(01:41):
we've solved the problem oflong-term durability.
And implants.
Let's face it, our uns cementedmodern implants can last decades
and decades.
We're not really worried aboutloosening.
We're less worried about polywear.
so what's left?
can we get the patients backsooner?
Can they get more active?
Can we be less invasive in ourapproach?
Can we.
Have them get rid of their gateaids quicker, even go home the
(02:04):
same day.
So all of that kind of cametogether at the same time.
The drive to outpatient surgery,patients being younger, patients
wanting to get home quicker, getback to things, and then people
talk.
They want, my neighbor had a DAhip, he was back golfing in two
weeks.
you're, if you don't do thatapproach, you're gonna have a
hard time competing with that.
So that all of that kind of cametogether at the same time for
(02:24):
me.
Joseph M. Schwab (02:26):
Dr.
Waddell, how about you?
Brad Waddell (02:28):
Yeah, so I, I'm in my 10th year of practice, so I
was fortunate to train in theera of where anterior hip was
coming about.
during my residency, I never sawan anterior hip.
I came into fellowship saying,I'm just gonna learn how to do
some of this, and I'll go backto what I know, what I've seen.
I recall the clinic where Iwatched a patient at two weeks
(02:53):
follow up and they just talkedabout how amazing they waltzed
down the hall.
They were moving their hip inways that I'd never seen any hip
do at any time point.
And so I distinctly recall themoment where I said, man, I'm
gonna lean into this.
So I was very fortunate to trainunder some really good surgeons
who taught me anterior approach.
Since then, it's been my go-toapproach for the last 10 years.
Joseph M. Schwab (03:17):
What were some of the big challenges that you
both faced doing anteriorapproach early on?
George Haidukewych (03:26):
I think the, just being familiar with the
anatomy, 90 degrees to the wayyou're used to looking at
everything, and the, learningthe exposures.
I think that whole operation, tobe honest with you, is about
careful soft tissue handling andexcellent exposure.
Really the reaming broaching isthe same as you do in any other
hip.
But being able to see and notdamage the TFL and other soft
(03:48):
tissue structures in and out ofthe hip, carefully delivering
the femur, there's a learningcurve to that.
you don't wanna start with a BMI60 with a broken nail on their
femur.
You wanna start with somebodyskinny, easy, and then gradually
learn from, several surgeons.
The exposure moves.
'cause once you have theexposure down and it becomes a
pretty straightforwardoperation.
But that was the biggest hurdle,is just to learn these moves and
(04:09):
the sequence of, okay, what do Ido if I can't see the as tabular
wall?
What's my checklist?
What do I do if I've done allthe releases, the femur is still
not coming up, what do I do?
So getting through that anddoing this when an experienced
surgeon, I think is critical.
Brad Waddell (04:24):
Yeah, I couldn't agree more.
I, definitely learned tips andtricks and pearls in, fellowship
where I got to skip some of thelearning curve.
But I also suffered from havingwatched some of the best
surgeons.
Did the world do it?
And, jumping right in, I wasexperiencing things that, I
didn't see them go through.
(04:45):
absolutely.
I think, soft tissue exposure,ch making sure everything's in
the right place.
There's no question, there's alearning curve to it.
even now, I don't do very manyposterior approaches, primaries,
but it can just come right backto you.
The anterior, thousands later, Istill will have times where I
(05:07):
struggle more with an anteriorthat I've done many more times
than a posterior.
I, I think soft tissue exposureand then proper releases, can
really set the case apart.
Joseph M. Schwab (05:19):
So let's talk a little bit about your pre-op
planning.
'cause I get the impression fromhearing both of you talk that
precise pre-op planning issomething critical for a
successful anterior approach.
Are there particular patient oranatomy factors that, you take
into account during the planningphase or make planning sort of
non-negotiable for you?
(05:39):
Tell me a little bit about thatprocess.
George Haidukewych (05:43):
Yeah, I think, I get sitting and
standing views of the pelvis,lateral views to look at the
lumbar, mobility and the pelvictilt.
I think that's become routine inmy practice.
Every new patient gets thosex-rays and you'd be surprised at
how much that can affect yourimpingement arc if you actually
model it.
And some of the, the CORIOGRAPHsoftware that I use.
(06:03):
Basically automates for me.
I don't have to get theprotractor out and start writing
all sorts of angles.
We enter the pictures and it'lldo an impingement analysis for
the case.
So if you think about it, you'retrialing before you even open
the patient, you know you'regonna need a size F, a size 52
cup, whatever, five, highoffset, zero ball, here's your
(06:23):
neck cut, here's your hipcenter.
So it gives you the position ofthe components.
That will not impinge takinginto effect, into, account
rather the lumbar tilt and thepelvic deformity, if any.
So it does the math for you,which is nice.
I simply ask my rep, what's thetarget?
They said 42 17, whatever it is.
That's my impingement free arcand it's a size 5 54.
(06:46):
that's saves me a lot of time insurgery because, if all of you
are on table surgeons.
Multiple trials are a pain inthe neck on a DA approach.
You gotta take everything out,put everything back.
It's not a quick, just poppingyour head on, it's laborious.
And if you're changing offset,changing leg length, changing,
version what have you doing thatahead of time to know you'll be
(07:07):
impingement free.
Really saves me a lot of time.
It's also pretty tough on atable to check for posterior in
stability.
I don't think any of us aretaking the boot out, flexing the
hip to a hundred degrees andinternally rotating and
contaminating the whole feed.
I've never seen anybody do it.
so checking for posteriorstability, again, impingement,
you could do that ahead of timewith the CORIOGRAPH software.
(07:28):
So I love it.
It's become routine for me in mypractice.
I do it on every patient.
Brad Waddell (07:34):
Yeah.
So to that point, you ask aboutpre-op, it's, non-negotiable.
There is a significant amount ofpre-op templating and planning
that goes into every case.
As George said, it's gotten awhole lot easier.
it's always been, x-rays 2D slapon, the cellophane thing and
(07:57):
make sure the sizing is right,but in terms of where we should
be putting it.
As opposed to just the size hasgotten, a lot easier and a lot
better.
It began with Smith+Nephew'smodeler, where they were the
first ones to actually modelimplant impingement, and now
we've jumped forward to 3Dmodeling, including bony
(08:18):
impingement, et cetera.
It's just made life a whole loteasier.
like George said, taking all ofthis into account prior to even
putting any, prior to touching apatient is, life altering for
me.
I, feel the same way.
Me and my rep, the engineers onthe CORIOGRAPH 3D modeling
prepared for us based on mypreferences in a meeting you
(08:40):
have with them.
But then, once I have theengineer's plans, me and my rep
will go over before the day,before cases.
We'll look at all of those,templates, models, and make
appropriate changes prior togetting into the operating room.
As George said, I've alreadytaken the patient through all of
these tests, and, it, certainlyhas made life a whole lot
(09:03):
easier.
I've found myself trialing lessand, cases are going faster and
smoother.
Joseph M. Schwab (09:10):
So does every patient get both two dimensional
and three dimensional planningor do you decide between the two
and how do you decide which oneyou're gonna do?
Brad Waddell (09:20):
For, three dimensional.
It requires a CT scan.
about 35% of my patients comefrom out of town, so we haven't
done it for those patients, butI want three dimensional on
every single person.
and we're working on ways to,expedite, right now it's about
the quickest turnaround you canget on 3D templating, which is
(09:42):
less than two weeks, butunderstandably, patients don't
wanna fly in town or drive in toget it.
And so with my practice, we'reworking on getting 3D for
everyone, but I'll tell you, thebenefits of 3D templating,
including the femoral version,where the neck cuts should be,
taking femoral version intoaccount.
(10:02):
certainly, over the last 10years, I've only had to change
the cup a few times.
maybe 5, 6, 7 times.
After I put the stem in becauseof a version that I wasn't
expecting, and we have theability to eliminate that step,
once a year, once every otheryear.
But still, those are stickingpoints that I remember.
(10:22):
Every one of those cups I've hadto change after putting the stem
in.
So certainly 3D templating is avery nice way to go.
And the benefits of it includethat Fal version.
Joseph M. Schwab (10:35):
George, how about.
George Haidukewych (10:37):
Yeah, I think said.
The I use the 3D selectively.
Probably 25, 30% of my patientsI'll send for the 3D planning
when I'm worried about boneyimpingement or like he
mentioned, femoral versionweirdness or some sort of
deformity.
I've had a few femoral deformitycases where I wasn't sure
whether I could sneak down likea primary catalyst stem, and
(10:59):
sure enough, they did the 3D andif.
I thought for sure I'd need anosteotomy.
So something unusual in theanatomy.
They all get three D's routine.
Grandma with a simple arthritichip, normal version.
Normal anatomy looks great.
I'll just do the 2D planning andI found that to be accurate.
It's faster and you could getthat very quickly.
I.
Joseph M. Schwab (11:19):
Have you found any differences in how you view
or assess or think about thingslike leg length or spinal pelvic
balance based on whether you'redoing 2D or 3D?
George Haidukewych (11:31):
it takes the, the software, 2D or 3D will
tell you your effect, if you putinto templated sizes on leg
length and offset, which is nicebecause let's face it, we've
seen these males that have thesegiant long femoral necks, huge
amount of offset.
And we're worried how are, we'regonna restore tension on those.
And, there, with the 3Dplanning, you can actually move
(11:51):
the cup and maybe not media,alize all the way to Kohler's
line to try to get some offsetthere.
You could change your neck cutsand play with different STEM
geometries.
It's really very useful.
So it gives you, i, I call itlike templating five oh one.
It gives you just a differentview of the hip in three
dimensions where you put the hipcenter and how you handle
femoral deformity.
So it's been, as far as do Iview the hip differently?
(12:14):
Yes, I think I understand it ata deeper level now that I can
actually move things in threedimensions.
It's very interesting to do.
It's great to teach, if you'reteaching residents and fellows,
it's a great tool to help themthink about hip center and
offset.
Joseph M. Schwab (12:28):
Brad, does having these tools, impact your,
having these tools at yourdisposal?
Does it impact your confidenceheading into surgery or are you
confident either way.
Brad Waddell (12:41):
No.
I'm a very nervous person andthere is a controlled confidence
that's been there and itcontrol, it continues to get
more and more.
certainly on three DI find thatleg length estimation is more
accurate.
I like that aspect of it.
(13:02):
the, to George's point in termsof teaching, it's a wonderful
tool, but I'll tell you, I thinkI've probably, Learned more
myself than I've been able toteach.
I'm a mentee of chit ronaut whocombined aversion is 45 degrees.
But I, think that combinedaversion of 45 degrees is a
(13:24):
posterior approach.
Specific combined verion.
And what I've found usingCORIOGRAPH, using 3D Templating
is that my combined inversion isin the low thirties.
and I've been able to see thatand learn more.
Again, more about myself.
If you talk to me 10 years ago,first year in practice, I was
(13:45):
shooting for a combinedinversion of 45 degrees in the
anterior, and I think that'sprobably too much.
It, has allowed me to, I think,become more confident and
certainly I think I've learnedmore about myself as a surgeon
using these, 3D templatesbecause I have so much
information in my disposal.
(14:08):
it's, it, I think it's gonnacontinue to make me a better
surgeon.
Joseph M. Schwab (14:12):
this raises an interesting question.
you both described seeingdifferences in intraoperative
adjustments that you might make,either decreasing the number of
adjustments you might make, orchanging how you would make
those adjustments as you've beenincorporating this, the sort of
extra planning, the twodimensional and
three-dimensional planning.
Are you seeing differences inoutcomes with this extra, with,
(14:37):
the, planning methodology thatyou've been using?
George Haidukewych (14:41):
obviously hard to assess.
the DA patients do so well.
I have a very low rate ofinstability, so that's, a good
thing.
but I have no, nothing tocompare it to because I've been
planning, with this ever since Istarted.
so it'll be it.
If you look at the instabilityrate in DA Hips is about 0.6%,
just depending on what study youread, like one to 200 about.
(15:05):
So it'll take a massive study,massive amount of patients to
prove, but there's no logic thatdefies.
the fact that if we put itimplants in accurately and we
can avoid impingement andoptimize leg length and offset
intellectually, they should havea better outcome over the long
term than those that where wedid not do that.
(15:26):
But again, it'll probably taketens of thousands of patients
randomized somehow to prove, butwhy would you not if you
couldn't?
It is basically the analogy Igive our students.
It's bill.
Building a custom suit forsomebody versus giving somebody
right off the shelf and puteverybody at 40 15 and hope for
the best.
Now you can actually define thetarget for that patient
(15:46):
specific.
Lumbar pathology or their pelvicO liquidity, and you could say,
okay, they need 45, 25 to avoidimpingement, and then you hit
that with the navigation.
We'll use the corry navigationto actually hit that target.
So if you can be that accurateto define the target for a
specific patient and then hitthat target now, it just takes
time to get enough data to provethat they're doing well.
Brad Waddell (16:09):
Yeah, I have a couple of thoughts on that and I
couldn't agree more that,anterior hips in my practice and
almost everybody's practice dotake a lot of people to see a
big difference.
we're following patient reportedoutcomes and if we properly
tension the muscles and if weproperly put the patient, then
(16:32):
you know, they're gonna have a,faster return to a forgotten hip
score.
Or they're going to just,muscularly feel better.
I've asked, my neurologyfriends.
Do you think an EMG would show adifference in muscle tension?
And we don't have a way to lookat that yet, but I think that's
where the next steps of this isgoing to go is we're gonna be
(16:55):
able to, see patients where theybelong, are gonna lead to
patients with better outcomes,faster return to activity,
faster, forgetting the hipreplacement faster.
retrieval studies are superimportant and when I was a
fellow, we did a retrieval studylooking at impingement on
liners, and large heads decreasedislocation, but we showed that
(17:21):
large heads didn't decreaseimpingement, and so we were
seeing deformities on the edgeof the cup.
that, that were there with a 22,28, 32, 36.
but we, so there was the samelevel of impingement, but
decreasing levels of dislocationbecause it jumped distance and
all that sort of stuff.
And so I think, to George'spoint, as we put things where
(17:45):
they belong.
In retrieval studies, we may seethat impingement is gonna
decrease.
Certainly there is a consequenceto that.
Impingement.
We don't know exactly what itis.
We don't have the ability totest it.
But in the macro scale,dislocations are probably gonna
be about the same.
They're gonna be and maybelower, 0.3% instead of 0.6%.
(18:07):
so hard to tell with, smallnumbers of patients.
Joseph M. Schwab (18:11):
Do you think we'd be able to identify a
subset of patients, who are athigher risk for postoperative
complications, poor outcomesthat would really, truly benefit
from this type of technologywhere you wouldn't need nearly
so many to see a substantialbenefit, from a research
perspective?
Have you thought about that?
George Haidukewych (18:31):
Yeah, I think, the subgroup that I'd
like to study is those with thea fixed posterior pelvic.
Tilt.
In other words, the aversion isaccentuated on, the DA approach.
So if you put in your standardfluoro, guided cup, half face
open or whatever enablingtechnology you use, you may have
(18:52):
a functional aversion of 30, 35degrees and you think it's 15,
right?
So I think, look, looking at asubset of those, fixed pelvic
obliquity, cases where thepelvis is stuck in a sitting
position.
I think that would be, a subsetthat without careful planning,
if you put your standardaversion on, you're gonna be
(19:14):
over univer and risk anteriorinstability.
That'd be a fascinating one.
And conversely, those with ananterior pelvic tilt, so you
will click an inlet view onx-ray.
those have a high risk ofposterior instability.
If you under univert the.
So those outliers, I think thatwould be great to look at that
subset to see.
we could probably do the study'cause half my partners don't
(19:35):
use any, advanced planning and,half of us do to see if there's
any difference.
But we'd have to go into thosehigh risk groups.
But those outliers are actuallythe ones where this technology
helps me the most.
Those were, you, if you readsome of the, earlier literature,
by door and Victor Doic, they'lltell you in some of these cases,
(19:56):
okay, add a little aversion ortake a little aversion off,
depending on the pelvicposition.
But what does that mean?
Add a little verion.
How many degrees?
These programs, a CORIOGRAPH canactually take that into account
and they'll tell you 43 17,they'll give you something that
specific, and that's yourimpingement free position.
Then you could hit it with thenavigation, you can actually hit
43 17.
(20:17):
So it's been, really helpful inmy practice.
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Joseph M. Schwab (21:27):
So apart from, the software telling you, for
instance, exactly what yourtarget might be for position,
are you ever able to, or do youever encounter a situation where
it's gonna change your surgicalstrategy or even change your
implant choice based on.
What's, what would be consideredimplant free?
Would you move to a dual mobil,excuse me, impingement free?
(21:49):
Would you move to a dualmobility?
Would you change your, type ofcup or just the position of the
cup?
George Haidukewych (21:55):
you can actually change that in the
program.
You can go to do a mobility, goto 36 head 40 head, depending on
your cup size, obviously changethe offset of the stem.
So the cool part on the 3Dplanning is you could play with
all this in real time.
It'll tell you immediately whenyou make that plan.
There's, little box that saysleg length and offset change.
And it simulates activities ofdaily living, which are great,
(22:17):
deep squat, things like that.
golf swing, what have you.
So it'll tell you whether you'rehaving external rotation or
internal rotation, stability, orimpingement.
It'll show you exactly on themodel where the impingement is.
Is it bone, is it liner?
Is it femoral neck?
And then you can add offset.
You can add change of bearing,like you mentioned, change of
stem, whatever you wanna do toget rid of that impingement.
(22:39):
It's an incredibly versatiletool for that.
Brad Waddell (22:43):
Yeah, so if we look back 10 or 15 years ago
when, dual mobility first cameto America in the modular state,
it was used when we couldn'tfigure out what to do.
I've found my dual mobilityrates have decreased because now
I know where to put the partsand, dual mobility is a backup
(23:04):
plan when, sure, there's stillinstances where it's used, but
dual mobility is a backup planfor when.
You can't figure out the pelvis,you can't figure out, where they
sit in space where they're gonnamove or not move.
I use less dual mobility nowbecause I put the parts in a
better position.
And to your question earlier, itis the outliers who matter.
(23:26):
It's the flat backs and it's theover the Lords who are going to
come out the front, flat back,come out the back overly
lordotic, and then it's thefused person who doesn't.
Excuse me, move sitting tostanding.
Those are the ones we reallyworry about.
And yeah, we're, actuallylooking at those now.
And, following into that secondquestion, being able to put the
(23:49):
parts where they belongdecreases the need for a backup
plan, like dual mobility.
Joseph M. Schwab (23:54):
Yeah.
Interesting.
So you both, relied on somedata, so brought up some
research here as far as, thegroups that are at risk, what
the current benefits are ofanterior approach on its own.
so one question.
Can you share any of the outcomedata about 3D planning?
(24:14):
Is that out there in theliterature yet?
And how do you rely on, how doyou use that to make your
decisions?
George Haidukewych (24:22):
There's a little bit of literature out
there about.
Actually looking at bonyimpingement, right?
Something we really don't thinkabout.
We think about implantimpingement a lot.
I think it's Doug Dennis'series.
They looked at, I think they hadabout a third of their patients
actually had some bonyimpingement when the surgeons
were, would put the cup or wherethey wanted.
Basically, they let you do yourstandard planning and they put
(24:44):
your plan, say it's a 40 20,whatever your cup position is
into their 3D program, and foundthat probably a third of the
time you'd have an impingement.
If you put this cup in your samespot every time, so there is
data that impingement modelingand 3D planning will help you
identify things that you didn'tforesee.
There's plenty of data, but it'sprimarily posterior approach at
(25:06):
this point about, The planningand robotic or navigated
execution, right?
So if you're doing robotic ornavigated execution, you have a
target.
Somebody's told you where to putthe cup, you don't just randomly
put it in the human being.
And that data shows prettysignificantly from a posterior
approach that it significantlydecreases the rate of
instability.
(25:27):
Having said that the instabilityrates multiple times higher from
the back than the front.
Therefore, we're gonna need somepretty big series to show a
benefit for the DA approach.
I think those will beforthcoming as the approach gets
more and more popular.
Joseph M. Schwab (25:42):
How do you use this evidence?
so George, for instance, youmentioned that half your,
partners, use, some sort of,planning technology like this
half don't.
and how do you share this typeof evidence with your
colleagues, with your hospitaladministrators, with your
colleagues across the country oraround the world?
(26:04):
To encourage adoption to talkabout, what direction we need to
take this in.
George Haidukewych (26:10):
Yeah, that's just a matter of education,
showing them the benefit.
one of the best benefits otherthan time surgeons are always
sensitive to operative time,right?
Time is money.
Time is more cases, anesthesia,time for the patient.
If you don't have to take asmany pictures, many of my,
partners will use C-Arm to reamand put the cup.
They're taking four or fivepictures just to try to
(26:31):
reproduce a real AP pelvis.
That's a lot of radiation ifyou're doing a couple hundred
hips a year, if you're takingextra 5, 6, 7 fluoro shots.
So I, the way I've gotten a fewof my partners to jump on board
is, number one, you get thetargets so you know where to put
the cup.
You could do it all withoutc-arm completely.
I don't use cm to put my cup inat all and, it's looks great.
(26:52):
The final pictures when you'redone.
All said and done.
It's exactly what it said.
So operative time, lesstrialing, more accuracy, less
radiation.
that's an easy sell for, mostpeople.
Joseph M. Schwab (27:04):
So, talk to me a little bit, and Brad, maybe
you can chime in too.
How do you translate the threedimensional plan or even the two
dimensional plan?
How do you translate that pre-opplan into cut position without
using intraoperative imaging?
Is it navigation?
What, does that look like?
Brad Waddell (27:20):
Yeah, it is navigation.
experience obviously helps withall of this, but.
the Smith+Nephew CORI system isthe intraoperative execution of
the plan made with CORIOGRAPH.
And CORI is the navigationsystem that allows you to put
the parts where you think you'reputting'em.
(27:41):
Of course, it's an evolvingtechnology that'll continue to
get, more in depth, but atpresent.
It's one of the most simple,easy ways to, execute, a hip
replacement, that I think is outthere.
to George's point.
and adding to George's point, Idon't wear lead.
I haven't worn lead in, seven oreight years.
(28:04):
and I still remember, my firstcouple of years of practice
changing scrubs multiple times aday'cause I was so wet.
From sweat and wearing big,heavy lead.
the CORI intraoperativeexecution allows you to put the
parts exactly where you haveplanned to put'em.
And, that's what has led to allthis pre-op planning is now,
(28:27):
once we had the ability to putthe parts where we wanted to put
'em, we found out that wasn'tperfect and that pushed more for
the preoperative plans and theability to.
Individualize this hipreplacement surgery for each
patient.
it's, the, query system has thefastest registration, the lowest
(28:48):
cost, all the different things,you could query.
We have every robot in ourhospital.
You can query who the techs who,which one they like to use best.
And it's the simple CORI, I'vedone, I'm getting close to a
thousand CORI Hips and, it, it'sbeen seamless from day one.
it's been a great, experience.
Joseph M. Schwab (29:09):
So you have an intraoperative monitor that, for
instance, the acetabularcomponent positioner that you're
putting in is it's able to tellyou when you've got it in the
exact right position.
Is that how it works?
Brad Waddell (29:23):
to George's point, we're shooting for 43 17, and so
I can get it at 43 17.
and so being able to plan for 4317 and then a live feedback.
Utilizing the tools that you useon a day-to-day basis, not a
giant arm.
That's in the way, out of theway, not the way I do a normal
(29:46):
hip.
it just tacks right onto theparts that I use every single
day.
Muscle memory is the same, andthen I put it in at 43 17.
so yeah, it's a seamless way to,to achieve that preoperative
plan.
Joseph M. Schwab (30:00):
George, if somebody wanted to double check
their position with, if they're,say they're moving from a fluoro
based system to CORI and theywant to double check, so they're
getting the visual input thatthey're used to, but they're
also getting the input from thesystem.
Can you bring fluoroscopy in anddouble check?
Is that easy enough to do, orwould that be a little more
challenging?
George Haidukewych (30:20):
No, it's easy.
it's CORI's a very smallfootprint.
It's a tiny little unit, so inmy cases I actually have Floral
and CORI both.
I use a fluoro at the end tomake sure I'm happy.
I, would never leave the orwithout an x-ray.
I think that's ridiculous.
But what I'll do is I do fourx-rays, four single shots, and
(30:42):
in incorporate CORI into this,we, you, when you first start
the case, you register theanterior pelvic plane by getting
the ASISs.
It takes a few minutes.
Do your routine exposure.
I still check my neck cut underfloral to make sure it's not too
vertical or too high or whathave you.
Make.
Put a little o osteotome where Iwanna make my cut, so I'm happy
with that.
Then I do the rest of theoperation really without x-ray.
(31:04):
Put the whole cup in.
If for some reason you don'tlike the way it looks, no
problem.
That's when I first starteddoing CORI a few years ago.
I didn't believe some of thenumbers I was seeing.
And you know how the pelvis onthe table can sag quite a bit
and be pulled with traction.
So what you think is.
10 of aversion is really 40 ofaversion.
You can get really crazynumbers.
(31:25):
So I would bring in the floor tocheck it going, let me see if I
trust this thing.
And it was right Every singletime I, my eye was wrong.
the navigation was correct.
So I highly encourage you, ifyou're a fluoro user, try to
wean yourself off.
It's just, use less and lessx-ray, but do single shots to
convince yourself.
To trust the navigation, but Iuse both in my or routinely.
(31:48):
I check my leg lengths at theend with an x-ray, make sure I
like my cup position.
My stem looks right down theshooter, so absolutely.
I use both in every case.
Joseph M. Schwab (31:57):
and George, you're doing this on an
orthopedic table, is that right?
George Haidukewych (32:00):
Yeah.
Yeah.
Honda Table.
Honda
Joseph M. Schwab (32:02):
On the Honda table and Brad, how about you?
What are you doing it on?
Okay.
Brad Waddell (32:06):
I'm on the H table as well.
I use x-ray as well.
I only take two shots.
I get the full cup in the STEMtrial in, that's when I take my
first shot.
And I agree with George.
STEM position is always what,again, after 10 years of doing
this, I still worry about STEMposition.
And I think it's somethingthat's just inherent in the
anterior approach.
(32:29):
To George's point, the pelvisthat you see on that standing
pre-op film is not the pelvisyou're seeing laying on that
table.
we did a study on that a coupleof years ago where we looked at
the pubic synthesis gyaldistance.
And so my partner in theoperating room recreates the
functional plane and recreatingthe functional plane is,
(32:53):
basically.
Getting the, cantor of the x-rayto where their pelvis would be
when they're standing up.
That's the pelvic tilt.
And so y yeah, when you look atsomething in the operating room
and they're laying on the table,you're gonna be wrong in
guesstimating in most patientsunless they have a neutral
pelvic tilt, which most peopledo not.
(33:15):
It's absolutely right that theCORI, navigation is gonna be
telling you the correct numberbased on, most likely their
standing film if you're shootingfor the functional plane.
But those two x-rays are not thesame.
Joseph M. Schwab (33:31):
George, I'm interested to know, because you
mentioned right at the beginningas you you were in practice, you
moved to anterior approach andlearning and understanding the
anatomy and understanding howthe anatomy, how the planes
work.
C 90 degrees opposite from, fromwhat you were used to.
Have these intraoperative toolschanged your understanding of
(33:55):
the surgical approach, orchanged the way you've done the
surgical approach?
Or is it pretty much what youcame to, came to learn at the
beginning?
George Haidukewych (34:05):
It's not that much different approach
wise.
You have to have goodcircumferential exposure of the
cup.
get a couple cobras in there andreally see a 360 because, they
say garbage in, garbage out.
You've gotta get good datapoints when you register the Ace
Tablum.
And to do that you gotta getdeep.
And some of these patients areheavy.
It's a long way down.
airplane to table away from me'cause I've already registered
(34:27):
the anterior pelvic plane so Icould tip the patient upward,
make it a lot easier toregister.
Registration of the socket takesabout.
20 seconds.
If you're, once you've done afew, it's very quick.
And then the acetabular fossa,it's very quick.
So I think the thing that gets,the only thing I would do
different if I wasn't doing thatis I don't need as perfect
exposure of the acetabular.
(34:48):
If you're navigating in myhands.
You gotta get good registration.
And to get good registration,you gotta have killer exposure
of the aceta.
Joseph M. Schwab (34:57):
Brad, how about you?
Brad Waddell (34:59):
Yeah.
To that point, about six, maybefive or six years ago, I was
starting to notice that in somecases I felt like I had a lot
more anterior acetabulumexposed, and in some cases I
felt like I had a lot moreposterior.
And, in fact we were talkingabout let's do a study on this
and find out why.
(35:19):
And now we know some patientsare anteriorly tilted, some
patients are posteriorly tilted.
And it wasn't until I was ableto see that before going into
the operating room.
Then seeing that I'm seeing morehere or there.
And that should change the waythat you ream that cup.
And if you're reaming everybodyexactly the same, you're blowing
out anterior or posterior walls,because some patients are gonna
(35:40):
be anteriorly tilted, somepatients posteriorly.
So I'll say that, this pre-optemplating, knowing what the
patient.
is gonna look like before I evenshow up in the operating room,
has allowed me to answer a sillyquestion that I had 6, 7, 8
years ago, that I couldn'tunderstand.
Why, am I seeing so much ofthis?
And now we know it's becausethey're tilted one way or the
(36:03):
other.
And, as we said earlier, theones that are really scary, or
the ones that present the mostthat way are the ones who are
fused with no mo mobility atall.
And that's why they're gonnapresent that way, laying down.
Joseph M. Schwab (36:16):
Gentlemen, I've really appreciated the,
what you've been able to sharewith us today about the
technology that you use.
I have a couple of quick followup questions before we close,
and Brad, I'm gonna start withyou.
I'd like you both to answer thisquestion, but let's have Brad
start.
If you could give one key pieceof advice, to surgeons who wanna
(36:37):
improve their anterior approachoutcomes, what would you say?
Is there a lesson you wish youknew when you started?
Brad Waddell (36:45):
I, think it's lessons that I was told I
shouldn't.
It takes a long time to learn,and that is introduce everything
one piece at a time.
Go slow.
Don't start something new on aneight patient day or an eight
case day.
and, then at the same time, knowthat there's a learning curve
with anything.
(37:06):
Frustration is common and soslow and steady, change one
thing in your practice at atime.
Don't change your practiceduring a an insane, busy time.
you gotta give yourself the timeto adjust and, get to the point
where, you become comfortablewith it before you start going
real fast.
Joseph M. Schwab (37:27):
George, how about you?
George Haidukewych (37:29):
That'd be two things for DA outcomes.
Number one, I, would suggestthat you learn from several
different surgeons watch theirmoves on exposure.
How do they see the socket?
What do they do if it's hard toget the reamer in and out?
What are, what's the checklistto get out of trouble?
And how do they get the femurout without doing unnecessary
releases?
When do you need to go to morerelease and, how do you do this?
(37:52):
So I think good exposure tricksare, number one, learn from
experienced surgeon.
See, several.
Then maybe do one with him orher so they can teach you.
And then as far as thetechnology, I agree, like
introduce technology a littlebit at a time.
So you just wanna navigate thecup.
Start there, do it in a cadaver.
Learn the buttons, the gizmos,and watch an experienced surgeon
(38:15):
do it.
And many of us have people thatvisit, they'll watch in the or
and we'll go upstairs and do itin a cadaver lab.
So you get a great registrationand then you'll see it's a very
easy, it really, makes theoperation slick.
Joseph M. Schwab (38:27):
And one final question as you both look ahead.
How do you see planning andintraop tools like you've been
talking about today, evolving ormaybe what excites you most
about what's coming up in totalhip arthroplasty?
George, let's start with you.
George Haidukewych (38:44):
Oh, I think handheld robotic execution's
gonna be the future.
We'll have the plan.
The plan will take minutes.
Instead of waiting two weeks foran engineer, it'll probably be
AI automated that it'll knowthat this patient has a
posterior pelvic tilt.
It'll give you the plan.
Then you'll have handheldrobotics.
Instead of bringing in thisgiant Volkswagen with an arm
into the operating room, you'll,it'll be part of your reamer.
(39:04):
It'll be part of the tool.
It'll help you make a neck cutexactly where you want it.
It'll help you put the hipcenter exactly where you want
it.
With robotic reaming andexecution, I think, and a small
footprint.
It won't be a giant milliondollar unit.
It'll be much smaller compact,so you could have multiple rooms
in the SUR Center using thedevices.
So I think that's coming downthe pike.
It's gonna be very exciting.
Joseph M. Schwab (39:25):
Brad, how about you?
Brad Waddell (39:27):
Yeah, I couldn't agree more.
I think that planning will get,more, both more efficient, but
also, more all encompassing.
again, there's still stuff we'relearning and as we learn what we
should be doing and what eachpatient may need, that's where
planning is just gonna getbetter.
Couldn't agree more that havinga small footprint relative.
(39:52):
I tell people all the time thatthe reason that F1 fifties are
made so fast with robots is'cause every single F-150 is the
same.
That's why that robot can justdo this back and forth, whereas.
We can't, we aren't ready forthat yet until we can
individualize each patient andthen have that brought to the
(40:13):
or.
so for me, being able to augmentthe tools that you use in a
small platform, allows, if itdoesn't work, you could just go
right to your standard tools.
And I think that a small plaplatform that augments the tools
that we use is the way of thefuture.
Joseph M. Schwab (40:32):
Excellent.
I'm looking forward to it.
The way you're describing it.
It's gonna be exciting to seewhat's coming down the pike.
gentlemen, I want to thank youboth for joining me today on the
AHF Podcast.
George Haidukewych (40:45):
My pleasure.
Brad Waddell (40:45):
Thanks for.
Joseph M. Schwab (40:48):
Thank you for joining me for this episode of
the AHF Podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content just like
this.
Please also drop any topic ideasor feedback in the comments
below.
You can find the AHF podcast onApple Podcasts, Spotify, or in
(41:11):
any of your favorite podcastapps, as well 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
happy, healthy, and wellplanned.
Hello and welcome again to the AHF
Podcast.
I'm your host, Joe Schwab.
Today we're joined by twoleaders in hip replacement
surgery, Dr.
George Haidukewych from OrlandoHealth, and Dr.
Brad Waddell from the CarrellClinic.
We'll discuss how preoperativeplanning with 2D and 3D tools is
(00:44):
transforming anterior approach.
It's shaping implant choices,improving accuracy in complex
cases, and guidingintraoperative execution.
Whether you're experienced inhip arthroplasty or just getting
started, you'll find valuableinsights in this conversation.
Dr.
Haidukewych, Dr.
(01:05):
Waddell, thank you for joiningus today.
before we dive into thetechnical details, how did each
of you come to adopt anteriorapproach in your practice?
What sparked your interest inthe technique?
George Haidukewych (01:18):
I've done all the approaches over the last
30 years and over the last fivehave.
Move to almost all directanterior for several reasons.
First and foremost, just lookingat the data of how well patients
recover.
I think it's really a patientdriven, they want the approach,
they want to get back toactivities the patients are
operating on are younger,they're more active, and I think
(01:41):
we've solved the problem oflong-term durability.
And implants.
Let's face it, our uns cementedmodern implants can last decades
and decades.
We're not really worried aboutloosening.
We're less worried about polywear.
so what's left?
can we get the patients backsooner?
Can they get more active?
Can we be less invasive in ourapproach?
Can we.
Have them get rid of their gateaids quicker, even go home the
(02:04):
same day.
So all of that kind of cametogether at the same time.
The drive to outpatient surgery,patients being younger, patients
wanting to get home quicker, getback to things, and then people
talk.
They want, my neighbor had a DAhip, he was back golfing in two
weeks.
you're, if you don't do thatapproach, you're gonna have a
hard time competing with that.
So that all of that kind of cametogether at the same time for
(02:24):
me.
Joseph M. Schwab (02:26):
Dr.
Waddell, how about you?
Brad Waddell (02:28):
Yeah, so I, I'm in my 10th year of practice, so I
was fortunate to train in theera of where anterior hip was
coming about.
during my residency, I never sawan anterior hip.
I came into fellowship saying,I'm just gonna learn how to do
some of this, and I'll go backto what I know, what I've seen.
I recall the clinic where Iwatched a patient at two weeks
(02:53):
follow up and they just talkedabout how amazing they waltzed
down the hall.
They were moving their hip inways that I'd never seen any hip
do at any time point.
And so I distinctly recall themoment where I said, man, I'm
gonna lean into this.
So I was very fortunate to trainunder some really good surgeons
who taught me anterior approach.
Since then, it's been my go-toapproach for the last 10 years.
Joseph M. Schwab (03:17):
What were some of the big challenges that you
both faced doing anteriorapproach early on?
George Haidukewych (03:26):
I think the, just being familiar with the
anatomy, 90 degrees to the wayyou're used to looking at
everything, and the, learningthe exposures.
I think that whole operation, tobe honest with you, is about
careful soft tissue handling andexcellent exposure.
Really the reaming broaching isthe same as you do in any other
hip.
But being able to see and notdamage the TFL and other soft
(03:48):
tissue structures in and out ofthe hip, carefully delivering
the femur, there's a learningcurve to that.
you don't wanna start with a BMI60 with a broken nail on their
femur.
You wanna start with somebodyskinny, easy, and then gradually
learn from, several surgeons.
The exposure moves.
'cause once you have theexposure down and it becomes a
pretty straightforwardoperation.
But that was the biggest hurdle,is just to learn these moves and
(04:09):
the sequence of, okay, what do Ido if I can't see the as tabular
wall?
What's my checklist?
What do I do if I've done allthe releases, the femur is still
not coming up, what do I do?
So getting through that anddoing this when an experienced
surgeon, I think is critical.
Brad Waddell (04:24):
Yeah, I couldn't agree more.
I, definitely learned tips andtricks and pearls in, fellowship
where I got to skip some of thelearning curve.
But I also suffered from havingwatched some of the best
surgeons.
Did the world do it?
And, jumping right in, I wasexperiencing things that, I
didn't see them go through.
(04:45):
absolutely.
I think, soft tissue exposure,ch making sure everything's in
the right place.
There's no question, there's alearning curve to it.
even now, I don't do very manyposterior approaches, primaries,
but it can just come right backto you.
The anterior, thousands later, Istill will have times where I
(05:07):
struggle more with an anteriorthat I've done many more times
than a posterior.
I, I think soft tissue exposureand then proper releases, can
really set the case apart.
Joseph M. Schwab (05:19):
So let's talk a little bit about your pre-op
planning.
'cause I get the impression fromhearing both of you talk that
precise pre-op planning issomething critical for a
successful anterior approach.
Are there particular patient oranatomy factors that, you take
into account during the planningphase or make planning sort of
non-negotiable for you?
(05:39):
Tell me a little bit about thatprocess.
George Haidukewych (05:43):
Yeah, I think, I get sitting and
standing views of the pelvis,lateral views to look at the
lumbar, mobility and the pelvictilt.
I think that's become routine inmy practice.
Every new patient gets thosex-rays and you'd be surprised at
how much that can affect yourimpingement arc if you actually
model it.
And some of the, the CORIOGRAPHsoftware that I use.
(06:03):
Basically automates for me.
I don't have to get theprotractor out and start writing
all sorts of angles.
We enter the pictures and it'lldo an impingement analysis for
the case.
So if you think about it, you'retrialing before you even open
the patient, you know you'regonna need a size F, a size 52
cup, whatever, five, highoffset, zero ball, here's your
(06:23):
neck cut, here's your hipcenter.
So it gives you the position ofthe components.
That will not impinge takinginto effect, into, account
rather the lumbar tilt and thepelvic deformity, if any.
So it does the math for you,which is nice.
I simply ask my rep, what's thetarget?
They said 42 17, whatever it is.
That's my impingement free arcand it's a size 5 54.
(06:46):
that's saves me a lot of time insurgery because, if all of you
are on table surgeons.
Multiple trials are a pain inthe neck on a DA approach.
You gotta take everything out,put everything back.
It's not a quick, just poppingyour head on, it's laborious.
And if you're changing offset,changing leg length, changing,
version what have you doing thatahead of time to know you'll be
(07:07):
impingement free.
Really saves me a lot of time.
It's also pretty tough on atable to check for posterior in
stability.
I don't think any of us aretaking the boot out, flexing the
hip to a hundred degrees andinternally rotating and
contaminating the whole feed.
I've never seen anybody do it.
so checking for posteriorstability, again, impingement,
you could do that ahead of timewith the CORIOGRAPH software.
(07:28):
So I love it.
It's become routine for me in mypractice.
I do it on every patient.
Brad Waddell (07:34):
Yeah.
So to that point, you ask aboutpre-op, it's, non-negotiable.
There is a significant amount ofpre-op templating and planning
that goes into every case.
As George said, it's gotten awhole lot easier.
it's always been, x-rays 2D slapon, the cellophane thing and
(07:57):
make sure the sizing is right,but in terms of where we should
be putting it.
As opposed to just the size hasgotten, a lot easier and a lot
better.
It began with Smith+Nephew'smodeler, where they were the
first ones to actually modelimplant impingement, and now
we've jumped forward to 3Dmodeling, including bony
(08:18):
impingement, et cetera.
It's just made life a whole loteasier.
like George said, taking all ofthis into account prior to even
putting any, prior to touching apatient is, life altering for
me.
I, feel the same way.
Me and my rep, the engineers onthe CORIOGRAPH 3D modeling
prepared for us based on mypreferences in a meeting you
(08:40):
have with them.
But then, once I have theengineer's plans, me and my rep
will go over before the day,before cases.
We'll look at all of those,templates, models, and make
appropriate changes prior togetting into the operating room.
As George said, I've alreadytaken the patient through all of
these tests, and, it, certainlyhas made life a whole lot
(09:03):
easier.
I've found myself trialing lessand, cases are going faster and
smoother.
Joseph M. Schwab (09:10):
So does every patient get both two dimensional
and three dimensional planningor do you decide between the two
and how do you decide which oneyou're gonna do?
Brad Waddell (09:20):
For, three dimensional.
It requires a CT scan.
about 35% of my patients comefrom out of town, so we haven't
done it for those patients, butI want three dimensional on
every single person.
and we're working on ways to,expedite, right now it's about
the quickest turnaround you canget on 3D templating, which is
(09:42):
less than two weeks, butunderstandably, patients don't
wanna fly in town or drive in toget it.
And so with my practice, we'reworking on getting 3D for
everyone, but I'll tell you, thebenefits of 3D templating,
including the femoral version,where the neck cuts should be,
taking femoral version intoaccount.
(10:02):
certainly, over the last 10years, I've only had to change
the cup a few times.
maybe 5, 6, 7 times.
After I put the stem in becauseof a version that I wasn't
expecting, and we have theability to eliminate that step,
once a year, once every otheryear.
But still, those are stickingpoints that I remember.
(10:22):
Every one of those cups I've hadto change after putting the stem
in.
So certainly 3D templating is avery nice way to go.
And the benefits of it includethat Fal version.
Joseph M. Schwab (10:35):
George, how about.
George Haidukewych (10:37):
Yeah, I think said.
The I use the 3D selectively.
Probably 25, 30% of my patientsI'll send for the 3D planning
when I'm worried about boneyimpingement or like he
mentioned, femoral versionweirdness or some sort of
deformity.
I've had a few femoral deformitycases where I wasn't sure
whether I could sneak down likea primary catalyst stem, and
(10:59):
sure enough, they did the 3D andif.
I thought for sure I'd need anosteotomy.
So something unusual in theanatomy.
They all get three D's routine.
Grandma with a simple arthritichip, normal version.
Normal anatomy looks great.
I'll just do the 2D planning andI found that to be accurate.
It's faster and you could getthat very quickly.
I.
Joseph M. Schwab (11:19):
Have you found any differences in how you view
or assess or think about thingslike leg length or spinal pelvic
balance based on whether you'redoing 2D or 3D?
George Haidukewych (11:31):
it takes the, the software, 2D or 3D will
tell you your effect, if you putinto templated sizes on leg
length and offset, which is nicebecause let's face it, we've
seen these males that have thesegiant long femoral necks, huge
amount of offset.
And we're worried how are, we'regonna restore tension on those.
And, there, with the 3Dplanning, you can actually move
(11:51):
the cup and maybe not media,alize all the way to Kohler's
line to try to get some offsetthere.
You could change your neck cutsand play with different STEM
geometries.
It's really very useful.
So it gives you, i, I call itlike templating five oh one.
It gives you just a differentview of the hip in three
dimensions where you put the hipcenter and how you handle
femoral deformity.
So it's been, as far as do Iview the hip differently?
(12:14):
Yes, I think I understand it ata deeper level now that I can
actually move things in threedimensions.
It's very interesting to do.
It's great to teach, if you'reteaching residents and fellows,
it's a great tool to help themthink about hip center and
offset.
Joseph M. Schwab (12:28):
Brad, does having these tools, impact your,
having these tools at yourdisposal?
Does it impact your confidenceheading into surgery or are you
confident either way.
Brad Waddell (12:41):
No.
I'm a very nervous person andthere is a controlled confidence
that's been there and itcontrol, it continues to get
more and more.
certainly on three DI find thatleg length estimation is more
accurate.
I like that aspect of it.
(13:02):
the, to George's point in termsof teaching, it's a wonderful
tool, but I'll tell you, I thinkI've probably, Learned more
myself than I've been able toteach.
I'm a mentee of chit ronaut whocombined aversion is 45 degrees.
But I, think that combinedaversion of 45 degrees is a
(13:24):
posterior approach.
Specific combined verion.
And what I've found usingCORIOGRAPH, using 3D Templating
is that my combined inversion isin the low thirties.
and I've been able to see thatand learn more.
Again, more about myself.
If you talk to me 10 years ago,first year in practice, I was
(13:45):
shooting for a combinedinversion of 45 degrees in the
anterior, and I think that'sprobably too much.
It, has allowed me to, I think,become more confident and
certainly I think I've learnedmore about myself as a surgeon
using these, 3D templatesbecause I have so much
information in my disposal.
(14:08):
it's, it, I think it's gonnacontinue to make me a better
surgeon.
Joseph M. Schwab (14:12):
this raises an interesting question.
you both described seeingdifferences in intraoperative
adjustments that you might make,either decreasing the number of
adjustments you might make, orchanging how you would make
those adjustments as you've beenincorporating this, the sort of
extra planning, the twodimensional and
three-dimensional planning.
Are you seeing differences inoutcomes with this extra, with,
(14:37):
the, planning methodology thatyou've been using?
George Haidukewych (14:41):
obviously hard to assess.
the DA patients do so well.
I have a very low rate ofinstability, so that's, a good
thing.
but I have no, nothing tocompare it to because I've been
planning, with this ever since Istarted.
so it'll be it.
If you look at the instabilityrate in DA Hips is about 0.6%,
just depending on what study youread, like one to 200 about.
(15:05):
So it'll take a massive study,massive amount of patients to
prove, but there's no logic thatdefies.
the fact that if we put itimplants in accurately and we
can avoid impingement andoptimize leg length and offset
intellectually, they should havea better outcome over the long
term than those that where wedid not do that.
(15:26):
But again, it'll probably taketens of thousands of patients
randomized somehow to prove, butwhy would you not if you
couldn't?
It is basically the analogy Igive our students.
It's bill.
Building a custom suit forsomebody versus giving somebody
right off the shelf and puteverybody at 40 15 and hope for
the best.
Now you can actually define thetarget for that patient
(15:46):
specific.
Lumbar pathology or their pelvicO liquidity, and you could say,
okay, they need 45, 25 to avoidimpingement, and then you hit
that with the navigation.
We'll use the corry navigationto actually hit that target.
So if you can be that accurateto define the target for a
specific patient and then hitthat target now, it just takes
time to get enough data to provethat they're doing well.
Brad Waddell (16:09):
Yeah, I have a couple of thoughts on that and I
couldn't agree more that,anterior hips in my practice and
almost everybody's practice dotake a lot of people to see a
big difference.
we're following patient reportedoutcomes and if we properly
tension the muscles and if weproperly put the patient, then
(16:32):
you know, they're gonna have a,faster return to a forgotten hip
score.
Or they're going to just,muscularly feel better.
I've asked, my neurologyfriends.
Do you think an EMG would show adifference in muscle tension?
And we don't have a way to lookat that yet, but I think that's
where the next steps of this isgoing to go is we're gonna be
(16:55):
able to, see patients where theybelong, are gonna lead to
patients with better outcomes,faster return to activity,
faster, forgetting the hipreplacement faster.
retrieval studies are superimportant and when I was a
fellow, we did a retrieval studylooking at impingement on
liners, and large heads decreasedislocation, but we showed that
(17:21):
large heads didn't decreaseimpingement, and so we were
seeing deformities on the edgeof the cup.
that, that were there with a 22,28, 32, 36.
but we, so there was the samelevel of impingement, but
decreasing levels of dislocationbecause it jumped distance and
all that sort of stuff.
And so I think, to George'spoint, as we put things where
(17:45):
they belong.
In retrieval studies, we may seethat impingement is gonna
decrease.
Certainly there is a consequenceto that.
Impingement.
We don't know exactly what itis.
We don't have the ability totest it.
But in the macro scale,dislocations are probably gonna
be about the same.
They're gonna be and maybelower, 0.3% instead of 0.6%.
(18:07):
so hard to tell with, smallnumbers of patients.
Joseph M. Schwab (18:11):
Do you think we'd be able to identify a
subset of patients, who are athigher risk for postoperative
complications, poor outcomesthat would really, truly benefit
from this type of technologywhere you wouldn't need nearly
so many to see a substantialbenefit, from a research
perspective?
Have you thought about that?
George Haidukewych (18:31):
Yeah, I think, the subgroup that I'd
like to study is those with thea fixed posterior pelvic.
Tilt.
In other words, the aversion isaccentuated on, the DA approach.
So if you put in your standardfluoro, guided cup, half face
open or whatever enablingtechnology you use, you may have
(18:52):
a functional aversion of 30, 35degrees and you think it's 15,
right?
So I think, look, looking at asubset of those, fixed pelvic
obliquity, cases where thepelvis is stuck in a sitting
position.
I think that would be, a subsetthat without careful planning,
if you put your standardaversion on, you're gonna be
(19:14):
over univer and risk anteriorinstability.
That'd be a fascinating one.
And conversely, those with ananterior pelvic tilt, so you
will click an inlet view onx-ray.
those have a high risk ofposterior instability.
If you under univert the.
So those outliers, I think thatwould be great to look at that
subset to see.
we could probably do the study'cause half my partners don't
(19:35):
use any, advanced planning and,half of us do to see if there's
any difference.
But we'd have to go into thosehigh risk groups.
But those outliers are actuallythe ones where this technology
helps me the most.
Those were, you, if you readsome of the, earlier literature,
by door and Victor Doic, they'lltell you in some of these cases,
(19:56):
okay, add a little aversion ortake a little aversion off,
depending on the pelvicposition.
But what does that mean?
Add a little verion.
How many degrees?
These programs, a CORIOGRAPH canactually take that into account
and they'll tell you 43 17,they'll give you something that
specific, and that's yourimpingement free position.
Then you could hit it with thenavigation, you can actually hit
43 17.
(20:17):
So it's been, really helpful inmy practice.
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Joseph M. Schwab (21:27):
So apart from, the software telling you, for
instance, exactly what yourtarget might be for position,
are you ever able to, or do youever encounter a situation where
it's gonna change your surgicalstrategy or even change your
implant choice based on.
What's, what would be consideredimplant free?
Would you move to a dual mobil,excuse me, impingement free?
(21:49):
Would you move to a dualmobility?
Would you change your, type ofcup or just the position of the
cup?
George Haidukewych (21:55):
you can actually change that in the
program.
You can go to do a mobility, goto 36 head 40 head, depending on
your cup size, obviously changethe offset of the stem.
So the cool part on the 3Dplanning is you could play with
all this in real time.
It'll tell you immediately whenyou make that plan.
There's, little box that saysleg length and offset change.
And it simulates activities ofdaily living, which are great,
(22:17):
deep squat, things like that.
golf swing, what have you.
So it'll tell you whether you'rehaving external rotation or
internal rotation, stability, orimpingement.
It'll show you exactly on themodel where the impingement is.
Is it bone, is it liner?
Is it femoral neck?
And then you can add offset.
You can add change of bearing,like you mentioned, change of
stem, whatever you wanna do toget rid of that impingement.
(22:39):
It's an incredibly versatiletool for that.
Brad Waddell (22:43):
Yeah, so if we look back 10 or 15 years ago
when, dual mobility first cameto America in the modular state,
it was used when we couldn'tfigure out what to do.
I've found my dual mobilityrates have decreased because now
I know where to put the partsand, dual mobility is a backup
(23:04):
plan when, sure, there's stillinstances where it's used, but
dual mobility is a backup planfor when.
You can't figure out the pelvis,you can't figure out, where they
sit in space where they're gonnamove or not move.
I use less dual mobility nowbecause I put the parts in a
better position.
And to your question earlier, itis the outliers who matter.
(23:26):
It's the flat backs and it's theover the Lords who are going to
come out the front, flat back,come out the back overly
lordotic, and then it's thefused person who doesn't.
Excuse me, move sitting tostanding.
Those are the ones we reallyworry about.
And yeah, we're, actuallylooking at those now.
And, following into that secondquestion, being able to put the
(23:49):
parts where they belongdecreases the need for a backup
plan, like dual mobility.
Joseph M. Schwab (23:54):
Yeah.
Interesting.
So you both, relied on somedata, so brought up some
research here as far as, thegroups that are at risk, what
the current benefits are ofanterior approach on its own.
so one question.
Can you share any of the outcomedata about 3D planning?
(24:14):
Is that out there in theliterature yet?
And how do you rely on, how doyou use that to make your
decisions?
George Haidukewych (24:22):
There's a little bit of literature out
there about.
Actually looking at bonyimpingement, right?
Something we really don't thinkabout.
We think about implantimpingement a lot.
I think it's Doug Dennis'series.
They looked at, I think they hadabout a third of their patients
actually had some bonyimpingement when the surgeons
were, would put the cup or wherethey wanted.
Basically, they let you do yourstandard planning and they put
(24:44):
your plan, say it's a 40 20,whatever your cup position is
into their 3D program, and foundthat probably a third of the
time you'd have an impingement.
If you put this cup in your samespot every time, so there is
data that impingement modelingand 3D planning will help you
identify things that you didn'tforesee.
There's plenty of data, but it'sprimarily posterior approach at
(25:06):
this point about, The planningand robotic or navigated
execution, right?
So if you're doing robotic ornavigated execution, you have a
target.
Somebody's told you where to putthe cup, you don't just randomly
put it in the human being.
And that data shows prettysignificantly from a posterior
approach that it significantlydecreases the rate of
instability.
(25:27):
Having said that the instabilityrates multiple times higher from
the back than the front.
Therefore, we're gonna need somepretty big series to show a
benefit for the DA approach.
I think those will beforthcoming as the approach gets
more and more popular.
Joseph M. Schwab (25:42):
How do you use this evidence?
so George, for instance, youmentioned that half your,
partners, use, some sort of,planning technology like this
half don't.
and how do you share this typeof evidence with your
colleagues, with your hospitaladministrators, with your
colleagues across the country oraround the world?
(26:04):
To encourage adoption to talkabout, what direction we need to
take this in.
George Haidukewych (26:10):
Yeah, that's just a matter of education,
showing them the benefit.
one of the best benefits otherthan time surgeons are always
sensitive to operative time,right?
Time is money.
Time is more cases, anesthesia,time for the patient.
If you don't have to take asmany pictures, many of my,
partners will use C-Arm to reamand put the cup.
They're taking four or fivepictures just to try to
(26:31):
reproduce a real AP pelvis.
That's a lot of radiation ifyou're doing a couple hundred
hips a year, if you're takingextra 5, 6, 7 fluoro shots.
So I, the way I've gotten a fewof my partners to jump on board
is, number one, you get thetargets so you know where to put
the cup.
You could do it all withoutc-arm completely.
I don't use cm to put my cup inat all and, it's looks great.
(26:52):
The final pictures when you'redone.
All said and done.
It's exactly what it said.
So operative time, lesstrialing, more accuracy, less
radiation.
that's an easy sell for, mostpeople.
Joseph M. Schwab (27:04):
So, talk to me a little bit, and Brad, maybe
you can chime in too.
How do you translate the threedimensional plan or even the two
dimensional plan?
How do you translate that pre-opplan into cut position without
using intraoperative imaging?
Is it navigation?
What, does that look like?
Brad Waddell (27:20):
Yeah, it is navigation.
experience obviously helps withall of this, but.
the Smith+Nephew CORI system isthe intraoperative execution of
the plan made with CORIOGRAPH.
And CORI is the navigationsystem that allows you to put
the parts where you think you'reputting'em.
(27:41):
Of course, it's an evolvingtechnology that'll continue to
get, more in depth, but atpresent.
It's one of the most simple,easy ways to, execute, a hip
replacement, that I think is outthere.
to George's point.
and adding to George's point, Idon't wear lead.
I haven't worn lead in, seven oreight years.
(28:04):
and I still remember, my firstcouple of years of practice
changing scrubs multiple times aday'cause I was so wet.
From sweat and wearing big,heavy lead.
the CORI intraoperativeexecution allows you to put the
parts exactly where you haveplanned to put'em.
And, that's what has led to allthis pre-op planning is now,
(28:27):
once we had the ability to putthe parts where we wanted to put
'em, we found out that wasn'tperfect and that pushed more for
the preoperative plans and theability to.
Individualize this hipreplacement surgery for each
patient.
it's, the, query system has thefastest registration, the lowest
(28:48):
cost, all the different things,you could query.
We have every robot in ourhospital.
You can query who the techs who,which one they like to use best.
And it's the simple CORI, I'vedone, I'm getting close to a
thousand CORI Hips and, it, it'sbeen seamless from day one.
it's been a great, experience.
Joseph M. Schwab (29:09):
So you have an intraoperative monitor that, for
instance, the acetabularcomponent positioner that you're
putting in is it's able to tellyou when you've got it in the
exact right position.
Is that how it works?
Brad Waddell (29:23):
to George's point, we're shooting for 43 17, and so
I can get it at 43 17.
and so being able to plan for 4317 and then a live feedback.
Utilizing the tools that you useon a day-to-day basis, not a
giant arm.
That's in the way, out of theway, not the way I do a normal
(29:46):
hip.
it just tacks right onto theparts that I use every single
day.
Muscle memory is the same, andthen I put it in at 43 17.
so yeah, it's a seamless way to,to achieve that preoperative
plan.
Joseph M. Schwab (30:00):
George, if somebody wanted to double check
their position with, if they're,say they're moving from a fluoro
based system to CORI and theywant to double check, so they're
getting the visual input thatthey're used to, but they're
also getting the input from thesystem.
Can you bring fluoroscopy in anddouble check?
Is that easy enough to do, orwould that be a little more
challenging?
George Haidukewych (30:20):
No, it's easy.
it's CORI's a very smallfootprint.
It's a tiny little unit, so inmy cases I actually have Floral
and CORI both.
I use a fluoro at the end tomake sure I'm happy.
I, would never leave the orwithout an x-ray.
I think that's ridiculous.
But what I'll do is I do fourx-rays, four single shots, and
(30:42):
in incorporate CORI into this,we, you, when you first start
the case, you register theanterior pelvic plane by getting
the ASISs.
It takes a few minutes.
Do your routine exposure.
I still check my neck cut underfloral to make sure it's not too
vertical or too high or whathave you.
Make.
Put a little o osteotome where Iwanna make my cut, so I'm happy
with that.
Then I do the rest of theoperation really without x-ray.
(31:04):
Put the whole cup in.
If for some reason you don'tlike the way it looks, no
problem.
That's when I first starteddoing CORI a few years ago.
I didn't believe some of thenumbers I was seeing.
And you know how the pelvis onthe table can sag quite a bit
and be pulled with traction.
So what you think is.
10 of aversion is really 40 ofaversion.
You can get really crazynumbers.
(31:25):
So I would bring in the floor tocheck it going, let me see if I
trust this thing.
And it was right Every singletime I, my eye was wrong.
the navigation was correct.
So I highly encourage you, ifyou're a fluoro user, try to
wean yourself off.
It's just, use less and lessx-ray, but do single shots to
convince yourself.
To trust the navigation, but Iuse both in my or routinely.
(31:48):
I check my leg lengths at theend with an x-ray, make sure I
like my cup position.
My stem looks right down theshooter, so absolutely.
I use both in every case.
Joseph M. Schwab (31:57):
and George, you're doing this on an
orthopedic table, is that right?
George Haidukewych (32:00):
Yeah.
Yeah.
Honda Table.
Honda
Joseph M. Schwab (32:02):
On the Honda table and Brad, how about you?
What are you doing it on?
Okay.
Brad Waddell (32:06):
I'm on the H table as well.
I use x-ray as well.
I only take two shots.
I get the full cup in the STEMtrial in, that's when I take my
first shot.
And I agree with George.
STEM position is always what,again, after 10 years of doing
this, I still worry about STEMposition.
And I think it's somethingthat's just inherent in the
anterior approach.
(32:29):
To George's point, the pelvisthat you see on that standing
pre-op film is not the pelvisyou're seeing laying on that
table.
we did a study on that a coupleof years ago where we looked at
the pubic synthesis gyaldistance.
And so my partner in theoperating room recreates the
functional plane and recreatingthe functional plane is,
(32:53):
basically.
Getting the, cantor of the x-rayto where their pelvis would be
when they're standing up.
That's the pelvic tilt.
And so y yeah, when you look atsomething in the operating room
and they're laying on the table,you're gonna be wrong in
guesstimating in most patientsunless they have a neutral
pelvic tilt, which most peopledo not.
(33:15):
It's absolutely right that theCORI, navigation is gonna be
telling you the correct numberbased on, most likely their
standing film if you're shootingfor the functional plane.
But those two x-rays are not thesame.
Joseph M. Schwab (33:31):
George, I'm interested to know, because you
mentioned right at the beginningas you you were in practice, you
moved to anterior approach andlearning and understanding the
anatomy and understanding howthe anatomy, how the planes
work.
C 90 degrees opposite from, fromwhat you were used to.
Have these intraoperative toolschanged your understanding of
(33:55):
the surgical approach, orchanged the way you've done the
surgical approach?
Or is it pretty much what youcame to, came to learn at the
beginning?
George Haidukewych (34:05):
It's not that much different approach
wise.
You have to have goodcircumferential exposure of the
cup.
get a couple cobras in there andreally see a 360 because, they
say garbage in, garbage out.
You've gotta get good datapoints when you register the Ace
Tablum.
And to do that you gotta getdeep.
And some of these patients areheavy.
It's a long way down.
airplane to table away from me'cause I've already registered
(34:27):
the anterior pelvic plane so Icould tip the patient upward,
make it a lot easier toregister.
Registration of the socket takesabout.
20 seconds.
If you're, once you've done afew, it's very quick.
And then the acetabular fossa,it's very quick.
So I think the thing that gets,the only thing I would do
different if I wasn't doing thatis I don't need as perfect
exposure of the acetabular.
(34:48):
If you're navigating in myhands.
You gotta get good registration.
And to get good registration,you gotta have killer exposure
of the aceta.
Joseph M. Schwab (34:57):
Brad, how about you?
Brad Waddell (34:59):
Yeah.
To that point, about six, maybefive or six years ago, I was
starting to notice that in somecases I felt like I had a lot
more anterior acetabulumexposed, and in some cases I
felt like I had a lot moreposterior.
And, in fact we were talkingabout let's do a study on this
and find out why.
(35:19):
And now we know some patientsare anteriorly tilted, some
patients are posteriorly tilted.
And it wasn't until I was ableto see that before going into
the operating room.
Then seeing that I'm seeing morehere or there.
And that should change the waythat you ream that cup.
And if you're reaming everybodyexactly the same, you're blowing
out anterior or posterior walls,because some patients are gonna
(35:40):
be anteriorly tilted, somepatients posteriorly.
So I'll say that, this pre-optemplating, knowing what the
patient.
is gonna look like before I evenshow up in the operating room,
has allowed me to answer a sillyquestion that I had 6, 7, 8
years ago, that I couldn'tunderstand.
Why, am I seeing so much ofthis?
And now we know it's becausethey're tilted one way or the
(36:03):
other.
And, as we said earlier, theones that are really scary, or
the ones that present the mostthat way are the ones who are
fused with no mo mobility atall.
And that's why they're gonnapresent that way, laying down.
Joseph M. Schwab (36:16):
Gentlemen, I've really appreciated the,
what you've been able to sharewith us today about the
technology that you use.
I have a couple of quick followup questions before we close,
and Brad, I'm gonna start withyou.
I'd like you both to answer thisquestion, but let's have Brad
start.
If you could give one key pieceof advice, to surgeons who wanna
(36:37):
improve their anterior approachoutcomes, what would you say?
Is there a lesson you wish youknew when you started?
Brad Waddell (36:45):
I, think it's lessons that I was told I
shouldn't.
It takes a long time to learn,and that is introduce everything
one piece at a time.
Go slow.
Don't start something new on aneight patient day or an eight
case day.
and, then at the same time, knowthat there's a learning curve
with anything.
(37:06):
Frustration is common and soslow and steady, change one
thing in your practice at atime.
Don't change your practiceduring a an insane, busy time.
you gotta give yourself the timeto adjust and, get to the point
where, you become comfortablewith it before you start going
real fast.
Joseph M. Schwab (37:27):
George, how about you?
George Haidukewych (37:29):
That'd be two things for DA outcomes.
Number one, I, would suggestthat you learn from several
different surgeons watch theirmoves on exposure.
How do they see the socket?
What do they do if it's hard toget the reamer in and out?
What are, what's the checklistto get out of trouble?
And how do they get the femurout without doing unnecessary
releases?
When do you need to go to morerelease and, how do you do this?
(37:52):
So I think good exposure tricksare, number one, learn from
experienced surgeon.
See, several.
Then maybe do one with him orher so they can teach you.
And then as far as thetechnology, I agree, like
introduce technology a littlebit at a time.
So you just wanna navigate thecup.
Start there, do it in a cadaver.
Learn the buttons, the gizmos,and watch an experienced surgeon
(38:15):
do it.
And many of us have people thatvisit, they'll watch in the or
and we'll go upstairs and do itin a cadaver lab.
So you get a great registrationand then you'll see it's a very
easy, it really, makes theoperation slick.
Joseph M. Schwab (38:27):
And one final question as you both look ahead.
How do you see planning andintraop tools like you've been
talking about today, evolving ormaybe what excites you most
about what's coming up in totalhip arthroplasty?
George, let's start with you.
George Haidukewych (38:44):
Oh, I think handheld robotic execution's
gonna be the future.
We'll have the plan.
The plan will take minutes.
Instead of waiting two weeks foran engineer, it'll probably be
AI automated that it'll knowthat this patient has a
posterior pelvic tilt.
It'll give you the plan.
Then you'll have handheldrobotics.
Instead of bringing in thisgiant Volkswagen with an arm
into the operating room, you'll,it'll be part of your reamer.
(39:04):
It'll be part of the tool.
It'll help you make a neck cutexactly where you want it.
It'll help you put the hipcenter exactly where you want
it.
With robotic reaming andexecution, I think, and a small
footprint.
It won't be a giant milliondollar unit.
It'll be much smaller compact,so you could have multiple rooms
in the SUR Center using thedevices.
So I think that's coming downthe pike.
It's gonna be very exciting.
Joseph M. Schwab (39:25):
Brad, how about you?
Brad Waddell (39:27):
Yeah, I couldn't agree more.
I think that planning will get,more, both more efficient, but
also, more all encompassing.
again, there's still stuff we'relearning and as we learn what we
should be doing and what eachpatient may need, that's where
planning is just gonna getbetter.
Couldn't agree more that havinga small footprint relative.
(39:52):
I tell people all the time thatthe reason that F1 fifties are
made so fast with robots is'cause every single F-150 is the
same.
That's why that robot can justdo this back and forth, whereas.
We can't, we aren't ready forthat yet until we can
individualize each patient andthen have that brought to the
(40:13):
or.
so for me, being able to augmentthe tools that you use in a
small platform, allows, if itdoesn't work, you could just go
right to your standard tools.
And I think that a small plaplatform that augments the tools
that we use is the way of thefuture.
Joseph M. Schwab (40:32):
Excellent.
I'm looking forward to it.
The way you're describing it.
It's gonna be exciting to seewhat's coming down the pike.
gentlemen, I want to thank youboth for joining me today on the
AHF Podcast.
George Haidukewych (40:45):
My pleasure.
Brad Waddell (40:45):
Thanks for.
Joseph M. Schwab (40:48):
Thank you for joining me for this episode of
the AHF Podcast.
As always, please take a momentto like and subscribe so we can
keep the lights on and keepsharing great content just like
this.
Please also drop any topic ideasor feedback in the comments
below.
You can find the AHF podcast onApple Podcasts, Spotify, or in
(41:11):
any of your favorite podcastapps, as well 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
happy, healthy, and wellplanned.
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