Dr. Abdel: You will not have to, but if it’s difficult, I would do an ETO to remove that femoral component.
Moderator Lachiewicz: How often would you say someone in the audience would have to do a trochanteric osteotomy to put your cup-cage in?
Dr. Abdel: 5-10% of the time.
Moderator Lachiewicz: Okay, Doug, custom triflanged…you’ve got the model, you’ve got the component…and I want you to do a custom triflanged in a patient with a well-fixed femoral component of whatever kind…you can take the head off. What type of exposure would be typical for you?
Dr. Dennis: I will agree that I do think the exposure for custom triflanged is a bit greater. Obviously, the ischium is one, but with the iliac flange…I’ll tell you…in the old days the first ones I did we had three rows of screws way up the ilium. I’ve had one case where my assistant was retracting the abductor and it went right through the abductor, obviously injuring the superior gluteal nerve. If I have a good trochanter that’s not severely osteolytic, I won’t hesitate to do a standard trochanteric osteotomy. I’ve published on a technique with the cables, how to put that back and that is a good thing with these. If you do that, it provides a lot of advantages. It gives you great exposure, but then you can also advance the greater trochanter.
And if you look at the literature of every one of the techniques utilized to try to solve this problem, they are all associated with high complication rates. Lots of dislocation. So, I like to do a standard trochanteric osteotomy then advance the trochanter and I don’t do that, Paul, if it’s one of those paper-thin trochanters and in a lot of these people the trochanters are already gone. But, that’s one area, Matt, I will give you. I do think the exposure would be greater.
Moderator Lachiewicz: Just give the audience a rough figure. In what percent of custom triflanges that you will do a trochanteric osteotomy.
Dr. Dennis: I would say one-third. But I have a low threshold because I think I know how to put the trochanter back and I get the advantage as far as instability.
Moderator Lachiewicz: Let me go to cost. I believe Tom Fehring did a study that says it’s a wash between the custom triflanged and putting two augments and a cage and a cup and so forth. Matt, what do you think?
Dr. Abdel: Another good question. The Fehring-Taunton paper looked at cost between those two constructs. I think the one thing that we’re missing in the cost here is the CT scan, the time that the patient waits. In a cup-cage construct it depends on how much you do it. If you do a cup-cage with a simple cup, acetabular screws and a half cage, it’s a lot cheaper than if you put in 3-4 additional augments. In these high-level, pelvic discontinuity cases, cost isn’t the issue. It’s giving them one good surgery and taking care of the problem.
Moderator Lachiewicz: Doug, who bears the CT cost—the patient, the company, how does that work?
Dr. Dennis: In the bundled payment model, if there are cost overruns it’s probably the hospital that ends up bearing that cost. The way I look at this is that these are typically multiply operated patients. They’re distraught. They’re very disabled. Cost is not high on my list. Giving them a functional limb that will allow them to walk again is the most important thing in my hands.
Moderator Lachiewicz: Thank you gentlemen. Excellent debate.
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