May 9, 2025 • 22 mins
Revolutionizing Hip Surgery in Barcelona: Anterior Approach Insights with Dr. Alfonso Alias
In this episode of the AHF Podcast, host Joe Schwab chats with Dr. Alfonso Alias, a consultant hip surgeon from Clinic Barcelona, about the transformative impact of the anterior approach to hip replacement surgeries. Learn how Dr. Alias and his team have improved patient recovery times and hospital stays, and gain insights on the differences between anterior, posterior, and lateral approaches. Discover the challenges and solutions in optimizing efficiency within the public healthcare system, as well as Dr. Alias's advice for surgeons considering a switch to the anterior method. Tune in to hear about his experiences, mentorship, and his journey to adopting advanced surgical techniques.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M Schwab (00:24):
Hello and welcome to the AHF Podcast.
I'm your host, Joe Schwab.
Our episode today features myconversation with Dr.
Alfonso Alias, a consultant hipsurgeon from the hip unit at the
Orthopedic Surgery andTraumatology service at Clinic
Barcelona in Spain.
Dr.
Alias has been instrumental ingrowing anterior approach in
(00:44):
Barcelona, and through hisefforts and the efforts of his
partners, patients arerecovering quicker and spending
less time in the hospital.
As a side note, I was recoveringfrom laryngitis when we talked,
so my voice is a little raspy.
Nevertheless, I was fascinatedto hear how much growth anterior
approach had undergone inBarcelona thanks to Dr.
(01:05):
Alias and his partners.
Let's listen in on a portion ofour conversation.
Dr.
Alias welcome to the podcast.
Alfonso Alías (01:16):
Thank you so much for having me.
It was honor for me.
I.
Joseph M Schwab (01:21):
so my understanding is you're in
practice in Barcelona, Spain.
Alfonso Alías (01:25):
Is correct?
Yeah.
I'm in hospital clinic inBarcelona.
Right.
Joseph M Schwab (01:29):
when you began there, was anterior approach,
hip replacement, something thatwas common, or did you bring
that, into the practice whereyou're at?
Alfonso Alías (01:38):
So when I started in the hospital, my chief was,
already performing anteriorapproach.
That was in 2019 at the end of2019, I started with my first
approaches and now as my regularapproach, like I said, it's like
five years from now, three of usare performing anterior approach
Joseph M Schwab (01:59):
And so what motivated you to take up
anterior approach when you gotinto practice?
Alfonso Alías (02:05):
So I've seen the difference, between my patient
and the from my chief who was,he was doing anterior approach.
I, since 2013, I think.
And I've seen for, in terms ofrapid recovery or, to get early
with, physiotherapy also becauseof the length of the stay.
(02:27):
And something was kind of adifference between the, his
patient and my patient.
That's why I wanted to start it.
Also, also maybe to, I wanted toall the unit to see, to do the
things in the same way, becauseotherwise I was doing the
posterior approach.
Another colleague was doing adirect lateral approach.
(02:48):
My chief was doing the anteriorapproach.
Then that's why I felt, it makessense just that everybody does
the same
Joseph M Schwab (02:55):
What was it that you noticed that made you
think the entire team should bedoing it all the same way?
Alfonso Alías (03:03):
You have no restrictions at all.
So when I was doing theposterior approach, we had.
some kind of restriction.
Yeah, you have to take careyou're standing up or when
you're moving.
This kind of movements.
If you go to the toilet, maybeyou have to have a height in
there in when you're sitting forthe first weeks.
Maybe it was just me that I wasmaybe very careful in the
(03:26):
beginning, and, but the, thepatients who were having the
anterior approach, were norestrictions at all.
We actually, they can dowhatever they want.
We have no restriction in, interms of, restriction of
movements it's like they can dowhatever they feel good to do.
Joseph M Schwab (03:44):
Was it a ward type situation where patients
from multiple surgeons might bein one room?
Room or, did have individualrooms?
How much were they seeing waysthat they were being treated
differently?
Alfonso Alías (03:57):
Usually we have single rooms and double rooms
and yeah, that happens a lotthat you have in the same room
people from posterior approachor for lateral approach together
with, with the people fromanterior approach.
Nowadays we are doing almost allour cases in anterior approach,
like I said, and, we have not somuch ref difference.
(04:18):
Really the difference is betweenthe direct lateral approach and
the anterior approach, for me.
With the posterior approach,it's not so much the difference,
but with the lateral approach,this is something like, you can
really really feel that thepatient is moving faster.
The pain is less.
It's very, very common that inthe first day they want to leave
(04:39):
the crutches and work withoutcrutches sometimes.
And that is a, a big difference,I think.
Joseph M Schwab (04:46):
And the system that you're in, is it a public
system in Spain?
Alfonso Alías (04:51):
Yeah.
I work in a university hospitaland in a public system, yeah.
Joseph M Schwab (04:55):
So tell me a little bit about how setup of
the medical system and thepublic hospital system in Spain
plays into your decision aboutwhat you choose to do for
patients.
Alfonso Alías (05:08):
Usually we have to say that the patient that we
get in our hospital are thepatient that are living in a, in
a zone in Barcelona.
But I think we have about350,000 people we have to take
care of, and, they are, they'regonna be referred to our
hospital.
So it's not that the people candecide which hospital you want
(05:33):
to choose, it's just that's thepublic system just allows you to
go in the hospital that is nearyour, your home
Joseph M Schwab (05:41):
With all of you and your partners the same,
surgical at this point, gettingthe teams, on getting the nurses
physiotherapists on board, areyou able to work on efficiency
or is that something that'sdifficult to, maneuver the
health system you're in?
Alfonso Alías (06:01):
It is very difficult.
It is one of, our challenge, Ithink, and because here it is
like, Your team, or even thedoctors, everybody's gonna get
paid the same amount of money atthe end of the month no matter
if you do two hips or twohundred.
Okay.
starting from that point, it issomething that is difficult to
(06:25):
talk about efficiency.
I was trained in Germany where,you know, the system is very
different and everybody wants tobe more efficient and everybody
wants to operate more patientsbecause it's better for the
hospital, it's better for thesociety also, but it's better
also for, the directors of thehospital just to get the, the
(06:47):
system moving, you know.
but here it's kind of different.
I think we're getting better andwe are trying to get better in
terms of efficiency, but, wehave a lot of things to, to
improve I was with, I wasvisiting Kristoff Corten and
seeing him doing 12 to 16 hipsin a day.
Joseph M Schwab (07:10):
Yeah.
Alfonso Alías (07:11):
it's not something that's gonna happen.
It's gonna happen in my hospitalovernight, you know, so you are
gonna have to work a lot.
And maybe we are never gonnahit, hit these numbers, but, But
for sure we are working on, ongetting better.
Joseph M Schwab (07:28):
Is efficiency one of the biggest challenges
that you've come across in yourpractice or as you've, anterior
approach, what, say has been oneof the biggest challenges?
Alfonso Alías (07:40):
I think that is nowadays my biggest challenge.
here, for example, I work inBarcelona.
a patient comes to me in my, inmy outpatient clinic and wants
to be, want to have his or herhip done, they're gonna have to
wait almost six months.
Joseph M Schwab (08:00):
Wow.
Alfonso Alías (08:00):
We are working in kind of, I think the NHS had
some kind of a more or less samesystem and we have this waiting
list that is what moves me toget better in terms of
efficiency because, you know,you can optimize the patient in
this time for example, peoplethat said I am, I'm BMI over 35.
(08:22):
They're gonna be in a differentclinic to, to, to get the, the
weight reduced before.
So you can do a lot of things inthese six months.
it is something we don't wantto, and we would like to, to
have something shorter, like onemonth or something like that.
Joseph M Schwab (08:40):
And how long after the surgeries are patients
staying in the hospital, in yourclinic?
Alfonso Alías (08:46):
One night.
Usually we do outpatient.
Joseph M Schwab (08:49):
Oh, you do.
Alfonso Alías (08:50):
Yeah.
But we were, we were the firsthospital in Spain starting with,
with the outpatient.
Joseph M Schwab (08:57):
Great.
Alfonso Alías (08:58):
we have done not so much cases and that is, also
something that, we want toimprove I think we want to.
Yeah, I hope that in the nextcouple years we can do maybe 20%
or 25% of our patients with, inlike outpatients.
(09:20):
You know, we are working in ahospital that is a high level
hospital.
We get all complicated cases,not because, not just because of
the surgery, but also becauseof, I don't know, liver
transplantation or.
people that are really sick,we're not a clinic who is doing
just ASA one or two.
So we have complicated cases andthat allows you not to do an
(09:47):
outpatient center whereeverybody's gonna go home the
same day.
Joseph M Schwab (09:51):
so how did your patients respond when you
started offering them basicallyoutpatient, total hip
arthroplasty?
Was that something they wereexcited about?
Were they hesitant?
How was, what was theirresponse?
I.
Alfonso Alías (10:03):
Yeah, we have started with the, with the, the
first patient was in 2018, was apatient who had already a hip
done in the other side.
So it's a patient who knows allthe process and knows everything
is gonna happen to him.
And then we started doing slowlymore and more.
And the patient, usually theydon't want to sleep in the
(10:26):
hospital.
They have to share a room withanother, with another patient.
but that is something that Ithink the oldest, patient we
have done is 77 years old.
And usually it's something youdo for the 60 years old, healthy
(10:46):
people.
we like, to have at the, at thefirst, the first patient, they
were all living around thehospital, so not so far away.
Joseph M Schwab (10:58):
Yeah.
Alfonso Alías (10:59):
the hospital.
We were scared in the first, inthe first cases, but till till
today, we had no problems at allwith all the patient that went
home.
And, and after you speak withthe patient and say, how was the
experience for you, and theanswer is always, it was okay.
It was nice.
I think everybody wa everythingwas under control.
And and I felt, I felt greatgoing home same day.
(11:22):
So that's why we wanted to domore.
Joseph M Schwab (11:25):
This episode of the A HF podcast is brought to
you by Mizuho, OSI, the way asurgical tool like the HA table
has enabled the adoption of theanterior approach has made a
real difference.
It's been about 20 years sincethe HA table first began
revolutionizing our ability toperform anterior approach
(11:46):
consistently.
Since then, we've seen thegrowth of hip preservation
techniques like arthroscopy andPAO.
The team at Mizuho OSI is takingthat 20 years of learning and
experience to prepare for thenext innovation, which will
further push forward what we canaccomplish in the operating
room.
(12:07):
What they have coming up isgonna take what you know about
the HA table to a whole newlevel experience, the difference
innovation makes for yourself byvisiting Mizuho OSI at this
year's Anterior Hip Foundationannual meeting.
Who knows what solution theymight bring out next, but you're
gonna want to be the first tosee it.
(12:29):
And now back to our podcast.
So your patients have beenfairly satisfied with the
outpatient experience at thispoint.
Yeah.
Talking a little bit about howyou do anterior approach and a
little bit specifically abouttable versus tableless, use of
fluoroscopy or robotics.
(12:50):
additional navigation.
What your, implant choice isand, and things that.
Tell me a little bit about whatyour setup is.
Alfonso Alías (12:59):
So in our setup, we operate on regular table.
Okay, that's, we do the anteriorapproach.
We use, the bikini approach for,I would say all of our patients.
We do like a, with a table.
we have been using, at thebeginning we were for
(13:22):
retraction, we were using theGelpi from Anelli.
And nowadays, is like 18 months,I think we started with, the
Gripper.
Joseph M Schwab (13:33):
From medEnvision?
Alfonso Alías (13:34):
From medEnvision, yeah.
Right.
And we're pretty happy withthat, so.
We'll, we love it.
yeah, so we are, we are doingthe, the approach, think we are
doing kind of different thingssometimes in terms of how you
treat the, the capsule, forexample.
Joseph M Schwab (13:54):
Yeah.
Alfonso Alías (13:55):
but, I will say that the approach is more or
less the same we are using thefluoroscopy at, once we have put
the cup in, so we don't use thefluoroscopy to put the cup, but,
but to take a look to the stem,to take a look to the length and
to take a look to the offsetusually.
Joseph M Schwab (14:14):
I see.
So you're putting the cup inwith anatomic landmarks.
Alfonso Alías (14:18):
Yeah.
and now also because I havestarted with the robotics, with,
the Rosa
Joseph M Schwab (14:23):
Mm-hmm.
Alfonso Alías (14:24):
from Zimmer and we are doing our first cases and
then, yeah, we are using themore fluoroscopy because of the
Rosa.
And then maybe we're gonna do itin the future.
We'll see.
Joseph M Schwab (14:38):
so you mentioned Kristoff Corten, and
you mentioned your training inGermany.
tell me a little bit about your,who your mentors have been and
what influences, they've,they've had to help, shape your
approach to direct anteriorapproach.
Alfonso Alías (14:59):
So when I was, when I was a resident, I was
doing a Watson-Jones in supineposition.
Okay.
is what, that was my approachwhen I was finished, with the
residency.
And I have started my practice,but, I've been, I was, it was
the classic one.
You know, with a, you know, withthis Bend shape incision,
Joseph M Schwab (15:20):
Yeah.
Alfonso Alías (15:22):
but it was, I was not so happy because usually
even from the beginning, youhave to remove or to detach the
first fibers of the gluteusmedius.
In order to get the stem down,and, sometimes you get it, you
can do it without touching thegluteus, but that was something
(15:43):
that in my hands and in thehands from the people from when,
from, from whom I am learned.
Always the first fibers.
I will say not, not one third ofthe gluteus, but maybe, 20% of
the gluteus in the front sideis, get detached from, from the
(16:04):
insertion of the stem, that wasin our hands.
Now, after that you can do the,your sutures, you can do
whatever.
And that's why I didn't like itso much
Joseph M Schwab (16:14):
if you could go back five years, in, into the
beginning of your practice, whatwould be something you wish you
would've known, or wish youwould've had available to you
when starting your, anteriorapproach journey?
Alfonso Alías (16:31):
Yeah, like to really understand the releases.
For me, at the beginning it waslike, I haven't, that's really
clear at the beginning.
Maybe I haven't visit so much.
maybe, yeah.
wasn't in, I was just in a ca inone cadaver lab I haven't seen
(16:53):
that.
Well, really, and I, in thebeginning, I was always
struggling with, with the liftof the femur, like everybody at
the beginning.
And, and now it's something thatI've really understand, and I
say hope be possible before, butyeah, this is a learning program
(17:14):
beginning, always, I don't knowif how was for you, but
Joseph M Schwab (17:19):
It.
It was just time and experiencefor you that taught you those
releases.
Alfonso Alías (17:23):
Yeah.
Yeah.
And also I have to say, I haveto thank really from the help to
Kristoff, to Kristoff Corten.
in the, in this month I wasspending with him.
I've seen everything so clearand everything was so easy.
And, yeah, it was like a realchange in my practice.
Joseph M Schwab (17:45):
Tell me a little bit about those
adjustments you've made based ongoing to see, for instance,
Kristoff.
is it adjustments in yourinstrumentation, in your
positioning, in your teamcoordination?
are the changes you're making?
Alfonso Alías (18:01):
So in the position of the instruments.
So I really like it that I waskind of a, a little bit more
random position of theinstrument from, depending on,
on every patient.
And at the beginning, but, afterep, I've been with, professor
(18:23):
Corten.
So everything was the same.
Every step was really the same.
And, and you don't have to tochange the way you do the
things, depending on how big isthe patient, how muscular is the
patient, or you can, you can do,I, I've learned that you can do
(18:45):
always the same.
And no matter if it's a ladywith 60, years old or a young
guy, muscular big and, anddifficult to do.
Joseph M Schwab (18:57):
And so it, it feels more like what you're
describing is a jointreplacement, hip replacement,
specifically in this casebecoming, a, bit more assembly
line.
E everything done the same wayeach time.
Alfonso Alías (19:12):
I think that every patient is different.
You can do it the same way, butin my opinion, maybe.
Sometimes it's not the same 87years old Dorr C femur, are
gonna put a cemented stem in, oryoung lady with, I don't know,
(19:36):
35 years old, I'm gonna put ashort stem in, not a, not a
regular one, for we changethings, but I mean, I meant yes,
in the way you do the approach.
Joseph M Schwab (19:48):
Yeah.
So if you were able to give someadvice, to surgeons who are
considering switching toanterior approach or are maybe
hesitant because of the learningcurve, what, would you share
either about your experience orwhat advice would you give, to
those surgeons who are thinkingabout the change in their
(20:08):
practice?
Alfonso Alías (20:10):
So first step, cadaver lab.
That is very, very, veryimportant.
Just to see, to have to, becauseit's not the same if I'm doing,
I'm seeing you to do theapproach in a video, and I say,
well, it looks very, very easy.
Joseph M Schwab (20:27):
Yeah.
Alfonso Alías (20:28):
you don't have the idea hold, you have to put
the retractors, the, this, this,they, you have a lot of tiny
details that can make your lifereally easier.
And, the second.
to visit somebody who is doingthe anterior approach and can,
and you can see really in realpatient are they performing an
(20:51):
anterior approach.
And the third step is, to startwith your fair case, with your,
with your first cases, withsomebody you who can help you in
just in case you struggle with,with, with approach.
Joseph M Schwab (21:08):
Alfonso, I've really enjoyed talking to you
today.
I really appreciate having youon the AHF podcast
Alfonso Alías (21:14):
Thank you so much for having me.
Like I said, it was really apleasure and I hope to see you
again maybe in London.
Joseph M Schwab (21:20):
Thank you for listening to this episode of the
AHF podcast.
Remember to like and subscribeso we can reach a wider
audience.
If you have an idea for a topic,leave it in the comments.
Remember, you can find us inaudio podcast form in your
favorite podcast app.
As well as in video form onYouTube slash at Anterior Hip
(21:41):
Foundation, all one word.
New episodes of the AHF Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
happy and healthy.
Hello and welcome to the AHF Podcast.
I'm your host, Joe Schwab.
Our episode today features myconversation with Dr.
Alfonso Alias, a consultant hipsurgeon from the hip unit at the
Orthopedic Surgery andTraumatology service at Clinic
Barcelona in Spain.
Dr.
Alias has been instrumental ingrowing anterior approach in
(00:44):
Barcelona, and through hisefforts and the efforts of his
partners, patients arerecovering quicker and spending
less time in the hospital.
As a side note, I was recoveringfrom laryngitis when we talked,
so my voice is a little raspy.
Nevertheless, I was fascinatedto hear how much growth anterior
approach had undergone inBarcelona thanks to Dr.
(01:05):
Alias and his partners.
Let's listen in on a portion ofour conversation.
Dr.
Alias welcome to the podcast.
Alfonso Alías (01:16):
Thank you so much for having me.
It was honor for me.
I.
Joseph M Schwab (01:21):
so my understanding is you're in
practice in Barcelona, Spain.
Alfonso Alías (01:25):
Is correct?
Yeah.
I'm in hospital clinic inBarcelona.
Right.
Joseph M Schwab (01:29):
when you began there, was anterior approach,
hip replacement, something thatwas common, or did you bring
that, into the practice whereyou're at?
Alfonso Alías (01:38):
So when I started in the hospital, my chief was,
already performing anteriorapproach.
That was in 2019 at the end of2019, I started with my first
approaches and now as my regularapproach, like I said, it's like
five years from now, three of usare performing anterior approach
Joseph M Schwab (01:59):
And so what motivated you to take up
anterior approach when you gotinto practice?
Alfonso Alías (02:05):
So I've seen the difference, between my patient
and the from my chief who was,he was doing anterior approach.
I, since 2013, I think.
And I've seen for, in terms ofrapid recovery or, to get early
with, physiotherapy also becauseof the length of the stay.
(02:27):
And something was kind of adifference between the, his
patient and my patient.
That's why I wanted to start it.
Also, also maybe to, I wanted toall the unit to see, to do the
things in the same way, becauseotherwise I was doing the
posterior approach.
Another colleague was doing adirect lateral approach.
(02:48):
My chief was doing the anteriorapproach.
Then that's why I felt, it makessense just that everybody does
the same
Joseph M Schwab (02:55):
What was it that you noticed that made you
think the entire team should bedoing it all the same way?
Alfonso Alías (03:03):
You have no restrictions at all.
So when I was doing theposterior approach, we had.
some kind of restriction.
Yeah, you have to take careyou're standing up or when
you're moving.
This kind of movements.
If you go to the toilet, maybeyou have to have a height in
there in when you're sitting forthe first weeks.
Maybe it was just me that I wasmaybe very careful in the
(03:26):
beginning, and, but the, thepatients who were having the
anterior approach, were norestrictions at all.
We actually, they can dowhatever they want.
We have no restriction in, interms of, restriction of
movements it's like they can dowhatever they feel good to do.
Joseph M Schwab (03:44):
Was it a ward type situation where patients
from multiple surgeons might bein one room?
Room or, did have individualrooms?
How much were they seeing waysthat they were being treated
differently?
Alfonso Alías (03:57):
Usually we have single rooms and double rooms
and yeah, that happens a lotthat you have in the same room
people from posterior approachor for lateral approach together
with, with the people fromanterior approach.
Nowadays we are doing almost allour cases in anterior approach,
like I said, and, we have not somuch ref difference.
(04:18):
Really the difference is betweenthe direct lateral approach and
the anterior approach, for me.
With the posterior approach,it's not so much the difference,
but with the lateral approach,this is something like, you can
really really feel that thepatient is moving faster.
The pain is less.
It's very, very common that inthe first day they want to leave
(04:39):
the crutches and work withoutcrutches sometimes.
And that is a, a big difference,I think.
Joseph M Schwab (04:46):
And the system that you're in, is it a public
system in Spain?
Alfonso Alías (04:51):
Yeah.
I work in a university hospitaland in a public system, yeah.
Joseph M Schwab (04:55):
So tell me a little bit about how setup of
the medical system and thepublic hospital system in Spain
plays into your decision aboutwhat you choose to do for
patients.
Alfonso Alías (05:08):
Usually we have to say that the patient that we
get in our hospital are thepatient that are living in a, in
a zone in Barcelona.
But I think we have about350,000 people we have to take
care of, and, they are, they'regonna be referred to our
hospital.
So it's not that the people candecide which hospital you want
(05:33):
to choose, it's just that's thepublic system just allows you to
go in the hospital that is nearyour, your home
Joseph M Schwab (05:41):
With all of you and your partners the same,
surgical at this point, gettingthe teams, on getting the nurses
physiotherapists on board, areyou able to work on efficiency
or is that something that'sdifficult to, maneuver the
health system you're in?
Alfonso Alías (06:01):
It is very difficult.
It is one of, our challenge, Ithink, and because here it is
like, Your team, or even thedoctors, everybody's gonna get
paid the same amount of money atthe end of the month no matter
if you do two hips or twohundred.
Okay.
starting from that point, it issomething that is difficult to
(06:25):
talk about efficiency.
I was trained in Germany where,you know, the system is very
different and everybody wants tobe more efficient and everybody
wants to operate more patientsbecause it's better for the
hospital, it's better for thesociety also, but it's better
also for, the directors of thehospital just to get the, the
(06:47):
system moving, you know.
but here it's kind of different.
I think we're getting better andwe are trying to get better in
terms of efficiency, but, wehave a lot of things to, to
improve I was with, I wasvisiting Kristoff Corten and
seeing him doing 12 to 16 hipsin a day.
Joseph M Schwab (07:10):
Yeah.
Alfonso Alías (07:11):
it's not something that's gonna happen.
It's gonna happen in my hospitalovernight, you know, so you are
gonna have to work a lot.
And maybe we are never gonnahit, hit these numbers, but, But
for sure we are working on, ongetting better.
Joseph M Schwab (07:28):
Is efficiency one of the biggest challenges
that you've come across in yourpractice or as you've, anterior
approach, what, say has been oneof the biggest challenges?
Alfonso Alías (07:40):
I think that is nowadays my biggest challenge.
here, for example, I work inBarcelona.
a patient comes to me in my, inmy outpatient clinic and wants
to be, want to have his or herhip done, they're gonna have to
wait almost six months.
Joseph M Schwab (08:00):
Wow.
Alfonso Alías (08:00):
We are working in kind of, I think the NHS had
some kind of a more or less samesystem and we have this waiting
list that is what moves me toget better in terms of
efficiency because, you know,you can optimize the patient in
this time for example, peoplethat said I am, I'm BMI over 35.
(08:22):
They're gonna be in a differentclinic to, to, to get the, the
weight reduced before.
So you can do a lot of things inthese six months.
it is something we don't wantto, and we would like to, to
have something shorter, like onemonth or something like that.
Joseph M Schwab (08:40):
And how long after the surgeries are patients
staying in the hospital, in yourclinic?
Alfonso Alías (08:46):
One night.
Usually we do outpatient.
Joseph M Schwab (08:49):
Oh, you do.
Alfonso Alías (08:50):
Yeah.
But we were, we were the firsthospital in Spain starting with,
with the outpatient.
Joseph M Schwab (08:57):
Great.
Alfonso Alías (08:58):
we have done not so much cases and that is, also
something that, we want toimprove I think we want to.
Yeah, I hope that in the nextcouple years we can do maybe 20%
or 25% of our patients with, inlike outpatients.
(09:20):
You know, we are working in ahospital that is a high level
hospital.
We get all complicated cases,not because, not just because of
the surgery, but also becauseof, I don't know, liver
transplantation or.
people that are really sick,we're not a clinic who is doing
just ASA one or two.
So we have complicated cases andthat allows you not to do an
(09:47):
outpatient center whereeverybody's gonna go home the
same day.
Joseph M Schwab (09:51):
so how did your patients respond when you
started offering them basicallyoutpatient, total hip
arthroplasty?
Was that something they wereexcited about?
Were they hesitant?
How was, what was theirresponse?
I.
Alfonso Alías (10:03):
Yeah, we have started with the, with the, the
first patient was in 2018, was apatient who had already a hip
done in the other side.
So it's a patient who knows allthe process and knows everything
is gonna happen to him.
And then we started doing slowlymore and more.
And the patient, usually theydon't want to sleep in the
(10:26):
hospital.
They have to share a room withanother, with another patient.
but that is something that Ithink the oldest, patient we
have done is 77 years old.
And usually it's something youdo for the 60 years old, healthy
(10:46):
people.
we like, to have at the, at thefirst, the first patient, they
were all living around thehospital, so not so far away.
Joseph M Schwab (10:58):
Yeah.
Alfonso Alías (10:59):
the hospital.
We were scared in the first, inthe first cases, but till till
today, we had no problems at allwith all the patient that went
home.
And, and after you speak withthe patient and say, how was the
experience for you, and theanswer is always, it was okay.
It was nice.
I think everybody wa everythingwas under control.
And and I felt, I felt greatgoing home same day.
(11:22):
So that's why we wanted to domore.
Joseph M Schwab (11:25):
This episode of the A HF podcast is brought to
you by Mizuho, OSI, the way asurgical tool like the HA table
has enabled the adoption of theanterior approach has made a
real difference.
It's been about 20 years sincethe HA table first began
revolutionizing our ability toperform anterior approach
(11:46):
consistently.
Since then, we've seen thegrowth of hip preservation
techniques like arthroscopy andPAO.
The team at Mizuho OSI is takingthat 20 years of learning and
experience to prepare for thenext innovation, which will
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(12:07):
What they have coming up isgonna take what you know about
the HA table to a whole newlevel experience, the difference
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year's Anterior Hip Foundationannual meeting.
Who knows what solution theymight bring out next, but you're
gonna want to be the first tosee it.
(12:29):
And now back to our podcast.
So your patients have beenfairly satisfied with the
outpatient experience at thispoint.
Yeah.
Talking a little bit about howyou do anterior approach and a
little bit specifically abouttable versus tableless, use of
fluoroscopy or robotics.
(12:50):
additional navigation.
What your, implant choice isand, and things that.
Tell me a little bit about whatyour setup is.
Alfonso Alías (12:59):
So in our setup, we operate on regular table.
Okay, that's, we do the anteriorapproach.
We use, the bikini approach for,I would say all of our patients.
We do like a, with a table.
we have been using, at thebeginning we were for
(13:22):
retraction, we were using theGelpi from Anelli.
And nowadays, is like 18 months,I think we started with, the
Gripper.
Joseph M Schwab (13:33):
From medEnvision?
Alfonso Alías (13:34):
From medEnvision, yeah.
Right.
And we're pretty happy withthat, so.
We'll, we love it.
yeah, so we are, we are doingthe, the approach, think we are
doing kind of different thingssometimes in terms of how you
treat the, the capsule, forexample.
Joseph M Schwab (13:54):
Yeah.
Alfonso Alías (13:55):
but, I will say that the approach is more or
less the same we are using thefluoroscopy at, once we have put
the cup in, so we don't use thefluoroscopy to put the cup, but,
but to take a look to the stem,to take a look to the length and
to take a look to the offsetusually.
Joseph M Schwab (14:14):
I see.
So you're putting the cup inwith anatomic landmarks.
Alfonso Alías (14:18):
Yeah.
and now also because I havestarted with the robotics, with,
the Rosa
Joseph M Schwab (14:23):
Mm-hmm.
Alfonso Alías (14:24):
from Zimmer and we are doing our first cases and
then, yeah, we are using themore fluoroscopy because of the
Rosa.
And then maybe we're gonna do itin the future.
We'll see.
Joseph M Schwab (14:38):
so you mentioned Kristoff Corten, and
you mentioned your training inGermany.
tell me a little bit about your,who your mentors have been and
what influences, they've,they've had to help, shape your
approach to direct anteriorapproach.
Alfonso Alías (14:59):
So when I was, when I was a resident, I was
doing a Watson-Jones in supineposition.
Okay.
is what, that was my approachwhen I was finished, with the
residency.
And I have started my practice,but, I've been, I was, it was
the classic one.
You know, with a, you know, withthis Bend shape incision,
Joseph M Schwab (15:20):
Yeah.
Alfonso Alías (15:22):
but it was, I was not so happy because usually
even from the beginning, youhave to remove or to detach the
first fibers of the gluteusmedius.
In order to get the stem down,and, sometimes you get it, you
can do it without touching thegluteus, but that was something
(15:43):
that in my hands and in thehands from the people from when,
from, from whom I am learned.
Always the first fibers.
I will say not, not one third ofthe gluteus, but maybe, 20% of
the gluteus in the front sideis, get detached from, from the
(16:04):
insertion of the stem, that wasin our hands.
Now, after that you can do the,your sutures, you can do
whatever.
And that's why I didn't like itso much
Joseph M Schwab (16:14):
if you could go back five years, in, into the
beginning of your practice, whatwould be something you wish you
would've known, or wish youwould've had available to you
when starting your, anteriorapproach journey?
Alfonso Alías (16:31):
Yeah, like to really understand the releases.
For me, at the beginning it waslike, I haven't, that's really
clear at the beginning.
Maybe I haven't visit so much.
maybe, yeah.
wasn't in, I was just in a ca inone cadaver lab I haven't seen
(16:53):
that.
Well, really, and I, in thebeginning, I was always
struggling with, with the liftof the femur, like everybody at
the beginning.
And, and now it's something thatI've really understand, and I
say hope be possible before, butyeah, this is a learning program
(17:14):
beginning, always, I don't knowif how was for you, but
Joseph M Schwab (17:19):
It.
It was just time and experiencefor you that taught you those
releases.
Alfonso Alías (17:23):
Yeah.
Yeah.
And also I have to say, I haveto thank really from the help to
Kristoff, to Kristoff Corten.
in the, in this month I wasspending with him.
I've seen everything so clearand everything was so easy.
And, yeah, it was like a realchange in my practice.
Joseph M Schwab (17:45):
Tell me a little bit about those
adjustments you've made based ongoing to see, for instance,
Kristoff.
is it adjustments in yourinstrumentation, in your
positioning, in your teamcoordination?
are the changes you're making?
Alfonso Alías (18:01):
So in the position of the instruments.
So I really like it that I waskind of a, a little bit more
random position of theinstrument from, depending on,
on every patient.
And at the beginning, but, afterep, I've been with, professor
(18:23):
Corten.
So everything was the same.
Every step was really the same.
And, and you don't have to tochange the way you do the
things, depending on how big isthe patient, how muscular is the
patient, or you can, you can do,I, I've learned that you can do
(18:45):
always the same.
And no matter if it's a ladywith 60, years old or a young
guy, muscular big and, anddifficult to do.
Joseph M Schwab (18:57):
And so it, it feels more like what you're
describing is a jointreplacement, hip replacement,
specifically in this casebecoming, a, bit more assembly
line.
E everything done the same wayeach time.
Alfonso Alías (19:12):
I think that every patient is different.
You can do it the same way, butin my opinion, maybe.
Sometimes it's not the same 87years old Dorr C femur, are
gonna put a cemented stem in, oryoung lady with, I don't know,
(19:36):
35 years old, I'm gonna put ashort stem in, not a, not a
regular one, for we changethings, but I mean, I meant yes,
in the way you do the approach.
Joseph M Schwab (19:48):
Yeah.
So if you were able to give someadvice, to surgeons who are
considering switching toanterior approach or are maybe
hesitant because of the learningcurve, what, would you share
either about your experience orwhat advice would you give, to
those surgeons who are thinkingabout the change in their
(20:08):
practice?
Alfonso Alías (20:10):
So first step, cadaver lab.
That is very, very, veryimportant.
Just to see, to have to, becauseit's not the same if I'm doing,
I'm seeing you to do theapproach in a video, and I say,
well, it looks very, very easy.
Joseph M Schwab (20:27):
Yeah.
Alfonso Alías (20:28):
you don't have the idea hold, you have to put
the retractors, the, this, this,they, you have a lot of tiny
details that can make your lifereally easier.
And, the second.
to visit somebody who is doingthe anterior approach and can,
and you can see really in realpatient are they performing an
(20:51):
anterior approach.
And the third step is, to startwith your fair case, with your,
with your first cases, withsomebody you who can help you in
just in case you struggle with,with, with approach.
Joseph M Schwab (21:08):
Alfonso, I've really enjoyed talking to you
today.
I really appreciate having youon the AHF podcast
Alfonso Alías (21:14):
Thank you so much for having me.
Like I said, it was really apleasure and I hope to see you
again maybe in London.
Joseph M Schwab (21:20):
Thank you for listening to this episode of the
AHF podcast.
Remember to like and subscribeso we can reach a wider
audience.
If you have an idea for a topic,leave it in the comments.
Remember, you can find us inaudio podcast form in your
favorite podcast app.
As well as in video form onYouTube slash at Anterior Hip
(21:41):
Foundation, all one word.
New episodes of the AHF Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
happy and healthy.
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