April 25, 2025 • 22 mins
Join me as I talk with Dr. Alex Sah and Dr. Michael Blankstein about transitioning to Anterior Approach during their practice.
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Episode Transcript
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Joseph M Schwab (00:24):
Hello and welcome back to the AHF Podcast.
I'm your host, Joe Schwab.
Most residents coming out oftraining today will have had
some exposure to anteriorapproach total hip arthroplasty.
Adult reconstruction fellows inthe United States will often
consider surgical approach as akey distinguishing factor when
choosing fellowships.
(00:45):
All of this is to say our youngorthopedic learners are coming
into practice with greater andgreater levels of experience in
anterior total hips.
But what do you do if you'realready an established surgeon
and you're looking to addanterior approach as part of
your practice?
Has the opportunity alreadypassed you by?
How much time do you need totake from your practice to get
(01:08):
comfortable with the approachand how steep is the learning
curve?
Well, my guests today have donejust that.
They're here to answer thosequestions for you.
Joining me today is Alex Sah ofSah Orthopedic Associates at the
Institute for Joint Restorationin Fremont, California and Dr.
Michael Blankstein at theUniversity of Vermont Medical
(01:28):
Center in Burlington, Vermont.
Both Mike and Alex started theirpractices doing posterior
approach and have gone throughthe process of adopting anterior
approach.
Let's listen in on theconversation.
Mike, Alex, thanks for joiningme.
Alexander Sah (01:46):
Thank you, Joe.
Michael Blankstein (01:47):
for having us.
Joseph M Schwab (01:49):
When you were considering this process of
changing your practice, movingfrom posterior approach and
adding anterior approach, Um,what factors were you
considering?
Was it economics?
Was it intellectual factors orsimply outcomes or, or maybe
something completely different,Alex, let's start with you.
Alexander Sah (02:08):
Those are all great considerations, Joe, and
making that transition from aposter approach or different
approach to anterior hipsurgery.
When I was in practice about 8years ago, I was doing
exclusively mini posteriorapproach.
People are doing very well.
People are going home same dayalready.
And we're doing them at thealso.
So, for us, it seemed like wecouldn't be doing any better.
(02:30):
We're very happy with it.
And I was looking at some of theother results being published,
as we know, early literature onanterior hip replacement is very
different than currentliterature on anterior hip
replacement.
So, a combination of factors wecan talk about later, but
probably because there weresurges not, who should not have
been doing anterior approach whowere doing it.
I think people were not learningappropriately and complications
(02:51):
were much higher.
Things being reported in theliterature, I think, were not
really showing.
How well trained and You havesurgeons were performing.
So that kind of literature, thatkind of negative backlash of the
early growth of entry approachmade me hesitant to adopt it.
And again, things were goingvery well for me with my
standard mini posteriorapproach.
So at least for me, it wasn'tabout economics or more business
(03:14):
or promotion or trying to bedifferent or setting myself
apart from others, which areperfectly reasonable ways and
reasons for other people toadopt something new.
But for me, it was simply aquestion that arose, which is,
could I be better?
I was very happy with what I wasdoing already, but the question
was simply, was there a waywhere I could be even better?
And if it wasn't for Joel Mattaand Charlie DeCook, who
(03:37):
approached me and were willingto teach me and asked me to be
involved, I don't know if Iwould have converted.
So, as You know, I was involvedwith the Anterior Hip Foundation
early on and Charlie and Joelasked me to give a talk on Why I
would even consider and yourapproach, having never done any
and being the only post your hipsurgeon in the room at the entry
of foundation.
(03:57):
Talk about being a black sheep.
So I felt very out of place, butthat meeting, as we all have
grown to love is just such aamazing environment to learn
from others and and askquestions that I quickly.
started to do them myself.
And, um, it was really becauseof that question.
Could I be better?
And Charlie was kind enough tocome out and do with the first
(04:20):
three cases with me.
And after those three cases, Inever looked back.
Joseph M Schwab (04:25):
Transcripts
Michael Blankstein (04:28):
heh, heh.
slight differences.
This is actually one of myfavorite questions that people
ask me, um, because I've trulychanged my practice.
So when I graduated in Canada, Ifinished my fellowship.
I was very happy with mytraining, moved to Vermont in
2012.
And one of my partners, NathanElms, who I hope listens to
(04:50):
this, started doing the anteriorapproach at the time.
We're essentially the samecohort.
And when I graduated in Canada,I think there was nearly one
anterior approach surgeon in theentire country.
So it wasn't even something Ithought about and I was so happy
with the way things were goingand I actually scrubbed it with
my partner in my first year inpractice and I literally
(05:12):
remember thinking, is crazy.
There's no way I'm ever going todo this.
I was disoriented.
I didn't know what's right,left, you know, posterior,
anterior.
The releases looked sochallenging.
And, um, and as a matter offact, I, you know, as you know,
I love academia and research andscience and I could quote it.
All the papers in the world thattalked bad, said bad things
(05:33):
about the interior approach,wound problems, the blood loss,
the peripatetic fractures, the,uh, the stem loosening, like you
name it, you know, the numbnessand the curve.
And it was just like, there's noway I was going to do it.
Um, things started, actuallystarted changing when I met you.
(05:53):
Dr.
Schwab, when we did the HipSociety Traveling Fellowship to
the UK and you, we went to manymeetings where you literally
were the only one who did theanterior approach.
So I felt very comfortable.
I was like, okay, what the guysin Canada don't do it.
The guys in the UK don't dothis.
So I'm good.
Um, and I kept with my, hardminded approach of, hey, I'm
(06:18):
sticking to the posteriorapproach.
And then somebody once said tome something interesting, which
was, how about you listen toyour patients?
What do they want?
Why are they asking you for theanterior approach?
And I'll tell you this onehumbling experience that I had
that really changed my practice.
Um, it was one day we weresitting in a meeting and they
(06:38):
were just talking about the waittimes and access to care in
Vermont.
And they said, well, thewaitlist to see Dr.
Blankson, this is 10, this isfive years in, I'm already doing
a good job.
I really don't havedislocations, you know, things
are fine.
to see Dr.
Blankson is that, oh, you cansee him next week.
The waitlist to see Dr.
Nelms is like five months.
(07:00):
I'd rather learn a new approachand do what people want than
speak badly about it for therest of my career.
Like, I'm a hip surgeon.
I love doing hip surgery.
Why not just learn a newapproach?
And this is really what I wantto do here and really is
compliment the AHF.
And all the teachers that Alexijust mentioned, DeCook, Schwab,
(07:23):
of course, the modern dayCharlie, the modern day Charlie,
Joe Matta.
I said, you know, I'm going togo to their courses and the way
the courses were taught, whichis so responsible, right?
So as hip surgeons, we've allseen bad things Okay.
Okay.
(07:55):
like you guys, I decided I'mgonna bark upon it, and just
like, just like Joe, just likeAlex said, like, haven't moved
back.
I haven't gone back.
It's been really rewarding.
Joseph M Schwab (08:07):
So you had your partner was able to scrub in
with you on your first few caseskind of help you through that
process.
Alex, what was that like foryou?
Alexander Sah (08:15):
That was a challenge, Joe, because I was
the only surgeon in myinstitution to be doing anti
approach.
So we were starting completelyfrom scratch.
So that means our nurses, ourtechs, our reps, right?
We didn't, we just got our firstHonda table.
All of this was brand new, sothat definitely was a challenge
because suddenly now, as Michaelsaid, has a surgeon, things are
(08:37):
upside down and backwards.
You're looking at the hip from acompletely different
perspective.
You're trying to learn ityourself, but at the same time
in the corner of your eye,you're trying to keep an eye on
the person managing the table.
Implant rep, the person runningthe C arm.
There's a lot more coordinationthat that's something that is
truly different with thatapproach because it's it's
really a coordination of all theteam members.
So being the first person in myhospital to do it was a
(09:00):
challenge.
But when you asked aboutlearning curve, I would say the
learning curve, it depends onhow you define it.
Learning curve, you learn alittle bit with it.
for many, many cases.
I think we all say we alwayslearn when we do another
anterior approach because we'realways trying to find ways to be
better.
So that learning goes on forquite a long time.
But when you're talking about alearning curve in terms of
(09:20):
avoiding complications orproblems with modern day
training and and Joe has beeninvolved with it a lot and is a
great teacher of it.
You can really avoid thosecomplications early.
So I think the learning curveactually can be very short with
modern training.
Joseph M Schwab (09:36):
Um, that actually raises a question.
So the, um, I, I, you I, I thinkthe way that both, um, Alex and,
and Mike that you've describedyour approach to the educational
processes, uh, as a verypositive one, um, what were the
biggest challenges or thebiggest, um, the, the biggest
(09:58):
difficulties that youencountered during that
educational phase or during thatgrowth phase?
of anterior approach in yourpractice.
Michael Blankstein (10:08):
I think the thing that was very important
for me was not to have theseearly complications, right?
I did, because then everyoneknows, okay, so this is a
posterior part surgeon, and nowhe's going to do the anterior
part, and if he doesn't go welleveryone's going to know about
it.
And I actually heard somestories about surgeons trying
and things not going bad andreverting back to the posterior
(10:30):
approach.
So I think this is, again, oneof the things that I learned
from you guys, which is let'schoose your first patients
appropriately.
Just in itself, just know whento do it, how to do it, have the
support personnel.
also don't change, another thingthat I learned was very
interesting, is don't change theimplants.
You have to, so for example, ifyou wanted to use an anterior
(10:52):
friendly stem, then you have toget comfortable with that stem
while doing surgery.
The posterior approach.
Um, and then it's learning,learning from every single step,
everything.
I'll give you another examplewas one of the biggest
challenges I had in thebeginning was cutting the neck
through the front.
And once it was too high, onceit was too low, and I brought an
(11:13):
extra, I'm like, okay, that'sstandardized.
Boom.
And it's like that every justthink is that a whole bunch of
little steps, you know,
Alexander Sah (11:20):
Early in the learning curve for me, Joe, you
know, it really wasn't achallenge to learn the technique
or go to a cadaver course, orthere was so much opportunity on
the web.
There are videos.
I mean, modern day trainingagain is very, very different
than early training.
I mean, when I think those.
learning curves were beingpublished and they would be more
challenging.
Modern day training has V.
(11:42):
R.
It has web, it has, you know,all kinds of materials on the
internet where you can watchvideos.
So really the only challengewhen first adopting was really
going somewhere to go to acourse.
It was really more of aninconvenience than a hurdle
because you had to take time outof your practice.
You had to go to a course andlearn it.
But It is well worth it becausethe ability to work in a cadaver
(12:03):
lab, go to one of theseeducational courses that are now
everywhere from various implantvendors is extremely helpful.
And I think one of the bestthings for me at least was
having that reverse visitation,having someone with you when you
do your first, I think probablysped the learning curve up by 10
20 cases.
Honestly,
Joseph M Schwab (12:24):
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So looking back, um, on youreducational journey, uh, to, to
(13:50):
sort of adopting anteriorapproach, what would you have
done differently?
Alexander Sah (13:56):
that's a good question.
You know, if if anything I wouldhave done differently, Joe is I
probably would have done itsooner in my career.
I probably waited longer than Ineeded to.
And really, the reason thatprompted me at least was
learning from people I trusted.
And I think that's like anythingelse that we do as surgeons.
We don't adapt or adopt to newtechnologies until we learn from
someone we know who does it.
(14:18):
And that's what really makes theAndrew Hitt Foundation unique.
The faculty and the people whoare members, because they're all
willing to teach.
It is amazing.
You can ask anyone a questionanytime.
They're willing to help.
They know everyone has questionsand been through that journey.
I think the support system isreally what sets it apart.
Joseph M Schwab (14:35):
How about Michael?
What would you have donedifferently?
Michael Blankstein (14:39):
I must say, I, I really have no regrets, I'm
happy, um, by the time I haddone it, I was, you know, I've
really mastered the posteriorapproach, which is nice.
We actually now have theopposite problem, that so many
people are so only with theanterior approach that they lost
their posterior approach skills.
So I've kind of like masteredthat, um, and then, uh, you know
(15:00):
what I tell my residents, I go,aren't we so lucky that we get
to do the surgery after peoplelike Joe Maddow I've already
figured everything out for us.
Like, like, like had I tried itearlier, I probably would have
maybe given up on it.
But by the time that I tried, wehad again, everything, all the
broaches figured out, all the xrays figured out the stems, the
(15:25):
just like also well laid out.
It was actually a really fun.
I think that I chose the righttime to join, to join the party.
Joseph M Schwab (15:36):
For both of you, you mentioned different
types of educationalopportunities between industry
courses and academy stylecourses, surgeon vision,
visitation and online videos.
What was your preferred way tolearn then?
And do you think that would bethe same way that you would
learn now?
Or with your experience, isthere a different sort of
(15:59):
learning style that you wouldgravitate towards?
Alexander Sah (16:03):
It's a great question, Joe.
I think, you know, when COVIDcame and we thought everything
was going to move onto theInternet and be web based, some
things have, but some thingshave not.
So I was sort of surprised thatnot everything's gone that
route.
Really, What I've learned is youcannot get away from in person
training.
There's really nothing betterthan cadaver training being with
your peers.
(16:24):
I think learning from obviouslyexperts in the field has huge
value.
I think learning from people youknow is also incredibly helpful
because then you have arelationship and you can ask
them questions later.
You can talk to them when you doyour first cases.
And I think The moderntechnologies such as cameras
that can let you watch livesurgery or have video recordings
(16:44):
that are so prevalent now reallyhelp because you're going to go
to a cadaver course, you mightnot do your first case for three
to four weeks later.
So to have that refresher, tohave something available to
review, I think makes it a loteasier doing that first case.
Michael Blankstein (16:59):
Yeah, I agree.
I think again, obviously we havemore great videos now and great
everything now, but thementorship model here is, I
think it's still the key.
If you are to transition.
mid career.
You need to really have somesupport around you.
So just like a yeah, I've flownin to see multiple surges before
(17:20):
I did my first one and I askedsomebody to be in the or with me
for that first one.
I know, Joe, you guys did yourfirst like 50 together.
You, you and your partner,something like that.
Joseph M Schwab (17:30):
That's correct.
Michael Blankstein (17:31):
Yeah.
So I think that's a, that's abig one.
Cause what you don't want to dois find yourself in a situation
where once I can, I, I can'texpose that femur or I, I had a
little crack in the calcar and Idon't know how to put a cable on
through the front.
So definitely be ready to handlethat.
Alexander Sah (17:49):
just going to say, Joe, there's no reason to
reinvent the wheel when you'restarting, right?
There are plenty of peoplewilling to help.
So take advantage of those whowant to help you get through it.
Joseph M Schwab (17:58):
Have been any surprising moments for you in
this journey or since youadopting anterior approach, uh,
as sort of the primary approachin your practice?
Alexander Sah (18:11):
I think the surprise for me was that I
literally never went back toposterior approach after doing
those anterior hip replacements,the benefits of it were
remarkable.
So when you hear about thembeing as great as they are, you
wonder if it's really just beingover popularized or being
exaggerated.
But again, my mini posteriorapproaches were doing very, very
(18:31):
well and I was very happy withit.
But the benefits I found fromanterior approach, having
patients supine, having theability to use CRM, having the
ability to restore leg lengthoffset and have quicker
recovery, all these things thatare said really you would see in
patients in the recovery.
So that's really what surprisedme is that I really didn't have
any hesitation to just move 100percent forward with that
(18:53):
approach.
Michael Blankstein (18:55):
yeah, same again, same benefits.
One of my earliest dayexperiences was actually a
working with the therapist thenI got, thank God you don't have
these precautions anymore.
well, I didn't realize myprecautions were such a big
deal.
But to be able to tell patients,hey, whatever you want within
reason.
Just avoid extreme legs ofmotion, a range of motion, and
(19:18):
that's it.
That was cool.
Because in the beginning, youknow, with the posterior
approach, even though we havedata showing you probably don't
need precautions, most of usstill Like some gentle
precautions and to be able tojust let go of that altogether
is, I think is, it means a lotto the patients.
But again, I want to highlightone of the things that, um, that
(19:38):
is really important here in myOkay.
So again, if you look at the, ifyou look at the science behind
anterior versus posteriorapproach, the differences are
very small still till today,right?
We're talking about if patientsdo well at three months, they're
probably going to do well withboth approaches.
Because if you have a surgeonWho's able to do a good job,
(19:58):
meaning, again, restore thelength, length so we're going to
go ahead and get started, andwe're going to go ahead and get
(20:25):
started and feel as natural as Ican the first day.
sure you that.
Why are we not who that?
interested Uh, Service.
Uh, Uh, Based, Of Marketing OfPortfolios.
Based.
Um, And of Course, Basearchy.
(20:47):
Uh, And.
making the recovery easier.
And also knowing Yeah.
Joseph M Schwab (21:19):
Join me next week for part two of my
conversation with Dr.
Alex Sah and Dr.
Michael Blankstein.
Thank you for listening to thisepisode of the AHF Podcast.
Remember to like and subscribeso we can reach a wider
audience.
I.
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 asin video form on YouTube slash
(21:43):
at anterior hip Foundation, allone 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 back to the AHF Podcast.
I'm your host, Joe Schwab.
Most residents coming out oftraining today will have had
some exposure to anteriorapproach total hip arthroplasty.
Adult reconstruction fellows inthe United States will often
consider surgical approach as akey distinguishing factor when
choosing fellowships.
(00:45):
All of this is to say our youngorthopedic learners are coming
into practice with greater andgreater levels of experience in
anterior total hips.
But what do you do if you'realready an established surgeon
and you're looking to addanterior approach as part of
your practice?
Has the opportunity alreadypassed you by?
How much time do you need totake from your practice to get
(01:08):
comfortable with the approachand how steep is the learning
curve?
Well, my guests today have donejust that.
They're here to answer thosequestions for you.
Joining me today is Alex Sah ofSah Orthopedic Associates at the
Institute for Joint Restorationin Fremont, California and Dr.
Michael Blankstein at theUniversity of Vermont Medical
(01:28):
Center in Burlington, Vermont.
Both Mike and Alex started theirpractices doing posterior
approach and have gone throughthe process of adopting anterior
approach.
Let's listen in on theconversation.
Mike, Alex, thanks for joiningme.
Alexander Sah (01:46):
Thank you, Joe.
Michael Blankstein (01:47):
for having us.
Joseph M Schwab (01:49):
When you were considering this process of
changing your practice, movingfrom posterior approach and
adding anterior approach, Um,what factors were you
considering?
Was it economics?
Was it intellectual factors orsimply outcomes or, or maybe
something completely different,Alex, let's start with you.
Alexander Sah (02:08):
Those are all great considerations, Joe, and
making that transition from aposter approach or different
approach to anterior hipsurgery.
When I was in practice about 8years ago, I was doing
exclusively mini posteriorapproach.
People are doing very well.
People are going home same dayalready.
And we're doing them at thealso.
So, for us, it seemed like wecouldn't be doing any better.
(02:30):
We're very happy with it.
And I was looking at some of theother results being published,
as we know, early literature onanterior hip replacement is very
different than currentliterature on anterior hip
replacement.
So, a combination of factors wecan talk about later, but
probably because there weresurges not, who should not have
been doing anterior approach whowere doing it.
I think people were not learningappropriately and complications
(02:51):
were much higher.
Things being reported in theliterature, I think, were not
really showing.
How well trained and You havesurgeons were performing.
So that kind of literature, thatkind of negative backlash of the
early growth of entry approachmade me hesitant to adopt it.
And again, things were goingvery well for me with my
standard mini posteriorapproach.
So at least for me, it wasn'tabout economics or more business
(03:14):
or promotion or trying to bedifferent or setting myself
apart from others, which areperfectly reasonable ways and
reasons for other people toadopt something new.
But for me, it was simply aquestion that arose, which is,
could I be better?
I was very happy with what I wasdoing already, but the question
was simply, was there a waywhere I could be even better?
And if it wasn't for Joel Mattaand Charlie DeCook, who
(03:37):
approached me and were willingto teach me and asked me to be
involved, I don't know if Iwould have converted.
So, as You know, I was involvedwith the Anterior Hip Foundation
early on and Charlie and Joelasked me to give a talk on Why I
would even consider and yourapproach, having never done any
and being the only post your hipsurgeon in the room at the entry
of foundation.
(03:57):
Talk about being a black sheep.
So I felt very out of place, butthat meeting, as we all have
grown to love is just such aamazing environment to learn
from others and and askquestions that I quickly.
started to do them myself.
And, um, it was really becauseof that question.
Could I be better?
And Charlie was kind enough tocome out and do with the first
(04:20):
three cases with me.
And after those three cases, Inever looked back.
Joseph M Schwab (04:25):
Transcripts
Michael Blankstein (04:28):
heh, heh.
slight differences.
This is actually one of myfavorite questions that people
ask me, um, because I've trulychanged my practice.
So when I graduated in Canada, Ifinished my fellowship.
I was very happy with mytraining, moved to Vermont in
2012.
And one of my partners, NathanElms, who I hope listens to
(04:50):
this, started doing the anteriorapproach at the time.
We're essentially the samecohort.
And when I graduated in Canada,I think there was nearly one
anterior approach surgeon in theentire country.
So it wasn't even something Ithought about and I was so happy
with the way things were goingand I actually scrubbed it with
my partner in my first year inpractice and I literally
(05:12):
remember thinking, is crazy.
There's no way I'm ever going todo this.
I was disoriented.
I didn't know what's right,left, you know, posterior,
anterior.
The releases looked sochallenging.
And, um, and as a matter offact, I, you know, as you know,
I love academia and research andscience and I could quote it.
All the papers in the world thattalked bad, said bad things
(05:33):
about the interior approach,wound problems, the blood loss,
the peripatetic fractures, the,uh, the stem loosening, like you
name it, you know, the numbnessand the curve.
And it was just like, there's noway I was going to do it.
Um, things started, actuallystarted changing when I met you.
(05:53):
Dr.
Schwab, when we did the HipSociety Traveling Fellowship to
the UK and you, we went to manymeetings where you literally
were the only one who did theanterior approach.
So I felt very comfortable.
I was like, okay, what the guysin Canada don't do it.
The guys in the UK don't dothis.
So I'm good.
Um, and I kept with my, hardminded approach of, hey, I'm
(06:18):
sticking to the posteriorapproach.
And then somebody once said tome something interesting, which
was, how about you listen toyour patients?
What do they want?
Why are they asking you for theanterior approach?
And I'll tell you this onehumbling experience that I had
that really changed my practice.
Um, it was one day we weresitting in a meeting and they
(06:38):
were just talking about the waittimes and access to care in
Vermont.
And they said, well, thewaitlist to see Dr.
Blankson, this is 10, this isfive years in, I'm already doing
a good job.
I really don't havedislocations, you know, things
are fine.
to see Dr.
Blankson is that, oh, you cansee him next week.
The waitlist to see Dr.
Nelms is like five months.
(07:00):
I'd rather learn a new approachand do what people want than
speak badly about it for therest of my career.
Like, I'm a hip surgeon.
I love doing hip surgery.
Why not just learn a newapproach?
And this is really what I wantto do here and really is
compliment the AHF.
And all the teachers that Alexijust mentioned, DeCook, Schwab,
(07:23):
of course, the modern dayCharlie, the modern day Charlie,
Joe Matta.
I said, you know, I'm going togo to their courses and the way
the courses were taught, whichis so responsible, right?
So as hip surgeons, we've allseen bad things Okay.
Okay.
(07:55):
like you guys, I decided I'mgonna bark upon it, and just
like, just like Joe, just likeAlex said, like, haven't moved
back.
I haven't gone back.
It's been really rewarding.
Joseph M Schwab (08:07):
So you had your partner was able to scrub in
with you on your first few caseskind of help you through that
process.
Alex, what was that like foryou?
Alexander Sah (08:15):
That was a challenge, Joe, because I was
the only surgeon in myinstitution to be doing anti
approach.
So we were starting completelyfrom scratch.
So that means our nurses, ourtechs, our reps, right?
We didn't, we just got our firstHonda table.
All of this was brand new, sothat definitely was a challenge
because suddenly now, as Michaelsaid, has a surgeon, things are
(08:37):
upside down and backwards.
You're looking at the hip from acompletely different
perspective.
You're trying to learn ityourself, but at the same time
in the corner of your eye,you're trying to keep an eye on
the person managing the table.
Implant rep, the person runningthe C arm.
There's a lot more coordinationthat that's something that is
truly different with thatapproach because it's it's
really a coordination of all theteam members.
So being the first person in myhospital to do it was a
(09:00):
challenge.
But when you asked aboutlearning curve, I would say the
learning curve, it depends onhow you define it.
Learning curve, you learn alittle bit with it.
for many, many cases.
I think we all say we alwayslearn when we do another
anterior approach because we'realways trying to find ways to be
better.
So that learning goes on forquite a long time.
But when you're talking about alearning curve in terms of
(09:20):
avoiding complications orproblems with modern day
training and and Joe has beeninvolved with it a lot and is a
great teacher of it.
You can really avoid thosecomplications early.
So I think the learning curveactually can be very short with
modern training.
Joseph M Schwab (09:36):
Um, that actually raises a question.
So the, um, I, I, you I, I thinkthe way that both, um, Alex and,
and Mike that you've describedyour approach to the educational
processes, uh, as a verypositive one, um, what were the
biggest challenges or thebiggest, um, the, the biggest
(09:58):
difficulties that youencountered during that
educational phase or during thatgrowth phase?
of anterior approach in yourpractice.
Michael Blankstein (10:08):
I think the thing that was very important
for me was not to have theseearly complications, right?
I did, because then everyoneknows, okay, so this is a
posterior part surgeon, and nowhe's going to do the anterior
part, and if he doesn't go welleveryone's going to know about
it.
And I actually heard somestories about surgeons trying
and things not going bad andreverting back to the posterior
(10:30):
approach.
So I think this is, again, oneof the things that I learned
from you guys, which is let'schoose your first patients
appropriately.
Just in itself, just know whento do it, how to do it, have the
support personnel.
also don't change, another thingthat I learned was very
interesting, is don't change theimplants.
You have to, so for example, ifyou wanted to use an anterior
(10:52):
friendly stem, then you have toget comfortable with that stem
while doing surgery.
The posterior approach.
Um, and then it's learning,learning from every single step,
everything.
I'll give you another examplewas one of the biggest
challenges I had in thebeginning was cutting the neck
through the front.
And once it was too high, onceit was too low, and I brought an
(11:13):
extra, I'm like, okay, that'sstandardized.
Boom.
And it's like that every justthink is that a whole bunch of
little steps, you know,
Alexander Sah (11:20):
Early in the learning curve for me, Joe, you
know, it really wasn't achallenge to learn the technique
or go to a cadaver course, orthere was so much opportunity on
the web.
There are videos.
I mean, modern day trainingagain is very, very different
than early training.
I mean, when I think those.
learning curves were beingpublished and they would be more
challenging.
Modern day training has V.
(11:42):
R.
It has web, it has, you know,all kinds of materials on the
internet where you can watchvideos.
So really the only challengewhen first adopting was really
going somewhere to go to acourse.
It was really more of aninconvenience than a hurdle
because you had to take time outof your practice.
You had to go to a course andlearn it.
But It is well worth it becausethe ability to work in a cadaver
(12:03):
lab, go to one of theseeducational courses that are now
everywhere from various implantvendors is extremely helpful.
And I think one of the bestthings for me at least was
having that reverse visitation,having someone with you when you
do your first, I think probablysped the learning curve up by 10
20 cases.
Honestly,
Joseph M Schwab (12:24):
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So looking back, um, on youreducational journey, uh, to, to
(13:50):
sort of adopting anteriorapproach, what would you have
done differently?
Alexander Sah (13:56):
that's a good question.
You know, if if anything I wouldhave done differently, Joe is I
probably would have done itsooner in my career.
I probably waited longer than Ineeded to.
And really, the reason thatprompted me at least was
learning from people I trusted.
And I think that's like anythingelse that we do as surgeons.
We don't adapt or adopt to newtechnologies until we learn from
someone we know who does it.
(14:18):
And that's what really makes theAndrew Hitt Foundation unique.
The faculty and the people whoare members, because they're all
willing to teach.
It is amazing.
You can ask anyone a questionanytime.
They're willing to help.
They know everyone has questionsand been through that journey.
I think the support system isreally what sets it apart.
Joseph M Schwab (14:35):
How about Michael?
What would you have donedifferently?
Michael Blankstein (14:39):
I must say, I, I really have no regrets, I'm
happy, um, by the time I haddone it, I was, you know, I've
really mastered the posteriorapproach, which is nice.
We actually now have theopposite problem, that so many
people are so only with theanterior approach that they lost
their posterior approach skills.
So I've kind of like masteredthat, um, and then, uh, you know
(15:00):
what I tell my residents, I go,aren't we so lucky that we get
to do the surgery after peoplelike Joe Maddow I've already
figured everything out for us.
Like, like, like had I tried itearlier, I probably would have
maybe given up on it.
But by the time that I tried, wehad again, everything, all the
broaches figured out, all the xrays figured out the stems, the
(15:25):
just like also well laid out.
It was actually a really fun.
I think that I chose the righttime to join, to join the party.
Joseph M Schwab (15:36):
For both of you, you mentioned different
types of educationalopportunities between industry
courses and academy stylecourses, surgeon vision,
visitation and online videos.
What was your preferred way tolearn then?
And do you think that would bethe same way that you would
learn now?
Or with your experience, isthere a different sort of
(15:59):
learning style that you wouldgravitate towards?
Alexander Sah (16:03):
It's a great question, Joe.
I think, you know, when COVIDcame and we thought everything
was going to move onto theInternet and be web based, some
things have, but some thingshave not.
So I was sort of surprised thatnot everything's gone that
route.
Really, What I've learned is youcannot get away from in person
training.
There's really nothing betterthan cadaver training being with
your peers.
(16:24):
I think learning from obviouslyexperts in the field has huge
value.
I think learning from people youknow is also incredibly helpful
because then you have arelationship and you can ask
them questions later.
You can talk to them when you doyour first cases.
And I think The moderntechnologies such as cameras
that can let you watch livesurgery or have video recordings
(16:44):
that are so prevalent now reallyhelp because you're going to go
to a cadaver course, you mightnot do your first case for three
to four weeks later.
So to have that refresher, tohave something available to
review, I think makes it a loteasier doing that first case.
Michael Blankstein (16:59):
Yeah, I agree.
I think again, obviously we havemore great videos now and great
everything now, but thementorship model here is, I
think it's still the key.
If you are to transition.
mid career.
You need to really have somesupport around you.
So just like a yeah, I've flownin to see multiple surges before
(17:20):
I did my first one and I askedsomebody to be in the or with me
for that first one.
I know, Joe, you guys did yourfirst like 50 together.
You, you and your partner,something like that.
Joseph M Schwab (17:30):
That's correct.
Michael Blankstein (17:31):
Yeah.
So I think that's a, that's abig one.
Cause what you don't want to dois find yourself in a situation
where once I can, I, I can'texpose that femur or I, I had a
little crack in the calcar and Idon't know how to put a cable on
through the front.
So definitely be ready to handlethat.
Alexander Sah (17:49):
just going to say, Joe, there's no reason to
reinvent the wheel when you'restarting, right?
There are plenty of peoplewilling to help.
So take advantage of those whowant to help you get through it.
Joseph M Schwab (17:58):
Have been any surprising moments for you in
this journey or since youadopting anterior approach, uh,
as sort of the primary approachin your practice?
Alexander Sah (18:11):
I think the surprise for me was that I
literally never went back toposterior approach after doing
those anterior hip replacements,the benefits of it were
remarkable.
So when you hear about thembeing as great as they are, you
wonder if it's really just beingover popularized or being
exaggerated.
But again, my mini posteriorapproaches were doing very, very
(18:31):
well and I was very happy withit.
But the benefits I found fromanterior approach, having
patients supine, having theability to use CRM, having the
ability to restore leg lengthoffset and have quicker
recovery, all these things thatare said really you would see in
patients in the recovery.
So that's really what surprisedme is that I really didn't have
any hesitation to just move 100percent forward with that
(18:53):
approach.
Michael Blankstein (18:55):
yeah, same again, same benefits.
One of my earliest dayexperiences was actually a
working with the therapist thenI got, thank God you don't have
these precautions anymore.
well, I didn't realize myprecautions were such a big
deal.
But to be able to tell patients,hey, whatever you want within
reason.
Just avoid extreme legs ofmotion, a range of motion, and
(19:18):
that's it.
That was cool.
Because in the beginning, youknow, with the posterior
approach, even though we havedata showing you probably don't
need precautions, most of usstill Like some gentle
precautions and to be able tojust let go of that altogether
is, I think is, it means a lotto the patients.
But again, I want to highlightone of the things that, um, that
(19:38):
is really important here in myOkay.
So again, if you look at the, ifyou look at the science behind
anterior versus posteriorapproach, the differences are
very small still till today,right?
We're talking about if patientsdo well at three months, they're
probably going to do well withboth approaches.
Because if you have a surgeonWho's able to do a good job,
(19:58):
meaning, again, restore thelength, length so we're going to
go ahead and get started, andwe're going to go ahead and get
(20:25):
started and feel as natural as Ican the first day.
sure you that.
Why are we not who that?
interested Uh, Service.
Uh, Uh, Based, Of Marketing OfPortfolios.
Based.
Um, And of Course, Basearchy.
(20:47):
Uh, And.
making the recovery easier.
And also knowing Yeah.
Joseph M Schwab (21:19):
Join me next week for part two of my
conversation with Dr.
Alex Sah and Dr.
Michael Blankstein.
Thank you for listening to thisepisode of the AHF Podcast.
Remember to like and subscribeso we can reach a wider
audience.
I.
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 asin video form on YouTube slash
(21:43):
at anterior hip Foundation, allone 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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