Optimizing functional outcomes: pushing the boundaries of hip replacement surgeries

Listen to Andrew Duckworth, Jonathan Vigdorchik, Jaime Carvajal & Ran Schwarzkopf discuss optimizing the functional outcomes of hip replacement surgeries.

This episode is kindly sponsored by Smith & Nephew.

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Transcript

[00:00:00] Welcome everyone to episode two of our Smith & Nephew sponsored special edition podcast series. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As you may know, this special edition series is focused on hip replacement surgery, including the current issues, emerging technologies, and what the future may hold for this area.

In this episode we'll be exploring the latest advances in optimizing outcomes of patient ongoing hip replacement surgery. And while, as we all know, the surgical techniques have made significant strides over the years achieving the best possible quality of life, a patient goes beyond just the procedure itself.

So with this in mind, we are going to take a dive into the challenges around the prevention and complications of the surgery and spec. Specifically look at the concept of safe zones and the role of pelvic tilt and spinopelvic mobility in achieving functional success. We will also discuss how increased computational capabilities and the development of new planning tools have the potential to transform the way surgeons approach hip replacement surgery by combining advanced planning with precise execution and the right implants for the right patients, [00:01:00] all with the hope that we can make a substantial difference to our patients' overall quality of life.

So for today's podcast, I have the pleasure of being joined by two guest surgeons and a colleague here from the BJJ. Firstly, I would like to welcome Dr Jaime Carvajal, who is an orthopaedic surgeon with Orlando Health in Florida. Jaime, great to have you with us. Hi. Hi everyone. Thank you for having me.

Secondly, I would also like to welcome Dr Ran Schwarzkopf, who is an orthopaedic surgeon based at NYU in New York. Ran, great to have you with us. Thanks so much. Good morning. It's a pleasure and honor to take part of this. This will be fun. Thanks Ran. And finally, I would like to welcome my Editorial Board colleague here at the journal, Dr

Jonathan Vigdorchik, who is based at HSS in New York. Jonathan, great to have you back with us. Thanks for having me. Looking forward to it. Some of my close friends here on the call, so it should be great discussion. Yeah. So guys, firstly, I, I thought we would kick off by discussing the concept of safe zones in hip replacement surgery.

So, Ran, if I could start with yourself for our listeners, can you tell us about the concept of the Lewinnek safe zones and why it's [00:02:00] been a critical reference point in hip replacement surgery? I think the first thing to remember that the Lewinnek paper that came out is many decades ago. But it was a land landmark paper at the time.

It was a new concept of thinking that we have to put implants in certain positions in order to achieve stability. You know, one of the, the two biggest complications we had at the time besides infections were dislocations when we looked at them old hip replacements. The old Sir Charnley hip replacements, even though.

It at the time they were remarkable with a 22 head. But it, it was a problem. So that was a new way of thinking. On the other hand, if you actually read the paper, it's based on a, on a handful of cases put together and looking at their stability and it doesn't have, the imaging we have today doesn't have the functional thought we have today, and it gave a safe zone that was with aversion of you know, five degrees to about 15, 20 degrees and an abduction angle.

And at the time those things worked, but we did hip replacements much differently. Patients would have hip replacement, it would be put in a [00:03:00] spica cast they would be non-weight bearing for three months. They all that. And the trauma of the surgery was so much more than we have now. So the patients formed an amazing amount of scar, you know, among us.

The one, the ones that are old enough that we managed to revise some of the Charnleys or the older hips. You, you open them up and take out the scar and immediately they're unstable. And you can't just go in and do a, a liner change in those cases. And it's, that, I think, kind of pushed us to start thinking, why are those hips so stable?

Even though when we look at the x-rays, they don't look where we put implants today. And with the evolution with that, our safe zones have changed because our protocols are different. Our patients are different and the activities they do are different. Hmm. So I think all of that changed and kind of necessitate us to move to different safe zones.

And I didn't even start talking about the whole hip spine and where that pushed us in thinking where things are. So, but that paper was a landmark paper and it was the first paper to make us think that we have to put implants in a certain [00:04:00] position to achieve stability. Absolutely Ran. And it's interesting, you know, the number of times I'm, I'm doing a podcast, or you go through the literature and there's some, as you have really nicely pointed out, there's some really strongly held orthopaedic dogma that's based on fairly, fairly interesting methodology, certainly compared to what we do, we do today.

And I think it's a really, a really important point. That, and Jaime, that sort of leads me onto yourself. You know, we sort of touched touch upon that, but you know. The challenges and limitations of this zone, you know, and how has that led to a debate in the community be about whether we should use it and also where we should go?

Yeah, so at the beginning when we were looking at that safe zone, that was the target that all the surgeons were using. I. And at some point everyone has started seeing some dislocations in patients within that safe zone. So that caught a lot of attention. There were two obviously major publications written on this, but two that are pretty well known as Tim Wright and Elposito, and then Matt Abdel from Mayo showing that most than more than [00:05:00] 50% of patients with these locations were within the safe zone.

So that really. Call our attention and everyone was like, do we need to continue using the safe zone as the way to go or the target goal for cup positioning? And everyone started seeing that there was something else into that equation, not just only how you put the cup in. And I think that's when Jonathan.

And a lot of my, my colleagues have been working on maybe talking about lumbar pelvic fixation, seeing how the pelvis moves, how the spine moves, and take that into consideration to avoid, obviously the unwanted complication of a dislocation. So we definitely moved away from saying. You need to put all the patients into 40 and 10 15 and say, we have to individualize patient care.

Look at different ways of how that you know, the dynamics of the lumbar pelvic unit to see how they're actually behaving in the, in every particular patient, and decide which is the best kind like component position target for each particular patient. Absolutely Jaime. [00:06:00] And so that sort of leads us nicely onto to you, Jonathan.

You know, it would be good to get your take on this. 'cause as Jaime says, you've written a lot in this area and we're gonna come on to talking about pelvic tilt and spine and pelvic mobility. But with, with, with regards to safe zones, is that how you have interpreted that change as well? Yeah. You know this paper from 1978, right?

300 patients, but he only had data on 113 of 'em and nine dislocations, right? Only with nine patients. He decided that. This particular safe zone is correct. And if you, if you look at it half of those dislocations, oh, sorry, three out of the nine are actually inside his own safe zone. So clearly what we're finding is that safe zones are not safe for particular patients, and we need to identify which one of those patients, you know, the safe zone is not going to be working for.

And how do we do that? Right? Lewinnek. Originally, he spent a lot of time when he was taking his x-rays and made sure he put this little leveling device on the patient's body and made sure that he was taking an [00:07:00] absolutely as perfect as possible AP pelvis x-ray with the pelvis level. Nowadays, when we talk about safe zones, I, you know, you say 25 degrees of anteversion.

How do you know where zero degrees of anteversion actually is? Nobody's actually speaking the same language, right? Murray came out with the landmark paper giving us three different definitions of anteversion. Nowadays, if you look at all the papers that cite the Lewinnek safe zone, we actually looked at almost 300 papers that cite the Lewinnek safe zone.

Only 37% of them cite that original article correctly. So the 200 papers in the literature talking about safe zones, don't actually talk about the safe zone Lewinnek did. Yeah. That's incredible. So it's, of course, it's true that we have no idea, you know, how these safe zones work and what the actual safe zone is until we start standardizing the language that we're using, standardizing the x-rays that we're taking, and then standardizing how we're putting these hips in.

Because if somebody goes and does a manual hip replacement and says, yeah, that's about 20 degrees of [00:08:00] anteversion, we have no idea how that person put that hip in. Yeah. Even when we measure their post-op x-ray, we have no idea what that anteversion is unless you've standardized how you've taken the x-ray. Yeah. So. Yeah, I think that's really interesting.

I agree. JV, it's, it's, you say, and again, it comes back to that, that concept thing, doesn't it? Is that if you then run with that concept, which might be maybe for whatever reason it's flawed, then it just can permeate the literature and then the literature becomes really hard to interpret exactly as you've, as you've described.

And so that. Guys that sort of moves us onto the concept, which we've sort of may mentioned already, and I'll maybe come back to yourself, Jaime, for this, you know, the concept of pelvic tilt and spino pelvic mobility in hip replacement surgery. And Jaime, maybe you can give us an overview of how our understanding of this has evolved over the past years to decade.

So, yes. So basically the more we obtain information about how the pelvic moves and how the lumbar pelvic unit works, then we understand that again, it's not a specific target. The pelvis actually moves through the [00:09:00] activities of daily living and that changes the way we put the implants. So if you go from standing, from sitting, from standing to sitting, obviously the pelvic rolls back and we increase the component anteversion.

To allow the the femur to flex. So understanding how the pelvic moves allows us to put the implants in a better place. So now we're talking more about a concept called functional. Pelvic plane is basically taken into consideration the way the pelvic moves to be able to put the implants in tar in, in a target zone.

And obviously Dr Jonathan said taking some x-rays prior to surgery during the pre-op evaluation, making sure that we get standing and sitting lateral x-rays to check for that for sagittal deformity and looking for mobility of the spine as well. So that will definitely, allows us to see which patients could be on high risk group, which patients we should actually change the way we put the implants in to allow the patients to have less risk of inter prosthetic [00:10:00] impingement, less risk of bone impingement, and obviously have better functional outcomes. That makes, that makes a lot of sense, Jaime.

And that sort of leads me on back, maybe back to yourself, Ran you know, the, all these concepts that, that Jaime just nicely described. Do we have data now or is there increasing literature to say that actually these factors influence, outcome, you know, patient satisfaction, hint, function. You know, I, I think the, the first thing is to, for surgeons that they always ask how do I, what's the hip spine?

What do I do with that? I think it's at the beginning is to think what's the issue? And the, the easiest example I give is how I started down the rabbit hole and actually was a publication in BJJ in 2015, Phan, Bederman and myself before that was even before. I met Jonathan and it all started, I was in the operating room and I was positioning a patient with ankylosing spondylitis on a lateral position.

And I positioned the patient the way that the pelvis would be where I wanted. 'cause that was prior to robotics navigation. And I'm about to drape, and the anesthesiologist says, wait, you [00:11:00] can't start. And I say, why? The head of the patient's not in the bed. And I'm like, what do you mean? The head of the patient's not the bed?

Because the patient was fused with his spine in a way. And then when we put the, the, the head on the bed, the pelvis was in a way that I told him, listen, I I, this is crooked for me. I need it straight. And that led me to think, wait, the, the patient probably stands differently and his acetabulum will be in the wrong place.

And then I tried to get in the lab at the time and I had a meeting with the spine surgeon, which was Sam Bederman and the guy that ran our biomechanics. And I said, let's do a cadaver study. He'll fuse the pelvis to the spine in different ways. I'll measure where the cup is. And, and, and that was kinda shot down.

Said, no one cares about that, that's not important. You know, nothing will happen with that. As in a reaction. We wrote the paper, kind of a review paper, a thought paper that went to the BJJ. And then I arrived six months later at NYU and I meet Jonathan and join him as a partner. And he just published his first paper with another spine surgeon.

And it's like, it just happened at the same time in different ways. And that kind of led me to think what's happening with that spine? So I think [00:12:00] we learned in the last decade. That every person stands and functions in a different way. That means their acetabulum sits in space in a certain way depending where their pelvis is.

Mm. And they have a cone of safety. There's a cone that of area that will allow the patient to extend, flex internally and externally. Rotate without impinging. And that depends where their pelvis is in space. 'cause that influences the cup. And up until now we operated to anatomy, we, we put the cup in an an, an anatomical reference to the pelvis, but every patient, the pelvis in somewhere else.

So we kind of moved forward now that we do kind of a dynamic assessment. We see the, the specific patient with our technology. Now we can dynamically evaluate his motions and movements and see which position will decrease his chance or increase the range of motion before they impinge. So, decrease the chance of impingement and increase the range of motion.

And some patients have a small, some patients are difficult. They only have a small area of [00:13:00] safety. And we have to maximize and sometimes even if we maximize it, they're still able to impinge. We are all, in general, we're all able to impinge, right? We can dislocate a hip in the OR. Right. That means at some point we're gonna cause impingement, so we wanna make that far enough that it won't happen to the patients and, and then we have all the other safeties, larger head, other things we can do offset that after the impingement to try and avoid it from dislocating.

Yeah. But. I think we have data to support this entire thought process and execution at this point. Absolutely. Right. I think that's really interesting how you say, you know, it's often just one patient, just a light bulb moment. You think, hang on a minute, why was that? You know, and actually then it sends you down that rabbit hole of all this research that you do know, and that's really nice.

And may JV I that come to yourself, you know, I, I know you've written a lot in this area, you know, you know, what are your thoughts on, on, on this, where the literature currently stands and, and how it is influencing the outcome for our, for the patients that we see. Yeah, it's, it's funny that I said that same, similar.

One patient, I had one patient, I had no [00:14:00] idea what to do with, so I presented at a spine conference and, and off we went. And, and then Ran joined us you know, he wrote the first paper on it in BJJ, and then we combined together to write the rest of them. Mm-hmm. Where it's currently standing. The literature's been very confusing, I would say over the many years, right?

We, we tried to standardize terminology in 2018. We, we got the late Larry Dorr, Andrew Shimmin, Ran and I, Aaron Buckland. We had a group of us meet at AAOS in 2018 and we wrote a terminology paper for BJJ to really standardize and help people talk the same language as we're writing these papers. That was kind of the first culmination of this.

Where we are today. I think we understand that certain patients are at high risk. We know that patients that have spine fusions and spine deformities have a much higher risk of dislocation. So that's a particular subset of people that we need to pay attention to, and we now understand how to work up these patients.

How do we take that information, figure out what's wrong with them, or [00:15:00] figure out how to do something differently during surgery? So at minimum we need to know a standing x-ray, either a standing AP pelvis or a standing lateral of the pelvis to know where that pelvis is, so that way we can determine is there spine deformity or not.

And if there is spine deformity, we may need to do something differently during surgery. So that's, we also know that things are gonna change postoperatively. There's certain patients where the preoperative state and the. Postoperative state, they're not the same. If you have big, it's like a knee. You've got big contractures, you've got a big deformity in your knee, you're gonna correct it, right?

You're not leaving a 10 degree varus knee and 10 degrees of varus postoperatively, you're gonna correct it. Same with the hip. If you've got a big anterior pelvic tilt and you do surgery on them, that's going to resolve after surgery. If you have a hypermobile pelvis, you know if a stiff hip driving spine deformity, you're gonna do a hip replacement.

That's gonna change after surgery. so we're in the state right now where we know that certain patients are at risk. We know how to [00:16:00] evaluate them. We kind of know how it's gonna change after surgery. And now we're in a stage where, what's the exact targets for these people? How are we gonna use technology to evaluate the target for that particular patient?

And then how are we gonna execute the plan? Yeah, yeah. Where the world is, that literature is in a different place than where the world is. Yeah, because the world is, there's only, when we survey the ACA surgeons, only about 20% of them are getting hips, spine x-rays, preoperatively. Wow. So people are either looking for, you know, certain signs on just an AP, AP pelvis where they should pursue further workup or they haven't bought into that at all.

That's interesting. It's, it's interesting that the world and the literature are kind of lagging behind each other, and I think over the next five years, once we get into technology and AI it's just gonna happen for people and that all these answers are gonna. Become more, you know, more used and more applicable.

That's very interesting, Jonathan, actually, 'cause actually that, that does lead us into what we were gonna talk about [00:17:00] next really nicely in terms of, you know, and I, I wonder whether it's one of those situations where people almost don't wanna know because they, they don't want to do, or they're frightened of it a little bit.

You know, and that can happen in, in medicine, can, and I think it's. That's when you, like you say, that may be a role in terms of advanced planning, combining, you know, planning, execution and implants, which we're gonna talk about really maybe has a role. And maybe Ran I can move to yourself, back to yourself, you know, can you maybe give us an oversight into how increasing computational capabilities are really enabling us to have a more precise and personalized planning for our, for our, for our patients.

So the technology that I currently use and do is a CT 3D planning software Choreograph. And it allows me to get the sitting and standing x-rays, which, you know, I'm lucky. I'm an institution where we have the EOS machine, so I send my patients and they stand and sit. And I, I can understand that many surgeons, especially in the US and the community, they don't have that.

They have an x-ray tech and they have an x-ray [00:18:00] machine in their office and. Things are more difficult but I'm lucky and I have, that's all my patients get that di sitting and standing AP lateral X-rays that EOS provides and they get a CT for planning. And then we do a dynamic modeling of multiple activities with the patient to see the safety zone in them.

So that allows us to do that act active modeling dynamic modeling of their pelvic and their spine and their relationship. And then I plan to put my implants accordingly. Yeah, I I, I think we're very accurate now in deciding where to put the acetabulum and we can execute extremely accurate on that.

So we have that. I do think the one thing we don't fully understand yet is how to accomplish the, the version on the stem. I think we have limitations of the anatomy, limitations of the stems we use, and I think the measuring. Of exactly what the version we placed. I think it's not as accurate yet with our technology compared to what we can do with the acetabulum and with different approaches.

A thing that's currently hitting my curiosity is the [00:19:00] effect of stems that are not placed down the femur. In anterior approach, the stems tend to go from anterior to posterior, and I think it changes maybe the moment arms of some of the muscles. Because it, it looks like it's sticking out the same, but the way it transfers into the femur is different.

Mm-hmm. It may move the femur differently in space. I know that in some technologies, some robotic technologies, that thing sometimes affect the leg length measurements, just because the position and how the, the, the technology measures things. Mm-hmm. So that's something I'm trying to look into and see how that affects things.

But I think technology allows us to hit a point and we know where to hit it much more compared to knee replacements where we can be extremely accurate, but we don't really know where to put our implants. Right. We all have our own theories and we have a device to put it exactly, but we don't really know what's the difference.

That's really interesting, Ran, and like, and that degree of planning is, is, is really, really impressive. And, and sort of Jaime, you know, Ran's touched on it a bit there, you know, how, how is, how is the combining of [00:20:00] those, those advanced planning tools that Ran's de described and you combine that with execution and implant selection, how is that potentially affecting the patient recovery and journey do you think?

Yeah. So in my experience I can see that having a visual look, especially with 3D modeling of how the components are gonna behave in a patient based on their lumbar, pelvic mobility mm-hmm. Allows me to see where could I be doing things better. And for me that's key because again, I'm moving away from.

One single target for every patient. Two, you know, one target for each patient. And I think that makes a huge difference. It prevents the risk of complications. Now one of the things that I say at some point is gonna happen is we're going to have to be fully into either navigation or what robotic surgery, because those planning devices will tell me to put the cup in maybe 32 and.

18. I mean, there is no, no way. I could definitely do that without my own eyes. I will have to have [00:21:00] some type of you know, technology to deliver that number and, and make sure that I'm in the right place. So I think a combination of pre-op planning, including 3D modeling, impingement profiles, and being able to target that particular composition with some sort of navigation or robotic surgery.

Will allow me to, you know, put the implants where they should be. Mm-hmm. Now, as Ran mentioned there's not a lot of data on like soft tissues and how they behave and how do we get the soft tissue into the equation. And that's, and, and the, and the femur is also, I. A big question mark still. So now that we get more CT based planning is gonna help us understand a little bit more of, you know, native version of the femur and how we can target that as well and find anteversion concept.

But I think we still have ways to go to, to include all the parameters into the question to prevent complications. No, I, I totally agree. Ja, Jaime, that makes a, it makes a lot of sense and. And maybe sort of, you know, [00:22:00] we've, we talking about obviously, you know, a lot about primary hip replacement surgery there, you know, and, and I suppose moving on from that, maybe I've come to you, Jonathan.

What is your experience with this in sort of maybe maybe 2, 2, 2, 2 things really. Maybe in the revision revision setting. And also just your experience and what do you think the evidence is with sort of dual mobility in this sort of setting as well? Yeah, and I think Jaime High did perfectly, you said prevention of complications, right.

We looked at a study where, you know, we looked at all the early re early revisions after total hip replacement that we did and ran, and I looked at all of our NYU patients. We looked at about, you know, 400 cases that we had done the revision surgery for within two years of their primary. So a hip replacement, which is supposed to be the greatest operation ever invented the last year, 30 years or more, with modern generation polyethylenes, well, who was being revised within two years after the [00:23:00] primary.

And we found that once we really drilled down to it, 50% of those revisions were completely avoidable. Had the first one just been done better. Right? And what was better mean, what we turned out to be that 50% of the 50 percents. So half of the avoidable complications were all had to do with acetabular component positioning.

So really thinking about who's at risk and then doing your surgery correctly can eliminate virtually half of all the revision surgeries that we do. We published that in BJJ 2019. It's probably one of my favorite papers ever written. We did get a lot of slack for it. Obviously we're Monday morning, you know, quarterbacking, I don't know what you call that in the uk.

Monday morning. Yeah. Striking or something. But, but you know, it really gets you to think about what are you doing during the primary. Yeah. Right. So how do we position our cups better? How do we use technology to figure out the safe zones? And then some patients, like Ran said, may not have a safe zone, so when you don't have a safe zone or you have a very small safe zone, [00:24:00] you need to use things like increasing offset slightly.

You need to use larger heads or potentially dual mobility. Yeah, right. Dual mobility is completely cost effective when you bring this location rates down from five, six, 8% down to below 1%. Mm-hmm. Right. You can justify the current cost of it, and we did a Markov analysis in BJJ there as well. Looking at that, so when do I use dual mobility In my practice, it's people that are at very high risk.

People with three or more levels that are fused. Maybe extremely hyper mobile yoga instructors things like that. Things that may be Parkinson's disease that we know are alcoholics, people you may not trust with some psychosocial issues where you can bring that dislocation rate down to, you know, less than 1% that of a normal population.

Mm-hmm. Right. That may be expanded if it's a surgeon who doesn't use technology and is afraid. Right. If he's afraid of a dislocation. Using a dual mobility, I think is a perfectly great example [00:25:00] for when to do it. You may not have the tools available to do something differently other than going to that larger head, and that's a great tool that we have.

Just know that that's not foolproof, right? You still need to combine good component position, good soft tissue wavelength, offset optimization, and the use of large femoral heads. Absolutely. And in terms of, you know. I'm gonna maybe just for our last sort of topic and question and maybe gonna ask all three of you the same question, if that's all right.

And I think, Jonathan, you just touched upon it there because I think, you know, from an, you know, if somebody from an outsider point of view in orthopaedics, you know, how do you improve on, like you just said, probably the, one of the best operations we have, if not the best operation, you know, in terms of outcomes and, and actually I think you've touched upon that like nicely there.

And I suppose my final question is, you know. Where do you think we are gonna go? Where, where are the future directions in this area in terms of optimizing surgical planning and technique? In, in, in, in terms of being able to prove that [00:26:00] we are improving an already very, very good operation. Jaime, maybe I'll start with yourself with that.

I know, I know it's a, it's quite open-ended, but I think it's really important. Yeah, no, I think it's, great to close these podcast saying that I think mass adoption, as Jonathan said, at some point we all have to be looking at the same things and the same problem the same way I. And targeting would allow us to have more information.

So I think in the next five years a lot of people are gonna continue seeing that, you know, personalizing this type of surgery to each patient will help. I think the use of technology is gonna ge is gonna obviously be more is gonna be more utilized during a regular primary total hips in in the world.

And I think the use of AI to help us navigate. All those equations and, you know to decide like safety algorithms for each particular patient will be tremendous help in in our future. Absolutely. Jaime and Ran, what would you add to that? I. So a, a few points that I, I've been trying to teach and understand.

So [00:27:00] to touch on what Jonathan talked about, the dual mobility. You know, in the past, in our history, we always tried to do upgrades in our hip. And the last great thing was the polyethylene, the highly cross-linked. I think most things after kind of were catastrophic and you know, like metal and metal. That came into decreased dislocation.

Big heads. Right. And I think that was a, now we had that misconception with dual mobility that everybody thinks a big head will stop the dislocation and just put a dual mobility in there. And they have to separate to three types of dual mobility. One is in revisions when we have large dual mobility heads, and that makes a huge difference and the literature supports.

The second one is the monoblock dual mobility, which is common in Europe and less common in the us. Which gives you an anatomical size head, it gives you a resurfacing side head, and that has a lot of stability into that. In the US we don't tend to use that. We tend to use the modeler, dual mobilities, which the difference in the head size is not that big.

So I think the biggest thing to understand that just putting a head that's 41 millimeters versus a 36 is not like putting a [00:28:00] 55 anatomical head. And our goal now is to avoid impingement. The impingement causes the dislocation. Then the, the jump distance tries to prevent it from jumping out, but with small differences, usually it's not enough.

So when I try and tell surgeons first, try and avoid that impingement, and that's where the technology comes. That's where the, the, the patient specific surgery, the modeling comes to try and avoid the impingement. And if you manage to do that and you, you have the offset of the stem, the offset of the liners.

There's much more tools that sometimes are stronger than just going to a dual mobility head that gives you a few millimeters. So try and think and the technology, how to avoid the impingement. Hmm. And the last thing I think is about a decade ago, we all try to fancy on how our patients jump on one leg one day after surgery.

And I think all of us kind of understood now we're doing surgery for 30 years. Our patients are young, and I tell my patients, my goal is that you have a, a 40, 30, 40, 50 years with this hip and nothing happens, right? I don't need you jumping on one leg at the first [00:29:00] week, first three months, let things grow in.

Let the bone grow. It's like a fracture, right? We need the bone to grow into the implant. You need some scar tissue. You need things to evolve. I. And I think that's also something that's changed as we're actually going backwards in hips and in knees and telling our patients, take it easy in the beginning.

The goal here is 40 years, not who can walk faster in the first week. Right. But those videos on TikTok are not beneficial for us. Yeah, right. And that's a great point, Ran, actually. 'cause like you say, this is, this is about longevity, isn't it? It's not about getting, getting back there in 24 hours or whatever.

I think that's a really lovely point. Jay, Jonathan, anything you would sort of finish up on that and where, where we're headed? Yeah, I, I think that for me it's always, it kind of brings it together here. It's the prevention of risk or complications, right? You can identify patients who are higher risk for fracture, so then you should cement their stem or use a collar stem, right?

You should identify patients who are at high risk for dislocation, so then you should plan their surgery correctly, execute it correctly, maybe use a larger headers. Vulnerability if you need to. Right? [00:30:00] Same thing, we have patients that are higher risk for infection, so we try to get them nutritionally optimized.

Can they lose weight and are there any things that get their A1C, their diabetes under control before we operate on 'em, and then use, you know, dilute paol iodine or make a mycin powder or whatever other strategies around mitigating infection, right? That's as a whole where we should go. We should look at every complication we have and try to eliminate them all.

The second place where we're gonna head is we haven't had the tools from industry to be able to do this easily, cheaply for everybody. So even though we've known that a safe zone should be 25, 28, 30 degrees for somebody, I. We haven't had a tool that everybody can use to execute that plan, like Jaime said, right?

How is he gonna hit 18 degrees of anteversion on a particularly difficult occasion? He's not right. He's gonna use the TAL, use anatomic landmarks and do his best unless he use his navigation, which will make him better unless he uses robotics, which will make him better, right? So [00:31:00] industry is going to evolve where the planning will become easier and the execution will become easier.

So that this type of information in terms of identifying who's at risk. Figuring out what to do differently. Doing something differently becomes kind of routine and easy for us. Yeah, I think that's a really nice, nice point to finish on, Jonathan. And like you say, I think with the, these advanced technologies that you have all described, I think once they become, you know, like you say, more universally accessible and affordable, then that's, that's where we're really headed, isn't it?

And that's a really nice point to finish on. Well, I, I'm afraid that's all we have time for today. But thank you to you all, you know, for taking the time to join us and for some really great insights and discussion about where we are. In this area. It was really great to have you all with us and, and some really interesting discussion to our listeners.

We hope you've enjoyed our special edition podcast that we hope has provided a deeper understanding into the concepts, you know, of pelvic tilt and spinal pelvic mobility and how this impacts function outcomes in in hip arthroplasty, as well as providing some insights into how planning tools have the potential to [00:32:00] really improve hip replacement surgery.

Ultimately, with the aim of enhancing patient satisfaction. Through the right combination of planning, implants, and execution. Feel free to be in touch with us about anything we've discussed here today, and thanks again for joining us. Everyone. Take care.