November 8, 2024 • 24 mins
AHF Podcast: Insights from Expert Surgeons on Anterior Hip Revision Techniques
In this episode of the AHF podcast, hosts Dr. Joe Schwab and Dr. Charles Lawrie dive into the intriguing world of anterior approach hip revision surgeries with notable guests: Dr. Kris Alden, Dr. Aldo Riesgo, Dr. John Horberg, and Dr. Jonathan Yerasimides. The panel discusses their backgrounds, experiences, and tips for tackling hip revisions using the anterior approach. Highlights include the benefits of using the HANA table, strategies for consistent exposure and stability, and advice for surgeons looking to venture into anterior hip revisions. The episode is packed with expert insights on advancing surgical practice and achieving optimal patient outcomes.
00:00 Introduction and Guest Introductions
01:03 Guest Backgrounds and Experiences
05:55 Discussion on Traction Tables
11:56 Tips for Surgeons New to Anterior Revisions
20:49 Equipment and Setup for Anterior Revisions
22:50 Conclusion and Next Episode Teaser
Meet our guest surgeons:
Dr. Kris Alden - https://www.krisalden.com/
Dr. John Horberg - https://www.premierboneandjoint.com/meet-dr-horberg
Dr. Aldo Riesgo - https://my.clevelandclinic.org/staff/22587-aldo-riesgo
Dr. Jonathan Yerasimides - https://www.louisvillehip.com/
Dr. Charles Lawrie - https://baptisthealth.net/doctors/charles-m-lawrie/1888379
Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/
Check out Dr. Yerasimides Anterior Approach Masterclass (including episodes on Acetabular and Femoral Revision) on YouTube! Find the playlist at https://www.youtube.com/playlist?list=PLDzGqZUR760dlZ8i9H78ZQuKRfBW5pXe7
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:07):
Welcome to another episode of the AHF
podcast.
Today, we get to talk about atopic that makes some surgeons
cringe while others can't getenough of it, revisions.
From simple and straightforwardto complex and daunting, today's
guests are excited to tacklethem all.
My guests today are Dr.
Kris Alden of the SteadmanPhilippon Clinic in Aspen,
(00:27):
Colorado, Dr.
Aldo Riesgo of the ClevelandClinic, Florida, Dr.
John Horberg of Premier Bone andJoint Center in Wyoming and
Jonathan Yerasimides of theLouisville Hip and Knee
Institute in Louisville,Kentucky.
Jonathan is also the immediatepast president of the Anterior
Hip Foundation and a prettyamazing surgeon.
(00:48):
But don't let his website foolyou, his hair is definitely gray
now.
And because this is such a biggroup, I've asked Dr.
Charles Lawrie vice president ofthe Anterior Hip Foundation to
join me today as co host.
Gentlemen, Welcome to therevision round table.
Let's start by having each ofyou briefly tell our listeners a
little bit about yourself, alittle bit about your training
(01:09):
and your practice.
And Aldo, why don't we startwith you?
Aldo M. Riesgo (01:13):
Yeah, so I grew up in Miami, Florida.
studied here for undergrad.
went up to New York for, medicalschool and my orthopedic surgery
training.
and then spent a year inCharlotte, during fellowship.
And that's really where, Ireally kinda, I guess my
anterior hip experience andexposure really took off.
(01:36):
and then I did back home inSouth Florida.
Yeah.
Ever since my practice is mostlyrevisions, somewhere between 50
and 70%, depending on theseasons and how things go.
And as far as hip exposures and,approach, I'm almost
exclusively, direct anterior forall my revisions now and
(01:56):
obviously on my, primaries.
Joseph M. Schwab (01:59):
Dr.
Kris Alden.
How about you?
Kris Alden (02:01):
Sure.
I, I grew up in Illinois.
I went to, undergrad, and,medical school in Chicago.
I did, an MD PhD program there.
And then I went to, JohnsHopkins hospital in Baltimore
for my residency.
And then I did a fellowship inadult reconstruction at the Mayo
(02:22):
clinic.
it's interesting.
I didn't have any exposure toanterior hip and residency or
fellowship.
I finished my fellowship in2008.
And then In 2011, I got, I waschatting with one of my, friends
from residency and he haddabbled and went to a course.
(02:44):
And so I actually reached out toJoel Matta and went out and saw
him and, jumped on the anteriorhip bandwagon.
And, 2011 was, the last time Idid a posterior hip revision.
I've been a hundred percentanterior since, since that time.
So it's been fun.
Joseph M. Schwab (03:04):
John Horberg, tell us a little bit about
yourself.
John Horberg (03:07):
Yeah, I grew up in Illinois, as well.
I grew up in downstate Illinoisand farm country and I did my
undergraduate and my medicalschool, in downstate Illinois.
And that's where I was firstexposed to the anterior
approach.
I had a couple of mentors thatwere just completing their
learning curve.
And then I, became fairlypassionate about it and chose a
(03:28):
fellowship that was almostentirely anterior, at, Virginia
tech and Roanoke, Virginia.
And I started practice and, I'ma part of that younger
generation, maybe that decidedthat I was going to go a hundred
percent anterior from day one.
And, I'm about five years intopractice now and have never done
an approach other than theanterior for primaries or
(03:48):
revisions.
I've found it to be, quiterewarding and I actually feel as
though I'm probably a little bitmore comfortable with the
anterior approach than anyother, exposure at this point.
Joseph M. Schwab (03:58):
Dr.
Why, or as we like to say, Dr.
Why not, how about we have you,tell us a little bit about
yourself.
Jonathan Yerasimides (04:04):
Yeah.
Jonathan, Yerasimides.
I grew up, just outside Kansascity, Missouri.
a small town, went to myundergrad in medical school, in
Kansas city at the university ofMissouri, Kansas city, residency
at university of Louisville.
then I went out to LA for spentone year with, with Joel Matta
(04:28):
because I thought, I was goingto be a a traumatologist.
This is 2005 and, Joel was, atthe top of his field and pelvis
and acetabular, fracture,reconstruction.
and I went out there not knowinganything about anterior
approach, never even heard ofit.
(04:49):
And, I saw him doing theseanterior approach hips and
thought, yeah, that's prettycool.
Went back to Louisville, became,full time faculty, trauma
faculty.
I was doing pelvis andacetabular fractures, but I
started doing these anteriorapproach hips, 2006, in
(05:12):
Louisville and nobody.
There wasn't anybody withinprobably three or 400 miles of
Louisville doing them at thattime.
And the prac, that part of mypractice started growing so
quickly.
that, after about four or fiveyears, I gave up the entire
trauma side and, and became a,Hip arthroplasty surgeon
(05:36):
essentially.
I think I did my first revisionin 2007.
and now I do all my revisions,minus things that need,
augmentation of theretroracetabular surface, I'll
do through an anterior approach.
Joseph M. Schwab (05:55):
So just to give our listeners a little bit
of background, how many of youare using a traction table, with
your setup and how many of youare using a, a standard
orthopedic table?
Jonathan Yerasimides (06:07):
I'm on the HANA table.
I think I'd be, I think I'd bedisowned from my orthopedic
daddy if I didn't use it.
I'm on the HANA table.
Kris Alden (06:18):
Yeah, I am as well.
I've been 100 percent tablesince the inception.
I just find it easier.
No disrespect to the off tableguys, by any means.
Aldo M. Riesgo (06:29):
Same table HANA table.
John Horberg (06:32):
Yep, I use the HANA table as well, especially
practicing in a ruralenvironment out in Wyoming.
Sometimes it's nice to have afree assistant, when you don't
necessarily have the staff youwant to have available.
Joseph M. Schwab (06:44):
So four of you on traction tables on the HANA
table, have any of you everdone, revisions off the table or
is it, has it been exclusivelyHANA table?
Jonathan Yerasimides (06:57):
I've never done a revision off the table.
I've done primaries off table.
but I've never done a revision,off table.
John Horberg (07:06):
I did dabble a little bit early in my practice
and off table, and I've done acouple of headliner exchanges,
but, nothing more complicatedthan that off the table.
Aldo M. Riesgo (07:15):
some of my partners do off table for their
primaries and their revisionsand I'll scrub in with them on
the tougher ones.
And every time I'm not likingthat experience.
I'm always happy that I thinkthey made the right choice with
the HANA table.
Charles Lawrie (07:28):
What is it about using the HANA table that makes
revision anterior approachsurgery easier for you guys?
Kris Alden (07:36):
I would say it's basically like having an extra
assistant.
you can manipulate the extremityand rotate it, apply axial
traction or distraction and nothave somebody, get tired holding
the leg.
So it just basically allows youto mobilize things much easier.
John Horberg (07:55):
There's more precision and control as well.
You can pull traction and thattraction is consistent.
you can apply rotation, thatrotation is consistent.
You don't have to worry about,exactly like Kris said, the
assistant getting tired orfidgeting or moving.
The, leg stays where you put it.
Jonathan Yerasimides (08:11):
For me, not ever having done it off the
table, the femoral elevationthat I get, using the hook,
again, I'm speaking from a, froma ignorant, point of the point
of view inside of the argument,but, I don't know if I can get
that elevation with, with just aretractor behind the trochanter.
(08:39):
for me, it's knowing I'm goingto get the femur up.
So I've got a straight shot downthe femur.
I'm not gonna, destroy thefemur.
doing a long revision stem
Aldo M. Riesgo (08:51):
yeah, I think the femur is easier, but also
what, Y mentioned about gettinglike retroacetabular I've done
now, if you posterior columnaugments, and I think the HANA
table by having the, the,basically the butt be
unsupported, It's just floatingthere.
It allows that soft tissue tofall back a little bit when I
come down the outer table, thepelvis, and I can get a little
(09:14):
easier exposure there.
So that's, I think it's a nobrainer.
if you do really complex.
revision work from the front.
John Horberg (09:26):
think adding to that as well, leg length
discrepancies are more easier todeal with.
if you have scarring or proximalmigration of the femur on the
operative when you're going offtable, you don't have the
ability to apply countertraction.
So having a post in the center,having the other leg tethered,
and then you pull traction onthe operative leg, it's easier
to pull the femur down distal inthose cases where the leg wants
(09:47):
to be, riding more
Joseph M. Schwab (09:49):
Do you ever get worried about traction
injuries in those circumstances,John?
John Horberg (09:57):
I, I haven't, it usually the portion of the
operation where I'm actuallyapplying traction is fairly
limited.
it's nice to be able to havecounter traction on the
contralateral leg and get needit.
But the majority of the case,especially the acetabular
exposure, the leg is offtraction and then it's only,
during reduction and specificportions of the
Joseph M. Schwab (10:16):
Do you, find that you approach draping
differently in your revisionscenarios or have you done
enough revisions on the HANAtable that you're pretty much
draping both revisions andprimaries the same way?
John Horberg (10:35):
I personally do it the same way.
leg and I err on the side ofclear overall, I haven't made
any major changes on my, mydraping aside from edging
proximal or distal if I know I'mgoing to expose
Jonathan Yerasimides (10:48):
Yeah, I think just like any revision for
me, it's just, I get a little,maybe wider, wider, field of
view on a primary.
I'm probably prepping the twothirds down the thigh.
On a revision, I'll typicallyprep all the way down to the
knee and on a primary, myproximal part of my draping is
(11:11):
roughly the belly button, theumbilicus.
I tell the nurses, straight fromthe belly button down to two
thirds on the knee on arevision.
Especially if I need access tothe inner table, the pelvis, or
I'm planning on extending thisto like a Smith, Pete, I'm
prepping above the, umbilicus.
Aldo M. Riesgo (11:30):
Same.
Kris Alden (11:32):
yeah, and I think it's harder for OR staff to
really contemplate different,draping protocols.
So I just drape everybody thesame, which is similar to what
Jonathan was saying.
Charles Lawrie (11:43):
So you guys are all very experienced anterior
hip surgeons.
and it sounds like all of youbasically figured this out on
your own.
y'all are really the pioneersbehind a lot of this anterior
revision work that we're seeingpop up in courses.
Now, do you have any tips forsurgeons who are experienced
primary anterior approachsurgeons, but haven't taken the
(12:04):
plunge into the revision worldyet.
Tips for getting started, anyparticular cases you would try
to tackle first.
Kris Alden (12:11):
Sure, I would probably start with the easier,
headliner exchanges.
And that's a easy, simple.
low stress kind of environment.
also go slow, debulk the capsulebecause there can be a lot of
scarring.
Even if it was a prior posteriorapproach, there can still be a
(12:31):
very robust capsule and that canvery much limit your exposure,
but debulking the capsule andgetting the appropriate exposure
starting with a simple,relatively easy, headliner
exchange, I think can be a veryrewarding experience.
And then obviously work up fromthere.
Jonathan Yerasimides (12:50):
When I did my first revision in 2007, I'd
never heard of anybody doing arevision from an anterior
approach.
And even when I was with Joel,we did some.
complex extended like hardwareremoval, total hips, but I'd
never seen, total hip implantsremoved or put back in through
(13:12):
an anterior approach, but I justgot to the point from the
primary where I said, I'mcomfortable enough to, do a
revision.
So if a surgeon that's let's doin primaries.
It's shit, I'm still unsure thatI'm ready to do a revision.
You probably ain't ready.
(13:34):
wait till you feel like, hell, Igot this.
because, you'll tell yourself ifyou're confident enough to, jump
into the revision pool.
Aldo M. Riesgo (13:45):
For me, I never really, I didn't see any DA
revision.
I think I saw one in Fellowship,and it was a triflange, and, so
the reconstructive part wasn'tthat hard, it was just the
exposure stuff.
I think, if you see that once,right?
You have all the tools as a hipsurgeon to just put it all
together.
And it, it's just more mentallydaunting than it is.
I think challenging from a, froman execution standpoint.
(14:08):
I saw a lot of PAOs as a chiefin, in my residency.
So to me, it always felt verynatural, Hey, if, I need to get
revision exposure for, from adirect anterior approach, just
start doing a PAO, start gettingaccess to the pelvis, get,
sorry, you're doing osteotomy,flip that ASIS over things like
that.
So to me, it really helped tosee it like once or twice.
(14:30):
And then from the primary side,I think getting, being
committed.
To always doing everything DA.
I think that really helps youget your exposures.
And I think if you can do reallytough primaries, get those tough
exposures, and then you've seensome of these maneuvers before
you can all put it together.
So yeah, I agree.
Start with cups, headliners,work your way up to there.
And then probably last isfemoral work.
(14:51):
Like femoral work is probablywhat I've, was the last part of
my kind of that last thresholdin my practice, like kind of
crossover.
so now I'll take out whateverstem from the front.
John Horberg (15:09):
Yeah, I couldn't agree more with what everybody
said.
I think, maybe the last twopearls for someone who's wanting
to jump into anterior revisionwould be just like selecting the
appropriate case, also selectingthe appropriate patient.
You don't have to be a hero andhave a large muscular male with
a wide pelvis as your firstcase.
You can choose a.
Okay.
A slender, elderly person with aforgiving body habitus, large
(15:31):
working space.
make the case that was yourfirst primary case the exact
same patient that's revisioncase.
Someone who's easy to work onand I think the other thing to
think about when we're doingrevisions is it is a different
animal than, A primary anteriorapproach.
We always focus on limitingreleases to the pubofemoral and
a certain extent around thecapsule.
(15:52):
You can get as much exposure asyou need after excising that
redundant Kris talked about.
You can take your releasesfurther on a revision case
because it's a differentoperation.
Just like with a posteriorapproach, it's a
Jonathan Yerasimides (16:03):
Yeah, I agree with that, John.
A hundred percent.
I think that, Talking to guys,over the past decade plus about
revisions.
when I'm describing to them orin a cadaver lab showing them,
my exposures, they're alwaystaken aback a little bit by how
(16:24):
much I'm releasing, especiallyaround the femur.
because in their brains, they'rethinking that, this primary
side, we're, trying to limit allthese releases of the rotators
and all that stuff.
In a revision, it's no holdsbarred.
You need to, release everything,revisions, completely different
surgery, don't think about itas.
(16:47):
we're doing this, limitedrelease, minimally invasive
thing.
It is, like, Wayne Proproskysays, he does MIS surgery every
day, maximally invasive surgery.
And, and that's what you need tohave in your brain in a
revision.
Joseph M. Schwab (17:06):
That actually raises an interesting question.
So anterior approach has really,one of the things from a primary
standpoint, it's forced us tothink differently about how we
do our reconstructions.
we talk less about adding leglength and offset and more about
anatomic reconstruction.
how has that changed the way youview, how you do a revision,
(17:29):
what's successful, what are thethings you need to do, the
things you don't need to do, howhas it changed the way you
approach revisions in general?
John Horberg (17:41):
I think even though we've just discussed how
important it is to take as muchrelease and as much tissue need
in order to get your exposure,the anterior approach is still,
in some ways internally aminimally evasive approach from
a revision in that you're notcutting any of the muscles.
off of the femur, aside fromperhaps releasing some of the
rotators and the conjoinedtendon, you still have dynamic
(18:02):
stability around the hip.
And for me, seen patients thatmobilize faster.
I have fewer about stability andmy concerns about stability
based on what's the bony anatomyand what's the, soft tissue
injury prior to my operation,rather than what am I doing to
the that might be causing themto become unstable.
And I'll use alternate bearingsand other techniques to improve
(18:25):
my.
stability, but I don't gochasing it through or
Jonathan Yerasimides (18:28):
Yeah, I think I've learned that, that
stability over the years,Stability does have a lot to do
with releases, of the musclesaround the proximal femur, but
as I've done this more and moreyears, starting to look at
things like, maybe, a lot of ourenhanced stability has to do
(18:53):
with just proper implantplacement, because from a
posterior approach, it's so hardto get consistent implant
positioning from the hip centerrotation to the anteversion
abduction on the cup with ananterior approach, it's very,
easy.
And I really think that the,that one of the things that
(19:15):
gives us.
Stability that's, heads andshoulders above, opposed to your
approach is the fact that the,implants are going to be in the
correct position every singletime.
and with the addition ofalternative bearings, like dual
mobility, it's, ridiculous.
I never put people on hipprecautions after.
(19:38):
A revision surgery, with my 32and 36 heads and certainly now
with dual mobility, I don't.
and it's not because I don't domassive releases, but my
implants are always in a goodposition and that's just more
reliable in a supine,positioning and having fluoro
available.
Aldo M. Riesgo (19:58):
Yeah, to me, with the anterior approach, like
when I was doing posterior hiprevisions and just in my
training, you get that post op xray, you're not using, usually
intraoperative imaging, anythingshort of a disaster, you'll
accept, while the anteriorapproach, you accept nothing
short of perfection in terms ofyour component placement.
(20:19):
And you're actually like, youknow exactly what's going to
look like.
You've recreated that offset,that length, you've put your hip
center where you need it to be.
So there's a, there's a lot moreprecision, at least in my hands.
And I think it's a moreergonomic approach for, me as a
surgeon, I'm standing up, I'mnot hunched over.
I'm not exhausted at the end ofthe case.
Like I would on a hard,posterior approach.
(20:40):
And I think hard hips are hardhips regardless of what approach
you do.
So I like having that kind ofprecision with the supine direct
anterior approach.
Charles Lawrie (20:50):
Thinking about people getting started with
anterior revisions, is thereanything extra or special
equipment wise that you guysneed for the exposure,
retractors, et cetera?
Kris Alden (21:02):
I actually use all the same retractors on a primary
that I do on a revision.
I wouldn't say there's anything,necessarily extra that I would
use on a revision.
Jonathan Yerasimides (21:12):
Yeah, I agree with Kris.
I have the exact same retractorset, whether I'm doing a
revision or a primary, it mightchange if I'm doing like an
osteotomy, the femur, I mightget some extra retractors, but,
for 90 percent of my revisions,it's the exact same tray, and I
think that also, it helps a tonwith, with your staff in the
(21:36):
hospital, with nurses, withscrub techs, my trays, my
draping are all the same.
patient to patient.
and there's no like guesswork,on the staff side, trying to set
something up on, M is this goingto be different than the last,
(21:57):
thing we just, the last case wejust prepped.
So it's consistency.
I think consistency, equates toefficiency, as well.
I think being consistent andlearning to use the same things.
For all the cases, we'll helpyou as a surgeon and it'll help
your efficiency in the operatingroom.
Aldo M. Riesgo (22:18):
Yeah, I agree with that.
I think that's part of themental, eliminating that mental
roadblock to doing revisions is,hey, this is the same trays,
same retractors, it's the samesurgery, I'm just doing maybe a
touch more here, a touch morethere.
John Horberg (22:35):
Yeah, the only equipment issue differences I
see at all are just the samedifferences in equipment you
would need for revisionregardless of approach having
the availability of burrs andextraction equipment and things
like that, but there's no, nochange at all in my setup, my
exposure, my draping,
Joseph M. Schwab (22:51):
Thank you for joining us for part one of the
AHF revision round table.
Join us again next week to hearmore tips, tricks, and pearls
from our panel of expertrevision surgeons, and also keep
your eye on our channel for somebonus revision surgery, content
coming soon.
Do you have any anteriorapproach, revision, tips, or
tricks that you want to share?
(23:12):
Leave a comment below, we wouldlove to hear from you.
And if you enjoy the contentwe're bringing you, remember to
like and subscribe so that wecan deliver even more, and reach
a wider audience.
If you have an idea for a topic,you can also drop that in the
comments.
Remember, you can find us inaudio podcast form in your
favorite podcast app, as well asin video form on YouTube slash
(23:36):
@anteriorhipfoundation, all oneword.
Remember to visit us on the webat anteriorhipfoundation.com
where registration for the AHF2025 meeting is already open.
Reserve your seat today.
And we'll see you next week forpart two of the AHF revision
round table.
Until then keep those hips happyand healthy.
Welcome to another episode of the AHF
podcast.
Today, we get to talk about atopic that makes some surgeons
cringe while others can't getenough of it, revisions.
From simple and straightforwardto complex and daunting, today's
guests are excited to tacklethem all.
My guests today are Dr.
Kris Alden of the SteadmanPhilippon Clinic in Aspen,
(00:27):
Colorado, Dr.
Aldo Riesgo of the ClevelandClinic, Florida, Dr.
John Horberg of Premier Bone andJoint Center in Wyoming and
Jonathan Yerasimides of theLouisville Hip and Knee
Institute in Louisville,Kentucky.
Jonathan is also the immediatepast president of the Anterior
Hip Foundation and a prettyamazing surgeon.
(00:48):
But don't let his website foolyou, his hair is definitely gray
now.
And because this is such a biggroup, I've asked Dr.
Charles Lawrie vice president ofthe Anterior Hip Foundation to
join me today as co host.
Gentlemen, Welcome to therevision round table.
Let's start by having each ofyou briefly tell our listeners a
little bit about yourself, alittle bit about your training
(01:09):
and your practice.
And Aldo, why don't we startwith you?
Aldo M. Riesgo (01:13):
Yeah, so I grew up in Miami, Florida.
studied here for undergrad.
went up to New York for, medicalschool and my orthopedic surgery
training.
and then spent a year inCharlotte, during fellowship.
And that's really where, Ireally kinda, I guess my
anterior hip experience andexposure really took off.
(01:36):
and then I did back home inSouth Florida.
Yeah.
Ever since my practice is mostlyrevisions, somewhere between 50
and 70%, depending on theseasons and how things go.
And as far as hip exposures and,approach, I'm almost
exclusively, direct anterior forall my revisions now and
(01:56):
obviously on my, primaries.
Joseph M. Schwab (01:59):
Dr.
Kris Alden.
How about you?
Kris Alden (02:01):
Sure.
I, I grew up in Illinois.
I went to, undergrad, and,medical school in Chicago.
I did, an MD PhD program there.
And then I went to, JohnsHopkins hospital in Baltimore
for my residency.
And then I did a fellowship inadult reconstruction at the Mayo
(02:22):
clinic.
it's interesting.
I didn't have any exposure toanterior hip and residency or
fellowship.
I finished my fellowship in2008.
And then In 2011, I got, I waschatting with one of my, friends
from residency and he haddabbled and went to a course.
(02:44):
And so I actually reached out toJoel Matta and went out and saw
him and, jumped on the anteriorhip bandwagon.
And, 2011 was, the last time Idid a posterior hip revision.
I've been a hundred percentanterior since, since that time.
So it's been fun.
Joseph M. Schwab (03:04):
John Horberg, tell us a little bit about
yourself.
John Horberg (03:07):
Yeah, I grew up in Illinois, as well.
I grew up in downstate Illinoisand farm country and I did my
undergraduate and my medicalschool, in downstate Illinois.
And that's where I was firstexposed to the anterior
approach.
I had a couple of mentors thatwere just completing their
learning curve.
And then I, became fairlypassionate about it and chose a
(03:28):
fellowship that was almostentirely anterior, at, Virginia
tech and Roanoke, Virginia.
And I started practice and, I'ma part of that younger
generation, maybe that decidedthat I was going to go a hundred
percent anterior from day one.
And, I'm about five years intopractice now and have never done
an approach other than theanterior for primaries or
(03:48):
revisions.
I've found it to be, quiterewarding and I actually feel as
though I'm probably a little bitmore comfortable with the
anterior approach than anyother, exposure at this point.
Joseph M. Schwab (03:58):
Dr.
Why, or as we like to say, Dr.
Why not, how about we have you,tell us a little bit about
yourself.
Jonathan Yerasimides (04:04):
Yeah.
Jonathan, Yerasimides.
I grew up, just outside Kansascity, Missouri.
a small town, went to myundergrad in medical school, in
Kansas city at the university ofMissouri, Kansas city, residency
at university of Louisville.
then I went out to LA for spentone year with, with Joel Matta
(04:28):
because I thought, I was goingto be a a traumatologist.
This is 2005 and, Joel was, atthe top of his field and pelvis
and acetabular, fracture,reconstruction.
and I went out there not knowinganything about anterior
approach, never even heard ofit.
(04:49):
And, I saw him doing theseanterior approach hips and
thought, yeah, that's prettycool.
Went back to Louisville, became,full time faculty, trauma
faculty.
I was doing pelvis andacetabular fractures, but I
started doing these anteriorapproach hips, 2006, in
(05:12):
Louisville and nobody.
There wasn't anybody withinprobably three or 400 miles of
Louisville doing them at thattime.
And the prac, that part of mypractice started growing so
quickly.
that, after about four or fiveyears, I gave up the entire
trauma side and, and became a,Hip arthroplasty surgeon
(05:36):
essentially.
I think I did my first revisionin 2007.
and now I do all my revisions,minus things that need,
augmentation of theretroracetabular surface, I'll
do through an anterior approach.
Joseph M. Schwab (05:55):
So just to give our listeners a little bit
of background, how many of youare using a traction table, with
your setup and how many of youare using a, a standard
orthopedic table?
Jonathan Yerasimides (06:07):
I'm on the HANA table.
I think I'd be, I think I'd bedisowned from my orthopedic
daddy if I didn't use it.
I'm on the HANA table.
Kris Alden (06:18):
Yeah, I am as well.
I've been 100 percent tablesince the inception.
I just find it easier.
No disrespect to the off tableguys, by any means.
Aldo M. Riesgo (06:29):
Same table HANA table.
John Horberg (06:32):
Yep, I use the HANA table as well, especially
practicing in a ruralenvironment out in Wyoming.
Sometimes it's nice to have afree assistant, when you don't
necessarily have the staff youwant to have available.
Joseph M. Schwab (06:44):
So four of you on traction tables on the HANA
table, have any of you everdone, revisions off the table or
is it, has it been exclusivelyHANA table?
Jonathan Yerasimides (06:57):
I've never done a revision off the table.
I've done primaries off table.
but I've never done a revision,off table.
John Horberg (07:06):
I did dabble a little bit early in my practice
and off table, and I've done acouple of headliner exchanges,
but, nothing more complicatedthan that off the table.
Aldo M. Riesgo (07:15):
some of my partners do off table for their
primaries and their revisionsand I'll scrub in with them on
the tougher ones.
And every time I'm not likingthat experience.
I'm always happy that I thinkthey made the right choice with
the HANA table.
Charles Lawrie (07:28):
What is it about using the HANA table that makes
revision anterior approachsurgery easier for you guys?
Kris Alden (07:36):
I would say it's basically like having an extra
assistant.
you can manipulate the extremityand rotate it, apply axial
traction or distraction and nothave somebody, get tired holding
the leg.
So it just basically allows youto mobilize things much easier.
John Horberg (07:55):
There's more precision and control as well.
You can pull traction and thattraction is consistent.
you can apply rotation, thatrotation is consistent.
You don't have to worry about,exactly like Kris said, the
assistant getting tired orfidgeting or moving.
The, leg stays where you put it.
Jonathan Yerasimides (08:11):
For me, not ever having done it off the
table, the femoral elevationthat I get, using the hook,
again, I'm speaking from a, froma ignorant, point of the point
of view inside of the argument,but, I don't know if I can get
that elevation with, with just aretractor behind the trochanter.
(08:39):
for me, it's knowing I'm goingto get the femur up.
So I've got a straight shot downthe femur.
I'm not gonna, destroy thefemur.
doing a long revision stem
Aldo M. Riesgo (08:51):
yeah, I think the femur is easier, but also
what, Y mentioned about gettinglike retroacetabular I've done
now, if you posterior columnaugments, and I think the HANA
table by having the, the,basically the butt be
unsupported, It's just floatingthere.
It allows that soft tissue tofall back a little bit when I
come down the outer table, thepelvis, and I can get a little
(09:14):
easier exposure there.
So that's, I think it's a nobrainer.
if you do really complex.
revision work from the front.
John Horberg (09:26):
think adding to that as well, leg length
discrepancies are more easier todeal with.
if you have scarring or proximalmigration of the femur on the
operative when you're going offtable, you don't have the
ability to apply countertraction.
So having a post in the center,having the other leg tethered,
and then you pull traction onthe operative leg, it's easier
to pull the femur down distal inthose cases where the leg wants
(09:47):
to be, riding more
Joseph M. Schwab (09:49):
Do you ever get worried about traction
injuries in those circumstances,John?
John Horberg (09:57):
I, I haven't, it usually the portion of the
operation where I'm actuallyapplying traction is fairly
limited.
it's nice to be able to havecounter traction on the
contralateral leg and get needit.
But the majority of the case,especially the acetabular
exposure, the leg is offtraction and then it's only,
during reduction and specificportions of the
Joseph M. Schwab (10:16):
Do you, find that you approach draping
differently in your revisionscenarios or have you done
enough revisions on the HANAtable that you're pretty much
draping both revisions andprimaries the same way?
John Horberg (10:35):
I personally do it the same way.
leg and I err on the side ofclear overall, I haven't made
any major changes on my, mydraping aside from edging
proximal or distal if I know I'mgoing to expose
Jonathan Yerasimides (10:48):
Yeah, I think just like any revision for
me, it's just, I get a little,maybe wider, wider, field of
view on a primary.
I'm probably prepping the twothirds down the thigh.
On a revision, I'll typicallyprep all the way down to the
knee and on a primary, myproximal part of my draping is
(11:11):
roughly the belly button, theumbilicus.
I tell the nurses, straight fromthe belly button down to two
thirds on the knee on arevision.
Especially if I need access tothe inner table, the pelvis, or
I'm planning on extending thisto like a Smith, Pete, I'm
prepping above the, umbilicus.
Aldo M. Riesgo (11:30):
Same.
Kris Alden (11:32):
yeah, and I think it's harder for OR staff to
really contemplate different,draping protocols.
So I just drape everybody thesame, which is similar to what
Jonathan was saying.
Charles Lawrie (11:43):
So you guys are all very experienced anterior
hip surgeons.
and it sounds like all of youbasically figured this out on
your own.
y'all are really the pioneersbehind a lot of this anterior
revision work that we're seeingpop up in courses.
Now, do you have any tips forsurgeons who are experienced
primary anterior approachsurgeons, but haven't taken the
(12:04):
plunge into the revision worldyet.
Tips for getting started, anyparticular cases you would try
to tackle first.
Kris Alden (12:11):
Sure, I would probably start with the easier,
headliner exchanges.
And that's a easy, simple.
low stress kind of environment.
also go slow, debulk the capsulebecause there can be a lot of
scarring.
Even if it was a prior posteriorapproach, there can still be a
(12:31):
very robust capsule and that canvery much limit your exposure,
but debulking the capsule andgetting the appropriate exposure
starting with a simple,relatively easy, headliner
exchange, I think can be a veryrewarding experience.
And then obviously work up fromthere.
Jonathan Yerasimides (12:50):
When I did my first revision in 2007, I'd
never heard of anybody doing arevision from an anterior
approach.
And even when I was with Joel,we did some.
complex extended like hardwareremoval, total hips, but I'd
never seen, total hip implantsremoved or put back in through
(13:12):
an anterior approach, but I justgot to the point from the
primary where I said, I'mcomfortable enough to, do a
revision.
So if a surgeon that's let's doin primaries.
It's shit, I'm still unsure thatI'm ready to do a revision.
You probably ain't ready.
(13:34):
wait till you feel like, hell, Igot this.
because, you'll tell yourself ifyou're confident enough to, jump
into the revision pool.
Aldo M. Riesgo (13:45):
For me, I never really, I didn't see any DA
revision.
I think I saw one in Fellowship,and it was a triflange, and, so
the reconstructive part wasn'tthat hard, it was just the
exposure stuff.
I think, if you see that once,right?
You have all the tools as a hipsurgeon to just put it all
together.
And it, it's just more mentallydaunting than it is.
I think challenging from a, froman execution standpoint.
(14:08):
I saw a lot of PAOs as a chiefin, in my residency.
So to me, it always felt verynatural, Hey, if, I need to get
revision exposure for, from adirect anterior approach, just
start doing a PAO, start gettingaccess to the pelvis, get,
sorry, you're doing osteotomy,flip that ASIS over things like
that.
So to me, it really helped tosee it like once or twice.
(14:30):
And then from the primary side,I think getting, being
committed.
To always doing everything DA.
I think that really helps youget your exposures.
And I think if you can do reallytough primaries, get those tough
exposures, and then you've seensome of these maneuvers before
you can all put it together.
So yeah, I agree.
Start with cups, headliners,work your way up to there.
And then probably last isfemoral work.
(14:51):
Like femoral work is probablywhat I've, was the last part of
my kind of that last thresholdin my practice, like kind of
crossover.
so now I'll take out whateverstem from the front.
John Horberg (15:09):
Yeah, I couldn't agree more with what everybody
said.
I think, maybe the last twopearls for someone who's wanting
to jump into anterior revisionwould be just like selecting the
appropriate case, also selectingthe appropriate patient.
You don't have to be a hero andhave a large muscular male with
a wide pelvis as your firstcase.
You can choose a.
Okay.
A slender, elderly person with aforgiving body habitus, large
(15:31):
working space.
make the case that was yourfirst primary case the exact
same patient that's revisioncase.
Someone who's easy to work onand I think the other thing to
think about when we're doingrevisions is it is a different
animal than, A primary anteriorapproach.
We always focus on limitingreleases to the pubofemoral and
a certain extent around thecapsule.
(15:52):
You can get as much exposure asyou need after excising that
redundant Kris talked about.
You can take your releasesfurther on a revision case
because it's a differentoperation.
Just like with a posteriorapproach, it's a
Jonathan Yerasimides (16:03):
Yeah, I agree with that, John.
A hundred percent.
I think that, Talking to guys,over the past decade plus about
revisions.
when I'm describing to them orin a cadaver lab showing them,
my exposures, they're alwaystaken aback a little bit by how
(16:24):
much I'm releasing, especiallyaround the femur.
because in their brains, they'rethinking that, this primary
side, we're, trying to limit allthese releases of the rotators
and all that stuff.
In a revision, it's no holdsbarred.
You need to, release everything,revisions, completely different
surgery, don't think about itas.
(16:47):
we're doing this, limitedrelease, minimally invasive
thing.
It is, like, Wayne Proproskysays, he does MIS surgery every
day, maximally invasive surgery.
And, and that's what you need tohave in your brain in a
revision.
Joseph M. Schwab (17:06):
That actually raises an interesting question.
So anterior approach has really,one of the things from a primary
standpoint, it's forced us tothink differently about how we
do our reconstructions.
we talk less about adding leglength and offset and more about
anatomic reconstruction.
how has that changed the way youview, how you do a revision,
(17:29):
what's successful, what are thethings you need to do, the
things you don't need to do, howhas it changed the way you
approach revisions in general?
John Horberg (17:41):
I think even though we've just discussed how
important it is to take as muchrelease and as much tissue need
in order to get your exposure,the anterior approach is still,
in some ways internally aminimally evasive approach from
a revision in that you're notcutting any of the muscles.
off of the femur, aside fromperhaps releasing some of the
rotators and the conjoinedtendon, you still have dynamic
(18:02):
stability around the hip.
And for me, seen patients thatmobilize faster.
I have fewer about stability andmy concerns about stability
based on what's the bony anatomyand what's the, soft tissue
injury prior to my operation,rather than what am I doing to
the that might be causing themto become unstable.
And I'll use alternate bearingsand other techniques to improve
(18:25):
my.
stability, but I don't gochasing it through or
Jonathan Yerasimides (18:28):
Yeah, I think I've learned that, that
stability over the years,Stability does have a lot to do
with releases, of the musclesaround the proximal femur, but
as I've done this more and moreyears, starting to look at
things like, maybe, a lot of ourenhanced stability has to do
(18:53):
with just proper implantplacement, because from a
posterior approach, it's so hardto get consistent implant
positioning from the hip centerrotation to the anteversion
abduction on the cup with ananterior approach, it's very,
easy.
And I really think that the,that one of the things that
(19:15):
gives us.
Stability that's, heads andshoulders above, opposed to your
approach is the fact that the,implants are going to be in the
correct position every singletime.
and with the addition ofalternative bearings, like dual
mobility, it's, ridiculous.
I never put people on hipprecautions after.
(19:38):
A revision surgery, with my 32and 36 heads and certainly now
with dual mobility, I don't.
and it's not because I don't domassive releases, but my
implants are always in a goodposition and that's just more
reliable in a supine,positioning and having fluoro
available.
Aldo M. Riesgo (19:58):
Yeah, to me, with the anterior approach, like
when I was doing posterior hiprevisions and just in my
training, you get that post op xray, you're not using, usually
intraoperative imaging, anythingshort of a disaster, you'll
accept, while the anteriorapproach, you accept nothing
short of perfection in terms ofyour component placement.
(20:19):
And you're actually like, youknow exactly what's going to
look like.
You've recreated that offset,that length, you've put your hip
center where you need it to be.
So there's a, there's a lot moreprecision, at least in my hands.
And I think it's a moreergonomic approach for, me as a
surgeon, I'm standing up, I'mnot hunched over.
I'm not exhausted at the end ofthe case.
Like I would on a hard,posterior approach.
(20:40):
And I think hard hips are hardhips regardless of what approach
you do.
So I like having that kind ofprecision with the supine direct
anterior approach.
Charles Lawrie (20:50):
Thinking about people getting started with
anterior revisions, is thereanything extra or special
equipment wise that you guysneed for the exposure,
retractors, et cetera?
Kris Alden (21:02):
I actually use all the same retractors on a primary
that I do on a revision.
I wouldn't say there's anything,necessarily extra that I would
use on a revision.
Jonathan Yerasimides (21:12):
Yeah, I agree with Kris.
I have the exact same retractorset, whether I'm doing a
revision or a primary, it mightchange if I'm doing like an
osteotomy, the femur, I mightget some extra retractors, but,
for 90 percent of my revisions,it's the exact same tray, and I
think that also, it helps a tonwith, with your staff in the
(21:36):
hospital, with nurses, withscrub techs, my trays, my
draping are all the same.
patient to patient.
and there's no like guesswork,on the staff side, trying to set
something up on, M is this goingto be different than the last,
(21:57):
thing we just, the last case wejust prepped.
So it's consistency.
I think consistency, equates toefficiency, as well.
I think being consistent andlearning to use the same things.
For all the cases, we'll helpyou as a surgeon and it'll help
your efficiency in the operatingroom.
Aldo M. Riesgo (22:18):
Yeah, I agree with that.
I think that's part of themental, eliminating that mental
roadblock to doing revisions is,hey, this is the same trays,
same retractors, it's the samesurgery, I'm just doing maybe a
touch more here, a touch morethere.
John Horberg (22:35):
Yeah, the only equipment issue differences I
see at all are just the samedifferences in equipment you
would need for revisionregardless of approach having
the availability of burrs andextraction equipment and things
like that, but there's no, nochange at all in my setup, my
exposure, my draping,
Joseph M. Schwab (22:51):
Thank you for joining us for part one of the
AHF revision round table.
Join us again next week to hearmore tips, tricks, and pearls
from our panel of expertrevision surgeons, and also keep
your eye on our channel for somebonus revision surgery, content
coming soon.
Do you have any anteriorapproach, revision, tips, or
tricks that you want to share?
(23:12):
Leave a comment below, we wouldlove to hear from you.
And if you enjoy the contentwe're bringing you, remember to
like and subscribe so that wecan deliver even more, and reach
a wider audience.
If you have an idea for a topic,you can also drop that in the
comments.
Remember, you can find us inaudio podcast form in your
favorite podcast app, as well asin video form on YouTube slash
(23:36):
@anteriorhipfoundation, all oneword.
Remember to visit us on the webat anteriorhipfoundation.com
where registration for the AHF2025 meeting is already open.
Reserve your seat today.
And we'll see you next week forpart two of the AHF revision
round table.
Until then keep those hips happyand healthy.
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