Dr. Hedley is just amazing. This guy has won the Otto Aufranc Award and the Charnley Award. He’s just been noted in so many things. I think since the Best Doctors in the US Rankings have come out since 92, he’s been in it every single year. He has things to tell us that you need to hear and you want to take some mental notes. So, let’s welcome to the show. Dr. Tony Hedley.
Dr. Anthony Hedley: Thank you.
Kevin: Sir, I’ve been following your career for a long time and you’ve done a lot of amazing things on the design side, implant side, instrument side, even a lot of cases that I’ve seen you do on VuMedi but I’d like to take just a moment to go back and let’s just see how we got from South Africa to Arizona. So, tell me a little bit about your journey.
Dr. Hedley: Yes. Well, the journey actually began as an idea in my mind when I was in the military actually. And I went to the military after high school and before med school and I made a decision during those months that South Africa was not going to be my permanent home. I was not a fan of apartheid and eventually, I decided to take advantage of the system and do med school, which I did in Johannesburg and it was very good. It was a very solid good education and I learned a lot, obviously. My dad was an engineer both civil and mechanical. So, I guess the inventiveness stems from there. Anyway, as I said, I went to med school and it was six years in med school at the end of which I left South Africa and went to London to St. Thomas’s hospital where I became a senior assistant/fellow to Allen Atlee. Allen Atlee was world-famous. He wrote a couple of textbooks and so on and he became my mentor London. It was kind of amusing actually because we went to the operating room and I distinctly remember the first one of his patients that we were going to operate on. She was the wife of the governor of Sri Lanka. And anyway, I can’t give you more details than that, but she needed a hip replacement. And Allen took a reamer and put it into the acetabulum at least 45 degrees or more in the wrong direction. And I kind of looked at him and I said, “No Allen, this way, this way, this way.” And he looked at me and he said, “Tony, come to the side of the table.” And I did and I finished the case for him. And that was the last time I ever saw him in an operating room. It was hilarious because I would do these cases for him and he would be waiting in the recovery room and say, “Well Tony, how did we do today?” Anyway, Allen was a delight and a highlight of my stay in London.
Anyway, I worked at St. Thomas’s hospital for a year and what was boiling down the road for me was a true fellowship at UCLA with Harlan Amstutz. And after my year at St. Thomas’s in London, I moved to Los Angeles and to UCLA. Wonderful experience. Harlan Amstutz is an inventive man. He has many ideas. And as you know, he was the protagonist for surface replacement, which I did a number of. I can tell you that the surface replacements that I did at UCLA was the most perfect series of hips I’ve ever done. They all failed. They all failed in the usual fashion. Big hips, thin plastic, osteolysis plus loosening and so on. So, they all failed and kind of changed my mind about surface replacement. Metal-to-metal surface replacements haven’t really replaced the metal-to-polyethylene. It’s brought along with it its own problems. And we all know what those are.
Anyway, I finished my fellowship at UCLA, and then they asked me to stay on in the ranks of the assistant professors, which I did and really, really wonderful time. I thoroughly enjoyed teaching students and young up-and-coming surgeons, really had a ball. I have an advantage in Africa about doing a lot of trauma, did a lot of IM rods. And in fact, I did a couple of hundred tibial rods. And the practice that I got in South Africa surgically stood me in great stead because when I was at UCLA, I was able to teach the med students in that quite a lot. And they liked being in the operating room with me as did the junior staff. So, I was at an advantage. I had also had training and a lot of experience with the AO techniques. The AO people were really out of Switzerland. When I first got to UCLA, they were treating fractures of the femur in traction. And I said, “No, no, no, this is not going to do.” And started rodding femurs and pleased everybody. I was the first one at UCLA to bone graft an open wound. It was a compound fracture of the lower end of the tibia and I got a lot of oohs and aahs out of that one. But it became an accepted technique. We bone graft the defect and even if it’s open leave it open and at a later date skin graft on top of that because it becomes vascularized.
Anyway, long story short, I had a great stay at UCLA that I enjoyed. I enjoyed my colleagues and I certainly enjoyed working with Harlan Amstutz who is really a good mentor and disciple. His bioengineering lab was run by two important people, Ian Clark who I believe is still around and Keith Markov. And both of those guys were the engineers in the bioengineering department were my fellowship began. My fellowship at UCLA was bioengineering primarily and it was a wonderful, wonderful year. Thereafter of course, I was back to orthopedics taking the students and doing what staff members do in an orthopedic department and had a lot of experience with my colleagues who I thought were excellent. So, I had a very rich stay at UCLA.
I became a little impatient with the bureaucracy at UCLA because at best I could get two cases done in a day and I sincerely wanted to do more than that and I had also unfortunately split with my wife. And I decided I was going to leave Los Angeles and I did that at the invitation of Joe Dupont in Phoenix who asked me to join his practice and help him with the research center here, the Harrington Research Center, which I did. I brought a couple of my projects and camped in at the Harrington Research Center and went into private practice with Joe. And that was back in– oh that would have been '81. My move to Phoenix, my transplant to Phoenix was finally completed in 1982 when I was firmly in the practice with Joe and Stu Phillips and so on. A really good time, good time. And I stayed on at St. Luke’s in that same practice until two years ago when things became very unpleasant thanks to the new owners of the department. It was not a scene that I enjoyed and I and my colleagues elected to leave which we did. We joined Abrazo who have lived up to all of their promises. So, it’s business as usual or as usual as the coronavirus will allow. I’ve done a lot of sitting and I hate that but the ambiance and the surroundings where we’re at now is terrific. I really am all in favor of it. I’m very happy with the environment.
I’ll give you an interesting aside. I had a girl by the name of Lee Breslauer who kept all my data. And she kept– I had sheets made for hips and knees and odd stuff but primarily total hips and total knees. Lee Breslauer kept all the stickersfor all of the total knees and hips that I did. And when I left St. Luke’s hospital, she gave me a cruiser and said, “All of your cases are on the cruiser.” Turned out that I had done thirteen and a half thousand cases at St. Luke’s. So quite a handful. Not quite as busy anymore because of one thing or another but had some very busy times and worked with some very, very nice people.
I started a fellowship when I started it at St. Luke’s and have taught 54 fellows and your referral to me was one of them. And I can tell you, having a fellowship has been one of my greatest pleasures. We have become friends and almost wherever I go in the country there’s a fellow. And generally speaking, they all do very well in their communities. So, it’s a very, very endearing and positive experience and I still have fellows and enjoy immensely teaching the younger people. So that about wraps it up.
Kevin: I have it on good authority that you were in the military at one time. Tell me about that experience.
Dr. Hedley: The military experience I had was– I guess most military experiences are the same. We were not really involved in major conflict. I was in the artillery and interestingly enough I wound up in the Natal field artillery which was exactly the same regiment that my father had been in WW2. Quite a coincidence. And in fact, I was in the officer’s mess one day and a head appeared around the serving hatch and it was the sergeant major. And he said, “Sir may I come and join you?” Because they kept the noncommissioned officers separate from the commissioned officers and he said, “May I join you?” And I said, “Absolutely.” And he came through and it was Sergeant Major Kreuger who looked at me and kept looking at me and then he said, “Hedley, huh.” He said, “I know your father.” I looked at him. He said, “Your dad and I were together in the western desert in the beginning of WW2. And then I traveled with the regiment and your father to Italy.” And my dad spent six years serving in the military and WW2. So, Krueger had a lot of things to tell me. Delightful man.
Kevin: Same unit. That’s just amazing.
Dr. Hedley: Isn’t it? Yes, and Kreuger was the sergeant major for my dad. Yes, really a coincidence and kind of made the stay in the military a little easier.
Kevin: Your passion for teaching is so apparent in your videos. I was watching some of the stuff you were doing on VuMedi and the turn up turned down procedure for DDH and that invaginated distal femoral allograft and I couldn’t help but say to myself, “This is a teacher trapped in an orthopedic surgeon’s body.”
Dr. Hedley: Don’t you believe it? There’s lots of opportunity in Orthopedics to teach and be inventive. I’ve enjoyed all of the things you just mentioned. I must say. The turn-up, turn down, even if I say it myself, is a wonderful procedure. I can’t imagine any other procedure for a high-riding DDH. And we’ve had such good results. I don’t see many of those kinds of cases anymore. But we’ve had wonderful results with the turn up turn down. And then more recently they asked me to do the commentary for the direct superior that I did with my colleague in Palm Springs, Dr. Roger, wonderful guy. So, I had a lot of fun with that. But yes, I enjoy teaching and certainly have had an opportunity to do a lot of teaching of good things.
Kevin: I want to talk about that Direct Superior for a second because that got my attention. As a Zimmer rep we went through a time in our company’s history when the two-incision hip was what was being promoted and the stem aspect of that procedure was very familiar to me as kind of a close cousin of the Direct Superior. Tell me a little bit about it, the advantages of it. And is it technically really difficult to do?
Dr. Hedley: I have done every approach to the hip known. Smith-Peterson, direct anterior-posterior. I’ve done them all and I am totally enchanted by the Direct Superior for primary hips. The one thing about the Direct Superior that is a real plus it is extensile. So, if you start with the Direct Superior and things are getting out of hand or you’re doing a revision, you just extend your incision and bingo there you have a normal posterior approach. So just from the ability to change horses in midstream, the Direct Superior is fabulous. And I think and I’m saying this with a lot of experience of different approaches, I think the Direct Superior is probably the finest approach to the hip I’ve ever seen.
I went to help Doug Roger down in Palm Springs. He came back and did one the next day and I went to make rounds and the patient’s bed was empty. And I thought, “Oh God, I’ve killed a woman.” She was up and walking and went home the same day. And it’s a very elegant approach. The only muscle cuts, if you want to call them that, is taking down piriformis and the obturator tendon, which gets put back as part of the closure. The rest is just a gluteus maximus split, take down the two tendons, open the capsule, you get an excellent view of the acetabulum. And the thing that I think is absolutely remarkable is the exposure of the femur, because you’re at the back you flex the hip up a little, drop the foot over the side of the table and you are looking straight down the canal. It’s a wonderful approach for the femur and you don’t hit the problems that you encounter with a direct anterior. Because with the direct anterior you have to go around the corner. Well, with this Direct Superior, there are no corners. It gets a straight shot with your reamer, straight shot with your broach, and it’s most unusual to have femoral complications. So, it’s turned out to be I think an absolutely superb approach that is atraumatic. It’s been a long time since I had to transfuse a patient and pain management is relatively simple. We have no precautions, have had no dislocations and that’s quite a track record. So, I’m obviously a big fan of the Direct Superior.
Kevin: One of my favorite hip stems that I have ever sold within this company has been the anatomic stem. It was a right and left proximal mid coat design. And that means automatically I’m a big fan of your Citation. I think you did a great job with that stem. I love that lateral machining assembly. You’ve got to be proud of that stem.
Dr. Hedley: I am, and I can’t take sole claim on that. I had a tremendous amount of help from Phil Noble, a bioengineer. And together we were able to create the Citation and I still do it. I think it’s a great stem.
Kevin: I’ll never forget the first time a Stryker rep ever showed that in my territory. He came out of the lounge just, looked like a bloodbath. And those rasps on that system were so sharp. It just completely sliced him up doing a demo. I think he got a lot of– I think he got some sympathy points on that. But that was quite a sight to see.
Dr. Hedley: Yes, I bet it was.
Kevin: Let’s talk about knees for a second. I’m under the impression that you were involved in the triathlon knee.
Dr. Hedley: I’ve been involved in knee since the PCA days back in 1982. And it was then PCA, then modular and it’s evolved from the PCA finally to the triathlon and having very, very good results with the Triathlon.
Kevin: Yes. I’d like to talk about Triathlon in just a minute, but I want to go back to the PCA. There’s all this chatter in our space about unsubmitted knees and it’s kind of making a resurgence of sort, but it’s going back to the future, isn’t it? I mean, I remember the PCA with the beaded implants and they were doing well back then as I recall.
Dr. Hedley: It’s been a long time since I cemented the hip and knee along with the robot, the majority if not all of my knees are cementless and I have been very, very happy. The fixation has been great and had very, very few complications. So, I think more and more people will get confidence enough to do cementless knees. As you said, maybe back to the future, but it sure as hell works in my hands.
Kevin: I didn’t even ask you. Are you going cementless on the patella as well?
Dr. Hedley: Yes. I am guilty of having done cementless patellas for years. I had a series of I think 600 something that I wanted to write up and I was vetoed because it’s off label, what was off label. So, I wasn’t allowed to give all my numbers. I had to report on 100 instead of 600. I’ve had very good success. The current design is good. Earlier designs needed a lot of help. The big fault was the fixation of the plastic to the metal backing. That was an engineering faux pas because the plastic would dissociate from the metal backing and then you have the metal backing articulating with the femur. And the Australians coined the term when you’ve had metal on metal because of the failed patella and you open up the knee and everything’s black. The Aussies called it Molina knee and boy they were right too. Anyway, those days are over. We don’t have the same problems. I know that Dick Scott put the hex on metal-backed patellae that caused an obvious failure rate, which was not his fault but a design issue. I think a lot of those fundamental problems have been taken care of. So, I am a believer in metal-backed patellae that do extremely well. And the beauty of a metal-backed patella is you can even put that device on a very thin patella. If you do a revision and you’ve got three or four millimeters a bone, you can still do metal-backed patellae even if the pegs stick out a little bit on the anterior cortex. As long as you’ve got ingrowth you’ve got a viable articulation. So, I’m a fan.
Kevin: Let’s talk about the triathlon knee. 2005, Stryker released that knee and at that time, most of the other systems on the market had been out a while and this was kind of the latest and greatest thing at that time. I know you’ve got, and I’m going to digress here for a second, but I know you have an art background and I know you’ve got an eye for things. I got a compliment. I don’t know how you played a part in this but there was a real design aesthetic going on with that knee system. The soft-touch handles, the selective nitriting of things, buttons were gold. even the trays that the instruments came in. I mean it was quite a job that they did in terms of the look and feel and I think that that gets lost sometimes in instrument design. But I got to say well done.
Dr. Hedley: One of the keys in the design of the Triathlon is the patellofemoral joint. And I happen to be very proud of that because that was a carryover from the modular, from it’s predecessor. And it was something that I worked very hard on because I think a bad patellofemoral articulation causes a block to flexion. The flexion isn’t good, et cetera. And the way things have turned out, the patellofemoral joint with the Triathlon is excellent. If you look where the patella sits when you flex the knee, it’s sitting right where you want it to and that’s in the notch and there is an articulation between plastic and metal even in deep flexion. And I think that’s one of the big points about the triathlon patellofemoral joint.
Kevin: I felt like I was watching the PBS show the Woodwright’s Shop the other day seeing you do that massive invaginated distal femoral allograft on VuMedi. So, I got to ask this. I need the follow-up, the patient follow-up.
Dr. Hedley: That patient that we used to demonstrate the procedure is the mother of a pair of country singers and she is still alive. She works as a waitress in a local country and western bar. She is on her feet almost every day and doing well after all these years. So, it’s been quite remarkable and she’s very happy, very happy.
Kevin: I’ve worked with many a surgeon over the years that have kind of transposed their Orthopedic skills into a wood shop in their backyard. And when I was watching you do that procedure, I felt that you have that same skill set that I’ve seen in these surgeons that I’m describing. Do you have a wood shop at your house and do you mess around with that?
Dr. Hedley: I’ll tell you the secret. When I was a kid, my grandfather used to give me tools. And every birthday and every Christmas that came along he would give me a new tool. And he paid for woodworking lessons along with what I got in junior school. So, I had a lot of encouragement to do that and it’s paid off. There are things that I learned in the woodshop that have served me extremely well.
Kevin: Dr. Berend said something recently that’s been rolling around in my head a lot lately. He said that joint reconstruction is not just about metal and plastic anymore. And I was just wondering what are your thoughts on the advent of robotics in this space, where it’s at now, where you see it going?
Dr. Hedley: I have to tell you. I was skeptical in the beginning about the robotics. I thought it’s another layer of stuff you got to think about in the OR. The robot that I’m involved with does exactly what they said it would do. And what it does do, I think that the contribution from the robot is not the actual cutting of bone. Although, that is obviously going to be all perfect. What you do with the CT scan and the computer preoperatively tells you where your cuts are going to be, et cetera, et cetera. And it allows you to preoperatively plan balancing. And I have partners that do a lot of robots. And when I look at their post-ops the knees are appropriately straight. They are balanced. They work well. I think the vast majority of them are cementless because the bone cuts are about as near perfect as you get them. So, there are a lot of pluses. I don’t think people should become intimidated by the robot. It’s an asset to be shared and it does contribute a lot to the outcome of the patient.
Kevin: I’ve seen a lot of presentations you’ve made on some really interesting cases. Is there one case in your career– I mean I know it’s hard to stratify all this stuff but is there one case in particular that just stands out that was just very notable to you whether it was an outcome or a creative way to get out of the OR, any thoughts?
Dr. Hedley: Well as a told you thirteen and a half thousand joints, it’s hard to pick on one. But you mentioned that invaginated graft. That was kind of a one-off kind of deal I must say. I’ve had a great deal of pleasure with the turn-up, turn down because if you do it right, there’s no other way to do it frankly. And the patients do extremely well. A number of these people come back to my office for follow-up and I’m going back 15-16 years or even more with some of those patients, and the majority of them are happy. I must say the stem that I used is the S-ROM it’s modular and I don’t think you could use any other stem. The whole idea of the modularity allows you to put the proximal femur where you want it rotation wise and the stem is basically an IM rod. I think it’s been the prostheses of choice for the turn up turn down.
Kevin: I’m seeing more and more surgeons integrate dual mobility into their practice, prior spine surgery, maybe an auto fuse spine situation. And I was actually thinking about that DDH case. Is that a situation where you consider dual mobility or what’s your threshold for having one of those implants opened on your table?
Dr. Hedley: I’ve had a minimal experience with it and it has clear advantages. I think it’s good. I kept the indications to do revisions and other issues like spasticity and so on and they’ve all done well. So, I have no problem if somebody said to me they would like to do a dual mobility. I think it’s. Just do it right.
Kevin: I was going down memory lane this morning just reading a history of hip replacement. It was an article I put on LinkedIn and there were just so many inspirational pioneers in that read that it was good to remember some of it because I’ve heard it my whole career, the Austin Moore, the Dr.Aufranc, the Judet brothers, McKee-Farrar. I could just go on and on. Who has been your primary inspiration in the reconstruction space over the years?
Dr. Hedley: Well, I don’t know if there’s one particular thing. I won the Otto Aufranc Award from the Hip Society for one of my papers. And Aufranc I think was a pioneer who inspired a lot of people not any one particular thing. I had an interesting experience with Otto. We were at New England Baptist and one of my colleagues was operating and doing a hip and I was in the observation level with Otto. Anyway, long story short, the guy reams the socket and put the socket in and everything and I think this was a dysplastic hip Anyway, the guy reamed the socket and put in the implant. And I Otto looked at me and he said, “25 degrees of retroversion.” And we were standing 50 feet away from the operating table. We looked at the post-op X-ray and he was 100% right. That old boy really knew his stuff. And those are the kind of people that inspire you. There’s no question about that.
Kevin: Dr. Zuckerman had a paper out recently where he was just talking about the three As of practicing medicine and the worth orthopedic space. And the three As were availability, affability, and ability. I was just curious, to the surgeons that listen to the show, if you were advising them on building a practice, is there anything beyond those three As that you think are important in the climate that we find ourselves in now.
Dr. Hedley: No, I quote the three A’s a lot. I think the one A that gets ignored a little bit is affability. Some guys get a little grumpy and so on and you really have to avoid that. Your patient has to feel that you are 100% on their side and that you’re an ally rather than just being indifferent. And that’s the best advice again. Ability obviously helps but the patient’s not awake to see your ability. All your patient is going to sense is the affability. And I think that that’s something I should remember and work on, be a friend, be a mentor, et cetera. And I love going to the patient waiting room after surgery and saying to the family things went really well and knowing that they did. There’s a great deal of satisfaction at that.
Kevin: You’ve been asked so many questions over the years. There’s a lot of interviews with you online I noticed. And I know you’ve probably heard a lot of the same questions over and over, but here’s one you may have never been asked. What is your advice to people that work in my profession that are on the other side of your table with a laser pointer that are responsible for putting these cases together for you, the medical device reps that listen to the show? Do you have any advice to them?
Dr. Hedley: Well, you’ve kind of hit the nail on the head there. Laser pointer and attention and guiding help for a scrub nurse or surgeon or whoever, the advice I’d give, don’t be a stranger. Participate, stand-up as close to the table as you can and keep an eye on things. You get some of these reps who hang around in the background. You want to take an implant out of a box and the guy’s nowhere to be found. That is not what I regard as good representation. So, participate I think is the keyword there.
Kevin: What’s next for you? I mean you got any projects that you’re working on or anything you’re excited about these days?
Dr. Hedley: My project is just staying alive.
Kevin: I get it. I had a surgeon that had some heart issues and I never really appreciated it till I found out he had heart issues because I would always say, “You know, it’s good to see you doctor.” And he would say “It’s good to be seen.” And I understand that a little bit more now.
Dr. Hedley: Well, I have a little bit of that in me because I don’t know whether you know this, but I had a lung transplant five years ago, double lung transplant. I got a crazy condition called IPF, which is idiopathic pulmonary fibrosis. And I was fishing with my son down in New Zealand and getting really short of breath and I thought, “This is strange.” We were kind of scrambling along a riverbank and he was way ahead of me. And I was having difficulty keeping up. So, when I got home, I thought, “I need to have this looked at.” So, I went to see a friend of mine who is a pulmonologist who I’ve known for many years by the name of Cash Beechler. And he did some pulmonary function tests, got a CT scan and a few things and I went, just find out the results. And he said, “Tony you have got IPF.” Now I was a nonsmoker. Okay. So, any lung issue was not from cigarettes. I was in the military but was never exposed to anything like Agent Orange. So, this just came out of the blue. And he said, “You got IPF.” And I said, “Well, what’s the story?” He said, “Well, it can just tick along with minimal impact on you or it can suddenly worsen and you’re in trouble.” Well, that’s what happened to me. I was operating in September, October I was on oxygen 24/7 and my PO 2 is was disgusting. On 5 liters of oxygen, I was about 84 and if I took the oxygen off and went to the toilet it was about 30. I was in trouble quite honestly. I was dying and I had already been referred to the lung transplant unit at St. Joseph’s hospital and they’d ran some tests at the beginning of October and they repeated those in two weeks. And the guy looked at me and said, “I’m moving you up in the waiting list.” And I got a call a couple of days later. And the guy said, “Would you please come down to the hospital? I want to talk to you about a pair of lungs that we think may be appropriate.” I never left the hospital. I had the lungs and my PO 2 right now as I’m talking to you is 98. It’s the best part of me. They did a fantastic job.
Kevin: That’s awesome. I worked with a nurse who never smoked a day in her life and didn’t have anything to suggest that this was going to be her path but ended up with lung cancer and she’s doing much better now. They’ve been able to bring it under control. But she is convinced it was the Bovie smoke after all those cases standing right beside the surgeon breathing it all in.
Dr. Hedley: Funny you should say that. I firmly believe that, firmly. Because there’s nothing else in my life that could have done it and I absolutely would echo that sentiment.
Kevin: Well, I’m glad you’re on the mend now.
Dr. Hedley: He’ll I’m mended, don’t worry. It was five years ago in October and things couldn’t be doing better.
Kevin: Dr. Hedley, you are truly a man in full and I feel confident your face is going to be on the orthopedic Mount Rushmore one day if and when it’s constructed. I just wanted to just say a huge thank you for your time in sharing your life with me and my audience. I really appreciate it.
Dr. Hedley: You’re very welcome, been a pleasure.
Kevin: We just spent 45 minutes in the presence of greatness. What an amazing man and what an amazing journey. If you want to see more about him just Google his name and look at all the things his hands have been in this space for so many years