What Makes a Great Hip Surgeon? Lessons from Michael Solomon

What does it really take to become a great hip surgeon — not just technically excellent, but trusted by patients, teams, and colleagues around the world? 🦴🌍

In this episode of the AHF Podcast, host Joe Schwab sits down with Dr. Michael Solomon, a high-volume hip and knee surgeon based in Sydney, Australia, who has performed over 10,000 hip and knee replacements and more than 900 joint replacements per year.

Together, they dive into:

• How a young medical student from South Africa became a global leader in hip surgery 🇿🇦➡️🇦🇺
• The mentors who shaped his approach — including legendary figures like Des Dall, John Steven, and Michael Millis
• Why Anterior Approach Total Hip Arthroplasty (THA) became such a key part of his practice, and how he navigated the learning curve without becoming a zealot about any single approach
• Where Anterior Approach fits (and where it doesn’t) in complex and high-risk patients
• The role of periacetabular osteotomy (PAO) and hip preservation in young patients
• How to set realistic patient expectations and why deep infection remains the complication that keeps him up at night
• The importance of team culture, consistency, and routines in the OR — and why “don’t take shortcuts” may be the most important surgical rule of all
• Advice for young surgeons on building a career: volume, humility, mentorship, and playing the long game 🧠💡

Dr. Solomon also shares his perspective on becoming a leader in the Anterior Approach community, his involvement with the Anterior Hip Foundation (AHF), and how collaboration, data, and honest conversations are reshaping modern hip surgery.

If you’re a hip surgeon, trainee, or just someone facing hip surgery and wanting to better understand your options, this conversation is packed with insight, nuance, and practical wisdom. 🎧

👉 If you enjoy this episode, please like, subscribe, and leave a comment with your questions or future topic ideas.

You can also find the AHF Podcast on Apple Podcasts, Spotify, and your favorite podcast apps, as well as in video form here on YouTube.

#AnteriorApproach #AHFPodcast #AnteriorHipFoundation #AHF

Transcript

Joseph M. Schwab: 0:21

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. Today's guest is someone whose career spans continence, decades, and just about every facet of modern hip and knee surgery. Dr. Michael Solomon is widely recognized as one of Australia's and probably the world's leading surgeons in arthritis surgery, joint preservation, and complex hip and knee reconstruction. After graduating from the University of Cape Town, he completed his orthopedic training in Sydney and went on to a traveling fellowship in the United States. Focusing on hip and knee replacement, as well as hip preserving techniques. Since then, he's performed more than 10,000 hip and knee replacements, averaging over 900 joint replacements each year. His expertise ranges from anterior approach hip replacement to peri acetabular osteotomy, and his clinical work extends across all ages from pediatric to adult patients. And his contributions to the field include extensive international lecturing. Research and hands-on training for students, registrars and fellows. But beyond the operating theater, Dr. Solomon is known for his commitment to service. He's operated and taught across the globe from the US and Canada to South Africa, India, China, and England. And he regularly travels to Tonga to provide voluntary orthopedic care. And if all that wasn't enough. He's actually a pretty good guy and we're really lucky to have him with us today on the podcast. Dr. Michael Solomon. Welcome to the AHF podcast.

Michael Solomon: 2:05

Thank you, Joe. Uh. That was quite an introduction, which I feel partly embarrassed about, but I, I appreciate, uh, you introducing me and I'm, I'm very happy to be here.

Joseph M. Schwab: 2:16

What initially drew you to pursue orthopedics and, and in particular hip surgery?

Michael Solomon: 2:23

So, as you mentioned in your introduction, I, I was born in South Africa. I went to medical school in South Africa and I left shortly afterwards. Um, but my father was an anesthetist or an theologist, as you would say, and he worked with a remarkable man called Desmond Dall. Um, and Des you may remember, there was a, uh, a cable system called the Dall Miles Cable Grip. Des was the Dall of the Dall Miles. And Miles was an, was Anthony Miles, who was an engineer who subsequently went to Bath in England. But my dad was des as anesthetist. So I would often, when I was a medical student, I would go to the operating room with my dad. Uh, and that way I would, uh, meet Des and, and I, and he was certainly one of my. Uh, mentors and inspirations, and that's how I got into thinking orthopedic surgery looks pretty cool.

Joseph M. Schwab: 3:29

So did you have mentors along the way who guided you and maybe shape your approach to surgery? Tell me a little bit about that.

Michael Solomon: 3:38

So, so I would, um, I would, I would recognize three people in my career. I think the first thing to say is, as I said, my dad was an anesthetist. When I was a medical student, I was kind of thinking, what do I want to do when I finish medical school? And I was working on the process of elimination, uh, and I thought anesthetics was boring, but I'll come back to that later because I think in the end he might've been right. I thought anesthetics was boring. I, I thought general medicine, I just wasn't cut out to be a physician. Uh, surgery I found interesting, but I, uh, I figured I wasn't gonna become a fine tuning ophthalmologist or. ENT surgeon. But orthopedics was, I thought, really cool. And I remember as a medical school, at medical school, we did our first term in orthopedics and they taught us how to examine the hip. And I thought, this is so straightforward, you know, look, feel, move, uh, how hard can it be? And I came home that evening and I said to my dad, I found it. I know what I want to be. So actually from, it was a six year course in South Africa, and from that moment onwards in my third year of a medical school. This takes me back to 1983. I wanted to be an orthopedic surgeon. That was it. That was my, yeah. Focus in life. And I was fortunate again, like I'd mentioned to, to have met Des uh, Dall. And uh, and then when I immigrated to Australia, um, I, uh, I, yeah, met others of course, but. The, the two people aside from, uh, Des Dall who has, who had a profound effect on my career. Des was really right at the beginning, so I was still a medical student, but there were two people. Uh, one is an Australian surgeon by the name of John Steven, who was a pediatric surgeon. He's now retired. Um, pediatric spine surgeon. Uh, just the most amazing, uh, mentor. Um. A giant in Australian, uh, orthopedics. Uh, um, so being a pediatric orthopedic surgeon, they, they, they're sort of a different Yeah. Class, I think in the sense that they are really, uh, patient and family focused more than anything. Um, and, uh, John taught me, he, he broke his finger when he was young and he had this. He still has it because of course he's still, he's still around, but he had this bent fourth finger and he would, and he would talk like this, and you would be in the middle of a 10 hour, as he called it, click clack, front and back, you know, spine surgery. He wanted me to be a spine surgeon. I said, no waste. But he would, you know, when, when there's blood everywhere in the, you know, the spine monitors are going off, he would say, now listen, don't panic. Just don't panic. Like I'm the assistant, he's the operator, and he's telling me not to panic. You know, it's easy being an assistant anyway, but, but that, so John was, was an amazing mentor to me. Uh, in fact, one of my, you know, you always think about when you operate the early patients, you really kind of. A bit nervous about, and, and John asked me to replace his hip joints. Uh, he's got one posterior approach hip and one anterior approach hip, which I'll tell you about later in the interview. But I found that quite a stressful, uh, procedure. And in fact, after the first, uh, hip replacement, I normally get x-rays and recovery. And, and he was lying there. I went to see him afterwards and he had hold up the ex, he was holding up the x-ray and said, now listen. He said, it's a bit Russ. I said, what are you talking about? He says, it's varus. You've put it in varus. I said, it's okay. It's a blade stem. It'll work perfectly. And it, and it did. Um, so, so my three mentors would be Des John. And of course, um, I, you know, my, my career has, has been influenced so much in terms of my patient care by none other than Michael Millis, uh, from Boston. Uh, Michael I was fortunate to visit, so when I finished orthopedics in Australia, I wanted, we were pretty well trained in Australia. Uh, you know, our training scheme is a, is superb. We had a lot of hands-on, we had a lot of cutting experience as trainees, as as registrars or residents. Um, and a lot of people didn't even do fellowships in my time and they went straight into private practice or public practice because they were really, really reasonably well tracked. I decided to do a, um, what I called an over the shoulder ship because I, I was, I was in a hurry and I thought, look, I'm gonna go six months. I'm gonna go and spend a month in Chicago with Wayne Paprosky, a month in Toronto with Alan Gross. Uh, I'm gonna spend, uh, go to Exeter for a couple of weeks and, uh, I'm gonna go to Boston. They wanted me to do tumors. Because I was getting a pediatric job as well as an adult job, and I thought, no, I don't really want to do tumors, but you know, you don't wanna upset the, the people who you like. John Steven, who was one of your mentors. I said, okay, I'll go to Boston. And when I was in Chicago, uh, with a month that I spent with Wayne Paprosky, one of his fellows had just come back from a course in, uh, Toronto. I think it was, it was somewhere in Canada. And he came back and said, you know, I heard this guy talk, his name's Michael Millis. He's, he's changing the shape of hip joints. He's turning hips. In dysplastic hips, he's making them look normal and he's an amazing guy and you gonna Boston, you're gonna look this guy up. So I thought, okay, I'll look him up. And in fact, no, I'll go one better. I mean, the internet was still very in its infancy in that day. You know, we are talking about 1988 now. Now 89 or there? No, hang on, wait a minute. I'm losing time. Sorry. We were talking about 90, we're talking about 1995. Anyhow, I contacted Mike and he said, I said, look, I'm gonna be in Boston. Do you mind if I come to the children's hospital and just spend a bit of time looking how you do osteotomies and learning? And he said, with's the greatest, the pleasure. And I, and so I, when I was in Boston, I struck up an amazing friendship with Mike. Uh, and, uh. I went to his clinics, I went to his operating room. Uh, I wasn't allowed a scrub because I was only there for three months. Um, but his clinics were, were incredible because Mike has the ability to communicate with patients and patients' parents on a level that is, you have to be there to see it and to appreciate how much he's respected by the patients. Their parents and the clinics would often run late. Uh, and this was, everybody would go crazy, you know, Millis is running late again. But it's because he cared and because he spent so much time with people and because he could, he really went into what their concerns and worries were. And so I would put Mike as probably my defining mentor, uh, because it's all very well being a good surgeon, but you've gotta be a good doctor to patients.

Joseph M. Schwab: 10:33

Yeah. So having mentors like that, especially the way you describe your relationship with Michael, you go back to Australia, you're starting your career, so very early on are there, are you running into challenges or finding. Uh, that you are encountering mistakes that sort of teach you some important early lessons that maybe, um, you, you, you wish you would've learned from your mentors?

Michael Solomon: 11:01

It's a great question. And Joe, you know, I think you come back from a fellowship and you suddenly think, oh, it's great. I'm gonna get into it. Uh, and it's like, well, where's all the work? You know, I, I, I've been seeing, yeah, why, why am I not, why are people not sending me patience? You know, because nobody knows about you. And no matter how good you've been and what you've learned and what skills you learned, you're, you know, you're not getting the work. So in Australia, I think having the ability to, um, be on at a public hospital system. You get a, a good kickstart because you start, you're on the on-call roster and you start getting some patients and you can start doing things, but at the same time, you kind of recognize that, look, you've gone overseas, you've seen all these joint replacements done. You, you've learned how to do pelvic osteotomies by watching, but not do. Yeah. And now you wanna do them. And so, uh, sometimes I think in my early career, I was guilty of spreading myself too thinly, uh, to try and get a start. Um, I. I, I certainly, um, I remember when I did my first pelvic osteotomy, there was nobody in Sydney doing pelvic osteotomy surgery. And, and when I went and spent three months in Boston, I would've spent about two and a half months with Mike Millis. I never scrubbed because I wasn't allowed to scrub. I was watching and I was taking notes, and now I'm suddenly in the thick of it top and the sweat's starting to pour. And in fact, with my first osteotomy, I got John Steven to scrub who'd never seen one. He'd done Salter osteotomies, but he had never done Ganz osteotomies. Um, and so I'm just telling him, okay, this is how we gotta do it, you know, and, and he's keeping a calm factor on me. Um, so I think, you know, I think pacing myself was important. Uh, and I learned that sometimes the hard way. Um, because in the end, you know, patients value, clarity, and reassurance and kind of a sense of partnership and, and you've just, you've gotta take away from the fact that you've learnt all this stuff. You actually gotta think, okay, well there's a patient on the other side here and what do I feel I'm skilled at doing? And how can I, how can I go into it and help them? And I, you know, initially I was consulting in about four different locations and I suddenly realized, this is crazy. Just, you know, slow down, get back to one place, let the patients come to you, start doing your work. You know, if you do good work, word gets out there. And that's what I did.

Joseph M. Schwab: 13:19

So how did you balance that, the sort of technical skill that you were honing? With and your clinical judgment with things like patient communication that you had observed from a Michael Millis, for instance.

Michael Solomon: 13:34

Well, I, I had a, and I won't call her a, a mentor, but she's my greatest supporter in life, and that's my wife. And the reason I bring her into this is. My wife Lucille has bad rheumatoid and she, she got rheumatoid. In fact, I think you met her when we, uh, we were in London

Joseph M. Schwab: 13:51

Yeah.

Michael Solomon: 13:52

She, she got rheumatoid when she was 20, when before all these disease modifying agents were present. And the reason I, I, I mentioned her is because you ask, how do I balance skill? And judgment with patient communication because Lucille's had multiple operations. Some have been okay and some have been awful in terms of outcomes. And I, I'd say to her, listen, I think we, I think you need to have this done. You need an osteotomy to straighten your leg. I mean, not obviously by me. And she would say to me, but why? You know, I'm not in pain and I'm thinking ahead, thinking B, yes. But I know what's gonna happen in years to come because of the angles they are. Um, so clinical judgment should be, uh. Should be, uh, should incorporate a, a really in-depth discussion with patients about their expectations and their fears. And I think that's, you know, you need to have a clear plan. You know, when I see a patient, whether they're having surgery or not, they need to leave my consulting room with a clear plan on the problem they came to be with. And, and the plan may not be what they like, um, but you, but you've got to, you, you know, you, you've gotta give somebody a clear plan. Because that instills some confidence in, in, in them and, and saying, okay, you know, he's been, you know, you're not sitting on a fence. Oh, we could do this, we could do that. You're actually saying, look, this is what I think your problem is. This is a way I think you should treat it or should be treated. Um, and, and I, and I use that sort of the sublimate thinking of experience that my wife's been through, thinking, is it gonna really make a big difference to their lives? What I'm recommending? That's the important.

Joseph M. Schwab: 15:31

Hmm. As. Um, you move from being sort of a, let, let's just say a competent surgeon to a master surgeon. Are there any key habits or routines that you think you developed that sort of made that difference? Something that you could tell sort of younger surgeons or trainees? This was something I really keyed into that took me to that next level.

Michael Solomon: 16:00

I think the first thing I would say is don't take shortcuts. No matter how simple it is, stick to the routine because if you stick to the routine, you, you will make less mistakes.'cause we all make mistakes. Um, I had a, a, a resident registrar, um, who I've become very friendly with over the years. Uh, an amazing guy. And, uh, the guy like six foot four. He was in his final year, finished his exam and I was doing a hip replacement with him and I was the junior consultant and I thought he was gonna break the leg. Like he was powerful and he was banging away and I'm thinking, my God, I just like, I, so I said, I should mention his name because only he will know. I said, Al, you gotta, you gotta feel the tissues, yet we don't wanna break this femur. You could easily break this femur. I mean, he's so powerful. So this is what I try and teach the, the younger generation that surgery. You've gotta learn surgical skill and you've gotta feel the tissues and understand that a little old lady with soft bone is not gonna be the same as a, you know, a 50-year-old athlete with strong bone. And you've just got to kind of appreciate that. I think the, and I'll bring another, uh, sort of family, uh, member into this, but my son, um. Was very fortunate to represent Australia at two Olympic games in the 400 meters. And he started running when he was 16. But what, when I watched how he approached life and the dedication and the consistency, and he would go to bed early, oh, I don't go to bed earlier, but be what I'm saying is he, he's, he tackled and he tackled his task with a plan. He stuck to that plan. And I think, I think in orthopedics, even if you're doing something simple, there is a roadmap, there is a plan, and you tackle the task according to your plan. And you don't take shortcuts. You feel the tissues, you respect your OR team, uh, and you, you know, you progress for the benefit of the patient. I remember I made one, I'll tell you what else I learned when I was, I was still a registrar, so I was still in training. And I had a lady with an ankle fracture who came in who needed fixing, and her daughter was a medical student and said, oh, can I come and watch? And I naively said, yeah, sure, no problem. And of course, during the operation things weren't going smoothly, and I was now sweating a bit because I knew she was in the background watching me fix her grandmother's ankle, which was, bone was as soft as anything. And I'm thinking, this is not good. I, she should not be in this theater. So that was the first and last time I ever led a relative. Happen to be in, in the, as a medical student into the operating area. But it, but you know, it's a message to young people that it's all being well, being competent, but you've gotta stick to your routine. Don't change your routine.

Joseph M. Schwab: 19:02

So talking about changing routines, at some point in your career you decided to migrate to anterior approach hip replacement, and you have this history, this legacy of, of gravitating towards innovation. Talk to me a little bit about that journey. Of course, you mentioned, uh, your mentor upfront who you did two hip replacements on, one posterior, one anterior. Um, tell me a little bit more about that journey.

Michael Solomon: 19:30

So a number of years, well, in Australia now, probably it's about 15 or 16 years ago, so I, I was familiar with. And, you know, with the Smith Peterson approach and, and with the Ganz approach for pelvic osteotomy. So the territory was familiar to, um, then in, in Australia a company introduced, uh, better tools. A, a, uh, a leg holder or traction table, whatever you wanna call it. Um, and a teaching program. And, you know, I thought I should have a look at this and so. Adopting new techniques. I, you know, so I did a, i I went to listen to a lecture. They had a visiting surgeon who came out and I thought, yep, this looks interesting. And of course, you see slides and it looks, oh, it looks easy, but of course it isn't easy when you're starting off. So I made an effort to go and, and learn from experts. I, I, I flew to, uh, Europe and, uh, visited two surgeons there who I, who I thought were superb in, in their surgeries. Uh, I watched some videos. I did some cadaver labs. I had a, uh, one or two when they were in Australia visit me and scrub with me so I could, you know, say, look, I've been struggling with this particular problem. You know, how do I get around? Uh, do I get around it? So I think when you adopt something new, learn from the experts, watch videos, do cadaver labs. I think one of the, and it's something that's current now because in Australia they just, um, introduced the ceramic resurfacing as a, as a, uh, bearing and an option. And I've been doing resurfacing for many years, but there are a whole, there's a new group of resurfaces who are now wanting to do ceramics and we've got a WhatsApp group. That incorporates maybe 20 surgeons, which is a fantastic tool because people post what their problems are and there are senior surgeons and there are junior surgeons on this WhatsApp group and the junior, even the senior surgeons post. And we just, you know, we, we kind of listen to each other and advice and experience. So I think all these things are critical because we have tools nowadays where we can adopt new technology and learn from our colleagues and peers in a very efficient manner. One of which is a WhatsApp group. So, you know, innovation is good, but innovation without judgment can be dangerous. I did a, a paper that was published with Richard Destiga many years ago. We looked at the adoption of the anterior approach in Australia and the learning curve and how many you needed to do to become proficient. We gotta remember that a learning curve comes at a patient's expense, essentially. Uh, and, and, and one has to be open and upfront and honest with a patient saying, you know, this is my experience. This is what I've done. I feel comfortable in doing your case. Uh, importantly, you don't start doing an anterior approach on a complex femoral deformity. You start with the simple cases.

Joseph M. Schwab: 22:26

Yeah. Uh, from your perspective, when you're thinking about patients undergoing hip replacement, are there, um, sort of routine education points for patients that you think are. Um, underemphasized preoperatively, but so patients undergoing either let's say hip replacement or hip preservation, are there things that you feel patients aren't getting routinely educated about that they would, uh, benefit from?

Michael Solomon: 22:53

I think if I had to, if I had to summarize that question, patient expectations are the hardest thing for a surgeon to, and a patient to grasp because what a patient may be expecting and what, you know, you can deliver may be two different things, and you need to impart that expectation, or, or sorry, your knowledge of what you can deliver. Onto them so they don't cloud their expectations. So I think patient expectations, uh, is important. You know, it's easy when you get somebody who can barely walk. They just wanna be able to walk. That's easy. But when you get somebody who is very sporty but is getting more pain and wants to do all these things, you've gotta temper it a little bit saying, look, you're getting a joint replacement. Uh, it's not your own hip and this is what you can do. And the majority will be able to do it. So I think patient expectations. I think the other thing which is a real, uh, it's a disaster if it happens, of course, is a deep joint infection. And I think, you know, even if I tell a patient, look, you've got a 0.3% chance of getting a deep joint infection, we all brush off. You know, I'm not gonna get a complication. We always think on the positive side is a patient, but when that patient gets a deep joint infection and it happens. It's a, it's a, it is a disaster for everybody in this, you know, it keeps you up at night. Uh, it's enormous amount of time trying to address the problem and, and every, all the ramifications, patient's, work, ramifications, family, et cetera. So I try and, you know, when I, when I tell them the important complications that can occur, I do emphasize that the deep joint infection is a serious problem. It's rare. You've gotta understand and we hope it's not gonna happen, but if you do get it, it's a long road ahead. So we gotta make sure that you are at the point where actually surgery is required. Um, and then, uh, you know, and then with, and on the, on the hip preservation side, again, it comes to expectations a bit, but also recovery. I find, you know, my PAOs take, take a long time to recover. Uh, it's not, you know, you're dealing with generally. Teenagers and young, 20-year-old, mostly females, uh, and they gotta understand that this is not an overnight success. They're gonna be on crutches for two months, maybe a little longer. It's gonna be a slow process.

Joseph M. Schwab: 25:19

Yeah. Were to,'cause I know we have a number of patients who, who listen to these types of, uh, these types of podcasts. If you were to give advice to a patient who's about to undergo a hip surgery, um, for instance, if you were to give them one question you could encourage them to ask their surgeon, that often gets overlooked, what might that be?

Michael Solomon: 25:44

You know, I would be telling a patient the question they need to ask the surgeon is to honestly answer if they were knowing what they know now about the patient's history and your examination. Would you recommend I undergo this operation if I was you or if I was one of your relatives? Because I think if the surgeon is honest, that is the key because, uh, you know, I, I recall a patient who was 97 who couldn't even come to my office. She was in so much pain. Her relatives came to my office. Her name was Fritz. A wonderful woman. And I said to the relatives, I said, which one's the patient? They had the x-ray. I said, no, no. They said, it's not us, it's our relative. She can't get out of the apartment. She's in so much pain. At the end of my day, it was a Friday afternoon, I went to her, a partner visited her and she was this large woman. Her name was Fritz, and I said, and she could, arthritis was so bad. She was in agony, constant. A a, a silly doctor had. Actually decided to get an MRI scan. I mean, she, the, the struggle to even get in the scan was crazy. She, the x-ray showed it all. But the reason I'm telling you the story is that I said to her, I said, Fritz, you've got two choices. You can have your hip replaced or you can live like this, but nothing else is gonna work. She said, when can you do it? I phoned my anesthetist. I said, Richard, I've got a lady. She's 97. She, she's in agony. She needs a hip done. He said, if she's 97, she's indestructible. We did her the following week. She lived to 105 pain-free. And so the point that I'm making is that there are clear times, you know, it is like you think, how do these people put up with it that you, you, you say you, you, I say sometimes I'm not leading. You leave this office until you say, I'm gonna have this operation. You can't live life like this. Okay. Because they're so bad. But then there are many other patients. You can see they're coping or they're anxious or they're hesitant. You know, arthritis is not gonna kill them. And I say, look, you'll know when you're ready, so come back when you feel you're ready. Uh, and yeah.

Joseph M. Schwab: 27:49

So we, uh, obviously we met at the European anterior hip meeting, but now you're also a part of the Anterior Hip Foundation on one of the international committees, uh, representing the, the basically Oceania and the Asia Pacific, uh, region. Um, how did you transition, or, or what made you transition from being, let's say, a learner of anterior approach to a leader in the anterior approach? Uh, uh, groups that are the, the advocate groups that are out there basically for anterior approach.

Michael Solomon: 28:24

Okay, so Hal, I'll start by telling you I'm not a zealot. I don't do a hundred percent anterior approach. Okay? And in fact, when I started 16 years ago, I was doing 20% or 30%. Now, I, I'm reckon I'm probably 85 to 90% because I do the approach that is best for the patient. Okay? Now I do feel, you know, so it, I, what I've, the, the steps I say is, does. Does this tech, does the approach or technology, does it improve outcomes that matter to the patient? So the anterior approach to me ticks that box because I think, you know, anterior approach patients recover earlier at the beginning. I don't think it makes a difference when you get to like four or five months. I think you, I can get two hip replacements walking into my office. One's had anterior, one's had posterior. If I'm blinded, I wouldn't know the difference. But I actually do think the early recovery, uh, it does make a difference. I tell patients, you know, if I have a patient who's morbidly obese, who needs a, like, you know, my patient, uh, dear old Fritz, there was no ways I was gonna struggle through an anterior approach with a stomach apron that was coming down almost to the mid thigh. It was just no point. I could turn it on a side, I could do a posterior approach. Quite slickly. She just needed to be out of pain. I could have put a doorknob in her hip and she would've been out of pain. You know, that's how much bad arthritis was. And so she got a posterior approach, and, and, and it wasn't about her getting a quicker recovery or getting outta hospital quicker. So, so, and there are patients who've got complex femoral deformities that I won't do an anterior approach. I, so I try and take a very sensible approach, but I would do it on the majority, and I would tell patients. If you don't fit my criteria, don't be alarmed. You're still gonna get a good outcome in the end because hip replacement's a great operation. You may not recover quite as quickly. I might give you some hip precautions, uh, initially, but you will be fine. So it's about educating the patient, what's best for them. So, you know, I, of course I like the approach and it is my favorite approach. And, you know, I'm very lucky, uh, in part of my operating team to have. An amazing, uh, rep who, uh, effectively runs the table. I do, I do use a leg holder who knows every move I do. And she's, and I work at three different hospitals and she's, uh, I'll give her a shout out. Her name's Bronwyn. She's unbelievable. And, and, and has, has just made me efficient, uh, care careful during the surgery. So you need a team, you need a great team. Um, and. So adopting new technology, you know, does it make the patient, is it better for the patient? Does it improve outcomes? Is it consistent for surgeons? Can many surgeons do this? Is this, or is this something that's kind of unique that only one or two skill people can do? So it's if you've got something that's good for the patient and anterior tick that box early on, uh, that's reproducible once you've been trained, uh, and it's not complex and that it helps in, uh, post-op outcomes. I think that's, yeah, that's why I adopt it.

Joseph M. Schwab: 31:41

So how did you go from your evaluation of that technique to being part of some of these advocacy groups like the European Anterior Hip meeting? The Anterior Hip Foundation.

Michael Solomon: 31:53

Well, I gotta blame you for the anterior hip foundation because you dove me in. But

Joseph M. Schwab: 31:59

All right. Guilty.

Michael Solomon: 32:02

I, um, look, when anterior approach started in Australia, it was a little bit of a taboo. Um, there were. Senior surgeons and, and of course well-established posterior approach surgeons who, um, I think they were more, uh, and, and, and to be fair, there was a commercial element in its introduction in Australia. The company that brought it into Australia had a different angle. You know, I went from being a posterior approach guy using a blade stem to an anterior approach guy using a fully coded. Uh, stem and the only re not that there was anything wrong with the blade stem or the approach, it's because I thought this technique, because I was familiar with the, uh, approach with my osteotomy experience, was a good technique and sounded intuitively the right way to go. But it's introduction into Australia was clouded with, um, sort of surgeon. Uh, there were some surgeons who went out on a limb to advertise. In fact, my wife told me one day, I, I'm, I'm sitting on this computer, and, uh, she said, who's the surgeon? I said, what are you talking about? You've never even heard of him. I said, I know, but in the local newspaper, there's a big advert here that says Anterior Approach surgery and the happy patients, you know, in Australia, you're not allowed to have patient testimonials on websites or, or advertising, but this was clear patient testimonials, but, but the effect was there. You know, this guy had advertised. Suddenly it was out there and every Tom, Dick and Harry wanted an anterior approach. It, it was a bit like when resurfacing started in Australia, you know, you've got 90 year olds turning up wanting a resurfacing because they'd seen something on the television about resurfacing. So it was so, so the start of anterior approach in Australia. Uh, was clouded with a bit of commercial advertising, which is, we are, we are more of a, sort of an English traditional type orthopedic society. Um, and, uh, so the beginnings were tough and everybody, the posterior approach guys were looking to see where's the problem gonna be. And of course, our joint registry, which is a superb, uh, document that comes out every year, is now in its 25th year. The joint registry showed that one particular implant. Had a higher revision rate and it was for fracture, uh, and loosening. And when they delved into it, of course this was the implant that was primarily used in the anterior approach because the anterior approach was brought in by a company. Um, and the surgeons using it were low, going through their learning curve. And as such, they were, the posterior guys were, oh, you see, it's a di it's a disaster approach. Look, you're gonna get the, the patient's home. You're gonna fracture, you're gonna get loose. So that was the start of it all, but actually at the joint registry. Over time started to show that in fact, the implant performed just like any other implant after two months. So there was a clear, there was a clear learning curve. It wasn't the implant, it was the technique. And once you learn the technique, you know those problems that went away. So now the anterior approach in Australia, we have about 35% are done an.

Joseph M. Schwab: 35:13

Yeah. Was this the impetus for you doing the, the um, uh, the learning curve paper that you talked about at the beginning?

Michael Solomon: 35:23

Correct, because what was interesting about that paper, um, and just, you know, you gotta do 50 cases to get, to get Yeah. Skilled. But what we did in that paper is we compared experienced surgeons who started the anterior approach to new surgeons, as in they just come out of their orthopedic residency. Who started the anterior approach and looked at their revision rates and the rate the joint registries de-identified. But, uh, because I was doing the approach and I knew the company that provided the majority of the implants, we could kind of work out on the joint registry, um, volume based on experience, and then we could see, you could see where the learning curve was coming and where the, where the difficulties were. And as people got better. Uh, and their volume got up, went up, so their, so their revision rate went down. So, so, uh, you know, I, so I went from learning myself to, to becoming what I felt to be competent in terms of what I was doing, but also being strict with my patient selection, uh, and then teaching the approach. Um, and then I guess, uh, you know, I've given talks in various places. Um, about technique and how I do the anterior approach. Um, based on experience,

Joseph M. Schwab: 36:47

So as you kind of look back at your career where it's gotten you to so far, is there a piece of advice you wish someone had given you when you were just starting out as a young hip surgeon?

Michael Solomon: 37:06

get well trained. Don't be in a hurry. Treat patients well. Treat staff well. Be generous to your staff. And I'm talking about office staff, operating room staff reps who help re um, you know, stay humble because ultimately cream rises to the top. And if you follow basic, you know, just be human. Just have some humanity and uh, and that's something you learn over time, uh, which is your mentors that help you mold you and your patients, help you mold you, and, and, and experience helps you mold you.

Joseph M. Schwab: 37:49

Along those lines, what does it mean to you to be a great hip surgeon? You know, if, if you were to do. Describe a, a colleague or a mentor or a friend as a great hip surgeon, what does that mean to you?

Michael Solomon: 38:02

You know, I think you've gotta balance the science and skill of surgery with, uh, the humility of patient care. And, and you've gotta treat your team with generosity and respect, because that's. I, I think if the, you know, and it's, it can sound cliche like, but truly we are here for, for our patients in the end, okay, yes, we can earn a good living, but actually we here for our patients. And so you get, you develop skills, you use science, you develop, you, you use innovation. But, but we've gotta impart that on our patients when we feel it is gonna be to their benefit. And you've gotta listen to your patients. You've gotta remain humble and you've gotta, you can't do it without a team. And you've gotta, you have to respect your team. And, and, you know, I would often do extra lists on a Saturday just to catch up. And, and the theater, you know, they put up a list, Solomon's doing a list on a Saturday. It gets filled with staff immediately because we have a fun time in theater. People like coming to the operating room. The, you know, we play tempo music, we don't play Tchaikovsky. So you know, when you do a joint replacement things, it's step and we stick to the same step. So they know, you know, this is step one, step two. So I tell my an to put the right music on, we gotta keep going.

Joseph M. Schwab: 39:29

Um, and given that you've seen sort of the changes or the growth or the, um, evolution, let's say of. Of medicine in general over your career. Is there any advice or encouragement that you'd give to specifically the young surgeons, maybe our learners or registrars who are listening today who are interested in making an impact to orthopedics?

Michael Solomon: 39:55

Yeah. You know, I, I, I still think it, it, it's a marathon. It's not a sprint. Okay? So don't, don't come out of your fellowship and suddenly say, I'm gonna do this, this, and this actually. Stick to what you've learned Well, and start doing what you've learned well, and as you've developed further skills surgically, you can then branch out with, with new things. But don't be in a hurry to try different things. Just start off simple and it, and it, you know, I'm guilty of not doing this, but it, it's, in hindsight, I look back and I'm thinking, okay, yeah, I was in like consulting in four different locations and I was. I was on call at three different hospitals. Actually, you don't have to do all that. Uh, just just stick to what you learned well, and do what you learned well, and patients will come because they will tell their friends that you're a good guy, you treated them well, and you did a good operation, and that's how your practice will grow. And I always tell pa uh, the residents and the new ones, it's gonna take seven, eight years to develop a practice. It's not gonna happen overnight.

Joseph M. Schwab: 41:04

yeah. Well, I think that's fantastic advice, and Michael, I've really appreciated having you, um, share some of your perspective, share your history and, uh, and, and share your, your, your personality with our guests here today on the AHF Podcast.

Michael Solomon: 41:23

Well, Joe, it's a pleasure and, and I, I have to compliment you, and I hope you put this into the, this podcast. But, but your podcasts are fabulous. Uh, and it's not just Yeah, this interview, but I've listened to many and I've listened to many people you've interviewed and, and some of them are really inspiring. And so I'd encourage you to keep going. You've got a wonderful manner of interviewing your style, and I, uh, I think it's terrific. And so, uh, you know, congratulations to you because I think you do a great job.

Joseph M. Schwab: 41:51

That's very kind and of course you're welcome back on the podcast now at any point. Just, just for having said that.

Michael Solomon: 41:57

That's

Joseph M. Schwab: 41:59

No, Michael, that's excellent. Thank you so much. I look forward, I hope to get to see you in Australia sometime in the near future. And, uh, thank you so much for being with us today,

Michael Solomon: 42:11

Thank you Joe. And uh, and thank you for everybody who listened in.

Joseph M. Schwab: 42:14

and thank you for joining me for this episode of the AHF podcast. As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this. Please also drop any topic ideas or feedback in the comments below. You can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation. All one word, episodes of the AHF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips and patients happy and healthy.