Medacta recently had the pleasure of interviewing Thomas Ellis, M.D. of Orthopedic One in Columbus, OH. Dr. Ellis is recognized as an authority in hip preservation with expertise in the treatment of hip labral tears, femoroacetabular impingement (FAI), trochanteric bursitis, hip dysplasia, and hip arthritis.
Dr. Ellis obtained his undergraduate degree from Stanford University and his medical degree from Vanderbilt University. He subsequently completed his orthopedic residency at Texas A&M University. He is an Engh total joint fellow from the Anderson Clinic and has completed two trauma fellowships; an orthopedic trauma fellowship from Hennepin County Medical Center and the John Border Memorial European AO trauma fellowship. During the interview we were able to discuss his experience with Medacta and the Anterior Minimally Invasive Surgery (AMIS) procedure. Below is the transcript of the interview.
Q: Tell me about your total hip arthroplasty education and early THA experience.
TE: My residency was all anterolateral total hips. My fellowship was at Anderson Clinic and 50% of the hips were anterolateral and 50% were posterolateral. Andy Engh, MD did lateral and Charlie Engh, MD did posterior hips. After my fellowship, I did a few anterolateral approaches and I had some problems with gluteal tears. The gluteal repairs were not healing and patients were limping. So I migrated to doing posterior hips. When I did posterior hips, I felt I was overly anteverting the cups to prevent dislocation and I had a few early dislocators. For the first 8 years of my practice, I went back and forth - on many occasions - doing anterolateral and posterior.
Q: What made you consider the anterior approach?
TE: It was 2008. I was dissatisfied with the two approaches in which I was trained. I liked the anterolateral approach because the dislocation rate was low and I didn't have all the postoperative precautions. I didn't like it because the patients tended to limp for a long time after surgery.
With the posterior approach patients didn't have the limp but I felt I had to excessively antevert the cup to minimize the risk of dislocation. I also had recurrent dislocators that were problematic to treat. Basically, the two approaches had positives and negatives. Neither of them were what I considered an optimal approach.
I was interested in the anterior approach because I didn't have to take down the gluteal muscles and wouldn't have to worry about patients having a chronic limp. Also, I didn't have to worry about dislocation. It had the advantages of both the posterolateral and anterolateral approaches without the disadvantages.
Q: How did you learn the anterior approach?
TE: I went to a competitive company's direct anterior course. I watched some lectures then we went to the lab to practice the procedure. There were four surgeons per cadaver. I practiced the procedure on the cadaver and then they said I was ready to do an actual case. The company sent a sales rep with anterior experience for my first case. My patient selection for my first case and the table I used were not ideal. It was a difficult learning experience for me because it was very hard to do the case. I did a couple more anterior procedures after that but I did not have the proper training.
I then went to another large orthopedic company's course. The teaching was similar to my first course. There were multiple tables with three surgeons to a cadaver and two faculty surgeons for all the tables. After the course, I went back to do some more cases. There was no proctor again - just the local sales rep. This time, I did the procedure without a table. I still struggled and the learning curve was very steep.
Still looking for answers, I went to another big company's course for more lectures and cadaveric training. There were two surgeons per hip so I didn't get to do my own hip at this course. I continued on doing anterior cases but it remained to be a difficult learning curve because I didn't have the right education. The duration of the cases were long. Complications included fractures, leg length discrepancies, excessive blood loss and muscle damage to the tensor fasciae latae and glutes. I needed two assistants and we were all exhausted at the end of the case.
Q: Why did you continue on with direct anterior procedure with such a steep learning curve?
TE: I would do it for a while and then I would stop. I would start doing it again then stop. I stopped doing it about seven times but the reason I kept going back to it, is that the procedure made sense to me. I knew it was the right thing to do for my patients. My patient selection became pretty narrow; I chose patients who were thinner - not muscular males. Patients who had good offset and the acetabular side was not complex. Patients who had no femoral deformities. When I became more comfortable, I started expanding my indications. After a few years, I felt I was getting proficient with the direct anterior without a table.
Q: How did you hear about Medacta and AMIS?
TE: I was interviewing candidates to join my hip preservation practice. I wanted someone who was also trained in hip arthroplasty. One of the prospective surgeons was a surgeon from Canada who had done a fellowship with Dr. John O'Donnell in Australia. This surgeon said he wanted to use Medacta if he joined my practice. He loved Medacta's anterior system. This made me start inquiring about Medacta.
Q: What made you want to learn more about Medacta and AMIS?
TE: In 2014, I was leaving the teaching institution where I had practiced. At the teaching institution, I had two surgical assistants in the OR. At my new practice, I was afraid I would only have one assistant, my PA. I felt I needed a table with only one assistant. So at that time, I attended a Medacta lab to see how the Medacta system worked.
Q: What did you discover?
TE: Once I had attended the Medacta Learning Center, I was incredibly intrigued. I understood it. AMIS - it made sense to me. I had always heard people say you can do the anterior approach to the hip and then there is the Medacta way to do the anterior hip. I had thought anterior approaches were all kind of the same but when I did the Medacta lab, I realized it was a very different procedure. It was a much more controlled - a much better procedure.
Q: Describe your AMIS learning experience.
TE: It was January of 2014. At this point I had already done over 800 anterior total hips. As I mentioned, I attended an AMIS Learning Center. I then went to an AMIS Reference Center. I visited Drs. Rob Greenhow and Craig Loucks that summer. The scrub techs, who worked with me, went with me to Denver and were able to participate in a cadaveric practice lab to learn the AMIS procedure. Dr. Loucks then visited my practice in Columbus where we met the night before and then he proctored my first three AMIS cases the next day.
Q: How would you compare the Medacta Orthopeadic Research and Education (M.O.R.E.) surgeon education program to other company's anterior education?
TE: The Medacta lab was very different. The big difference was the cadaver access and the access to the proctoring surgeons. Each surgeon had their own cadaver and got to do the entire procedure. We all had one-on-one proctoring from one of the faculty surgeons. I was not offered, by the other companies, to go watch an experienced surgeons operate. I believe some other companies do this, but it was not offered to me, and it was not a part of the routine training.
With Medacta, visiting an AMIS Reference Center was not only possible, but it was highly encouraged. The Reference Center visit was extremely valuable because you get to see how experienced surgeons do the AMIS procedure and I picked up more of the nuances of the technique.
To have a proctor surgeon visit and scrub in for the first cases was never offered by the other companies. They would send an experienced sales rep but this was, by no means, the same caliber of support compared to an experienced proctor surgeon scrubbing in with you.
The intensity of training with Medacta was much greater and much better.
Q: Medacta's AMIS education program has multiple steps. You mentioned the Reference Center, Learning Center and Proctor surgeon for your first cases. Another step is Continuous Education. After you have done your first set of AMIS cases, Medacta encourages you to repeat any of the steps which, will in turn aid in decreasing your learning curve. Tell us about your AMIS Continuous Education.
TE: It was September of 2014 when Dr. Loucks proctored my first cases. After about 3 months, I was having some trouble with exposure and I wasn't quite sure why. So, Dr. Greenhow came out in December and scrubbed in with me for the day. In the first case he helped me figure out exactly what was my problem. I had slipped back into some old habits. At that point I had done a fair number of AMIS hips but to have a faculty surgeon visit you and give you some additional pointers was another big leap forward.
Several months after that, I went to Chicago to visit Dr. Peter Thadani. I had done enough AMIS hips that I was looking for some very specific pointers on how to improve my femoral exposure. That visit was very helpful.
Things were going very well after that, but then I saw a couple of fracture complications. Dr. Thadani then came to me to watch a few of my cases. He validated my technique and passed along a few tips and pearls.
After doing the AMIS approach for two and a half years, I visited Dr. Frederic Laude, one of the pioneers of the AMIS technique, and observed his technique. That was incredibly helpful. Since I had many AMIS cases under my belt at that time, I was just able to focus on refining my technique.
I would do cases for a while and I would go visit a proctor or I would do cases for a while and proctor would visit me. This engagement was incredibly helpful in speeding up the learning curve. That is something that has never been offered by other companies that I worked with.
Q: When you first saw the AMIS technique, what was your first impression? How did it differ from the direct anterior approach that you were doing?
TE: It's the management of the capsule. That's the difference for me. It's using the capsule as the retractor so you are not pushing and pulling on the muscle to get your retraction. That is what allows you to get your acetabular exposure. That, along with the AMIS table, allows me to have just one person holding retractors. The AMIS technique has controlled releases. It is a very step-wise, sequential release that is very reproducible. It's the same sequence every time.
With other companies' teaching of the anterior technique, the steps are somewhat the same but they vary with each, different teacher. If you go to other companies' courses, you can be taught fifty different ways to do the procedure. With Medacta, the same technique, with the same sequence of steps, is taught by all the AMIS faculty. You can go from proctor to proctor to proctor and 90% of the steps are the same.
Q: Would you elaborate on the difference between AMIS and other anterior techniques when it comes to how soft tissue management is taught.
TE: While there was variability on how each proctor taught, the instruction for direct anterior normally would teach releases by starting at the front and just releasing attachments all the way to the back. It was more carte blanche on how releases were done versus sequentially releasing as you go. Or releasing as needed, as taught by AMIS faculty. Direct anterior would expose the whole piriformis fossa and release the whole quadrant. The pubofemoral release was never well delineated in their education. The discussion around what ligaments may keep the femur from releasing was never really discussed. In contrast, the detailed anatomic release of the AMIS procedure, and the order that the ligaments are to be released, is very well delineated and taught. This is not the case with the other companies. Depending on who your proctor is, your experience will be different.
Q: How has the AMIS experience affected your practice?
TE: My practice has grown immensely. I did 110 total hips the year before I learned AMIS with 100 of them being direct anterior. Now my practice has grown to 300 total hips this year with 98% of them being AMIS. The patients want anterior hips.
For me and my staff, having the AMIS table has been very beneficial. Physically it is much easier to do than direct anterior without a table. Before, my two assistants and I were worn out at the end of the day from manipulating and positioning the legs. Now I only need one assistant. There is little retraction. For the acetabular portion, my PA doesn't have to hold anything. For the femoral component, sometimes she holds two retractors, sometimes just one and sometimes nothing. The procedure is more efficient and faster.
It is easier and much more enjoyable for the staff and me. It has completely changed my quality of life. Because there is less trauma and blood loss, it is a delicate procedure. Patients are able to go home the same day, so I don't have many patients in the hospital. If the patient doesn't go home the same day, their hospital stay is only for one night. I'm now getting home earlier and I'm not exhausted when I get home.
