November 15, 2024 • 17 mins
AHF Revision Roundtable Part Two: Advanced Techniques and Patient Outcomes
In this episode of the AHF revision roundtable, Joe Schwab and co-host Dr. Charles Lawrie rejoin the panel of expert orthopedic surgeons, including Dr. Jonathan Yerasimides, Dr. Aldo Riesgo, Dr. John Horberg, and Dr. Kris Alden, to discuss femoral revision techniques. The conversation covers the detailed procedures and strategies for effective femoral exposure and release, the benefits of the anterior approach, and the use of outpatient settings for revision surgeries. Panelists also delve into technology and instrumentation needs, the potential advantages of new advancements, and the current limitations in anterior approach revision practices.
00:00 Welcome Back to AHF's Revision Roundtable
00:30 Techniques for Femoral Side Revisions
03:34 Challenges and Solutions in Femoral Revisions
06:46 Anterior Approach Benefits and Patient Outcomes
08:13 Outpatient Setting for Revisions
12:45 Instrumentation and Future Innovations
16:13 Closing Remarks and Additional Resources
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
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Joseph M. Schwab (00:07):
Welcome back for part two of the AHF's
revision roundtable.
If you missed the first part ofthe roundtable, you can click
here to start at the beginning.
Let's rejoin the conversationwith our panel, Dr.
Jonathan Yerasimides, Dr.
Aldo Riesgo, Dr.
John Horberg, and Dr.
Kris Alden, as well as my cohost, Dr.
(00:29):
Charles Lawrie.
Charles Lawrie (00:31):
while we're talking about femoral side of
revisions, when we think aboutprimary anterior approach
surgery, we all have this sortof ladder of releases that we do
to get the femur exposed wellenough to do our broaching.
Obviously need a little bit moreexposure in the revision
setting.
can you all walk us through,what that ladder of releases
looks like and any extensilemaneuvers you may have to do if
(00:53):
you're really struggling to getthe straight shot down the femur
you need for those revisionstyle implants.
Jonathan Yerasimides (01:00):
So for me, I'm doing, the lion's share of
my releases before I even try todislocate or drop the hip.
I went through a.
when I first started doing theseof treating it like a primary
where I would drop the leg andthen try to do my releases after
(01:22):
I dropped the leg, it's verydifficult because the femur gets
pinned behind the acetabulum.
and now when I know I'm doing afemoral revision, I get down to
the capsule and the old scarand.
First, I'll find the intervalbetween scar and minimus and
(01:44):
medius, because I want to clearoff the superior and lateral
portion of that capsule first.
So I excise all scar while thehip is still reduced, the legs
are still up in a neutralposition.
I'm excising.
All the scar back to muscle inthat superior and lateral
portion.
(02:04):
Then I'm going to take my bovieand I'm going to bend the tip of
it.
And I'm going to get around theposterior aspect of the
trochanter, prior to doinganything else.
So the table's low, so I can seeI'm cutting out all the superior
and lateral cartilage.
scar tissue, then I'm going toclear the trochanter where I can
(02:27):
get my finger down and hook thetip of my finger around the tip
of the trochanter.
I don't just want to feel it.
I want to be able to get aroundit.
Then I'd go to the, medial sideand excise, I think John said
earlier about, that, pubofemoralligament, that has to be that,
(02:47):
scar tissue at this point,completely, released.
I debulk the anterior scar, thenI'll externally rotate,
dislocate the hip.
Keep it fixed at 90 degrees ofexternal rotation, and then take
my Bovee and bend the tip and goaround the posterior medial
side.
So I'm doing a circumferentialrelease of the femur prior to
(03:10):
even dropping it down.
And it is, it cuts 30, 40minutes off the case and it
makes it guaranteed.
So you're not going to fracturetrochanters as well, because if
you're doing a revision,somebody old and the tropes
caught behind the, theacetabulum and you're dropping
it before you've cleared it andgot that lateral translation,
(03:32):
you're going to fracture thetroch off.
Joseph M. Schwab (03:35):
Are there any tests you're doing, Jonathan, to
verify that you've done, as muchrelease as you need to?
Jonathan Yerasimides (03:42):
if I can't dislocate, if I'm, doing the
femur, and this is the femuronly, if I'm doing the
acetabulum, I don't do anyfemur, barely any femur
releases.
But if I know I'm doing thefemur, if I can't get, At least
90 and preferably over 90degrees of external rotation.
(04:02):
from the very beginning, beforeI drop the leg, I'm not ready to
drop the leg.
Charles Lawrie (04:09):
So what if you release circumferentially around
the femur and you're stillstruggling, any extra maneuvers
or tips,
Jonathan Yerasimides (04:17):
usually what happens.
And it usually means I haven'treleased enough because I'll
think I've done all the releasesI can do on earth.
And then I'd end up dropping theleg and the damn thing still,
stuck.
So if it's not, if it's notrotating enough.
That means I need to go back tostep one, which is looking at
that saddle region and that,that superior lateral portion of
(04:41):
the capsule and scar.
And I need to excise more therebecause the medial side is
usually fairly easy to see.
It's the, it's that superiorlateral portion that, that
you're usually deficient on.
Kris Alden (04:55):
I would just add like Charles, when you said
you're really struggling, justliterally take everything out
and start over for whateverreason that generally just
works, go back to step one andredo your, femoral exposure,
external rotation, thosereleases.
And, usually it just happenseven if you're not, you don't
(05:17):
think you're doing a lot morefor whatever reason, it just
seems to work.
Charles Lawrie (05:21):
any role for a iliac wing osteotomies or a
tensor, fascial auto releasesoff the pelvis.
Aldo M. Riesgo (05:30):
Yeah, so for me when i'm starting a revision I
start off the back with a Tforelease.
Sorry, Kris.
I cut you off there.
Kris Alden (05:38):
know that's okay.
Aldo M. Riesgo (05:39):
question.
Kris Alden (05:41):
Yeah, I've only needed to do a TFL release in
certain, isolated, like if I'mdoing a really complicated
femoral revision and, I'm justreally struggling, then I will
go ahead and release it.
But I haven't found, the Iliacwing osteotomy to be really
something I've needed to go to.
Jonathan Yerasimides (06:00):
Yeah.
I agree with
Kris Alden (06:01):
repair is a very simple thing to do at the end.
Like it's very low morbidity atall.
So it's, it's, very simple todo.
Jonathan Yerasimides (06:11):
Yeah.
John Horberg (06:15):
I think the tensor fascia releases is sometimes
beneficial if you're going to bereaming and broaching for a
straight stem and you havesomebody with a large muscular
TFL that's fibrotic andadherent.
I don't want to tear the muscle.
So that's the indication I have.
And it's usually at the pointwhere I'm instrumenting the
femur as opposed to gettingexposure.
And then speaking to theprevious question, another test
(06:36):
I do to confirm that my releasesare enough is with the hook for
the bed in place, I just liftthe femur and if I can't lift
the femur with traction off sothe grader clears the
Charles Lawrie (06:46):
we've talked a lot about the benefits that we
see as surgeons doing thesecases from the anterior
approach, right?
the anterior approach isfantastic, extensile exposure in
particular to the acetabulum.
What benefits have you seen inyour patients, do you think,
doing these cases from ananterior approach instead of a
posterior approach?
John Horberg (07:11):
I think just looking at patients, in the
hospital after a revision, we'veall seen those simple socket
revisions from a posteriorapproach where the patient's
laying in bed, they've got apillow strapped between their
legs, they're miserable, they'renot get wanting to get up and
mobilize.
And, the first time I did a,femoral osteotomy for a revision
(07:32):
stem.
I dreading going in and roundingon the patient the next morning
because I figured they be,incision halfway down their leg,
moping, painful, going to be fewdays.
And it amazes me how quicklythese people mobilize.
I had a, the patient I'mthinking of got up, sitting at
the edge of the bedside I hadn'trounded earlier because they
(07:54):
were wanting to go home.
And it's not always the case,but you see these people walk
into clinic and you'll havepartners who do posterior
approach primaries andrevisions, have people with a
walker hobbling in there andeven sometimes fairly complex
reconstructive revision casesor, walking into the clinic,
they're doing well, they'remobilizing faster, they're
living their
Kris Alden (08:13):
Now I would add that, I've adapted the anterior
approach revision to theoutpatient setting.
And so I've had lots of patientsgo home from the ASC, And I
think the recovery is justquicker.
and obviously in my opinion,much less pain.
So I think they just mobilizefaster and, just lends itself
(08:36):
well to a quicker recovery,probably longterm, not a lot
different, but I would say shortterm, definitely, all the
advantages of the anteriorapproach primary applied to the
post, the anterior approachrevision.
Joseph M. Schwab (08:49):
Talk more about that, Kris.
What types of revisions are youdoing in the ASC setting?
Kris Alden (08:55):
I've done almost everything.
So I've done, full revisions,usually not, I'm, able to like,
obviously like shorter stems.
Like I w I've had, for example,like a primary stem that's,
(09:15):
loosened, and I've gone backwith a more, robust primary
stem, like a cry revision, forexample, done those in the,
outpatient setting.
converted, like a resurfacingtotal hip, like taking
everything out and put inprimary implants, done that
(09:37):
type.
so lots of different options,for patients, usually it's the
younger, healthier andmotivated.
So if you have somebody that'solder and sicker, obviously.
That type of revision surgerywould be more applicable to the
hospital setting.
But, if the patient is excitedabout it, they're motivated,
(09:59):
then, the outpatient revision iscertainly something been done
doing for a long time.
Joseph M. Schwab (10:05):
Anybody else doing revisions in the
outpatient setting?
Jonathan Yerasimides (10:09):
I've done some, it just, You can't, do
Medicare in the outpatient inASC yet.
So it has to be a non Medicarepatient with, something
straightforward.
certainly heads and liners,although, you're not finding a
whole lot of, under Medicare.
Age people that need headlinerexchanges.
(10:33):
but certainly conversions, andsimple things like cup revision.
I've not done any femoralrevisions yet through an ASC.
I think it's certainly possible.
it's just finding the peoplebecause, Revision codes are
still inpatient only on theMedicare side of things.
(10:54):
I
John Horberg (10:59):
Yeah, I would echo what Jonathan said.
We've done the exact same thing.
patients, plenty of conversions.
I have removed a stem or two,surgery center for people who
had a posterior approach and agrowth discrepancy.
but the, biggest limiting factorfor me doing them at our
ambulatory Medicare payer statuswon't allow us to do most
(11:21):
revision codes.
yeah.
Most of my revisions that arenon infected or major
reconstructions go home the sameday, from the hospital as well,
or at least have the option to,but, I'd like to do more in our
surgery center,
Aldo M. Riesgo (11:37):
I think obviously the payer stuff is
important for if you're doingoutpatient revision work for me
from an orthopedic standpoint,if I don't do an osteotomy
femoral or pelvic, I think thepatient can go home, especially
if they're motivated.
I think your EBL is cut downtremendously, right?
Your surgical time, everything'scut down.
I think the biggest advantage ofthe anterior approach revisions
(11:58):
is i've never had to take theglute max tendon off a femur
I've never had to take theposterior septum off a femur to
do my work.
All my work is anterior to theseptum to the intermuscular
septum and the gluteal sling.
So to me, in a posteriorapproach, you have to separate
that cause you have to move yourfemur forward to get your
exposure and you're parting thered sea in the wrong direction.
(12:18):
I like to, if you keep all thatback, the patient's obviously
going to do better.
They're going to get up and gothe next day better.
Their gluteal sling and tendonare.
Intact and attached to the femurand all of our osteotomies in
some way or another are allanterior to that right for
femoral work So for me, that'sbeen the biggest advantage for
me And I've done DA revisionsfor my partners who do posterior
(12:40):
on patients who requested it andwe scrub in together and they
round the next day They'rethey're amazed.
Joseph M. Schwab (12:47):
from your guy's perspective, you're at the
forefront of doing theseanterior approach revision
surgeries.
What are the big unsolvedproblems right now in anterior
approach revision surgery?
Jonathan Yerasimides (12:59):
augments that were created to fit on the
inner table of the pelvis for meIs the biggest thing because all
the, the acetabular augmentsthat we use, down on the inner
table of the pelvis, weren'tcreated to, go there.
(13:20):
you always have to have a burrand manipulate the bone a little
bit to get these things to fit.
Now, anterior columnaugmentation is not, It's not
going to be a big moneymaker forimplant companies, frankly,
cause there's not a whole ton ofthem being put in.
So it's probably relatively lowon the list of, of importance,
(13:43):
but hopefully with, 3d printingand stuff of that, like that,
where they're making, 3d printedcustom augments, maybe we can
start getting some implantsthat, there are some augments
that actually fit where we'reoperating.
Kris Alden (13:59):
I would say that, in addition to what Jonathan said,
I completely agree with that.
But I think also, for complexfemoral revisions, the
instrumentation to do thefemoral implant is generally
more posterior approachfriendly.
And, I think there's ways toadapt the instrumentation to the
(14:19):
anterior approach that wouldenable and facilitate anterior
approach revision on the femoralside.
I, think that's something thatwe really need to focus on and
that hasn't really been, on theforefront of a lot of the
implant companies, radar, and asanterior approach, the primary
(14:41):
side, exceeds, posteriorapproach.
I think we're going to see themore ubiquitous, adoption of
anterior approach revisions.
And so hopefully theinstrumentation will play catch
up.
Aldo M. Riesgo (14:53):
I think a lot of surgeons who Would like to maybe
take the leap into directanterior revisions, but don't
feel quite comfortable orworried about things like
assessing femoral version.
How do they do that with the legdown and across and, the
stability testing, right?
It's a, it's an inexact science.
So I think as we move forwardand we incorporate technology
(15:14):
and robotics and augmentedreality and navigation, things
like that, that can help give alittle more, confidence for some
of those surgeons who feel thatwould be a limiting step.
they, a lot of surgeons justlike to get their hands on the
leg and trowel it around.
And it's going to be a littlebit different, with the anterior
approach.
So there's, that little bit of,helping them get used to the new
(15:36):
learning curve.
Jonathan Yerasimides (15:38):
I will say the new, not to spill any beans,
but the new HANA table comingout is going to allow people to
do a full, range of motion test,with the foot still, connected
to the table.
Joseph M. Schwab (15:54):
We'll have to get a OSI on here to give us a
demo.
Jonathan Yerasimides (15:58):
rumor.
It's a rumor.
Yeah.
I don't know.
I have no knowledge.
No, no agreements have beenbroken, but, but yes, that's
what I've heard.
Joseph M. Schwab (16:10):
level six evidence, rumors, and innuendo.
gentlemen, thank you.
really, this is a pleasure forgiving us your time today.
thank you for helping to educateour listeners.
And of course, thank you for allyou do, for your patients.
If you're interested in learningmore about today's guests, you
can check out our show notes fortheir practice links.
(16:32):
we'll also link to some of theanterior approach masterclass
videos that we have on the AHFYouTube channel.
Do you have any anteriorapproach, revision, tips, or
tricks that you want to share?
Leave a comment below.
We would love to hear from you.
And if you enjoy the contentwe're bringing remember to like
and subscribe so that we candeliver even more and reach a
(16:54):
wider audience.
If you have an idea for a topic,you can also drop that in the
comments.
Remember, you can find us anaudio podcast form in your
favorite podcast app.
As well as in video form onYouTube/@anteriorhipfoundation
all one word.
Remember also to visit us on theweb at anteriorhipfoundation.com
(17:17):
where registration for the AHF2025 meeting is already open.
Reserve your seat today.
And we'll see you next week foranother episode of the AHF
podcast.
Until then I'm your host, JoeSchwab, asking you to keep those
hips happy and healthy.
Welcome back for part two of the AHF's
revision roundtable.
If you missed the first part ofthe roundtable, you can click
here to start at the beginning.
Let's rejoin the conversationwith our panel, Dr.
Jonathan Yerasimides, Dr.
Aldo Riesgo, Dr.
John Horberg, and Dr.
Kris Alden, as well as my cohost, Dr.
(00:29):
Charles Lawrie.
Charles Lawrie (00:31):
while we're talking about femoral side of
revisions, when we think aboutprimary anterior approach
surgery, we all have this sortof ladder of releases that we do
to get the femur exposed wellenough to do our broaching.
Obviously need a little bit moreexposure in the revision
setting.
can you all walk us through,what that ladder of releases
looks like and any extensilemaneuvers you may have to do if
(00:53):
you're really struggling to getthe straight shot down the femur
you need for those revisionstyle implants.
Jonathan Yerasimides (01:00):
So for me, I'm doing, the lion's share of
my releases before I even try todislocate or drop the hip.
I went through a.
when I first started doing theseof treating it like a primary
where I would drop the leg andthen try to do my releases after
(01:22):
I dropped the leg, it's verydifficult because the femur gets
pinned behind the acetabulum.
and now when I know I'm doing afemoral revision, I get down to
the capsule and the old scarand.
First, I'll find the intervalbetween scar and minimus and
(01:44):
medius, because I want to clearoff the superior and lateral
portion of that capsule first.
So I excise all scar while thehip is still reduced, the legs
are still up in a neutralposition.
I'm excising.
All the scar back to muscle inthat superior and lateral
portion.
(02:04):
Then I'm going to take my bovieand I'm going to bend the tip of
it.
And I'm going to get around theposterior aspect of the
trochanter, prior to doinganything else.
So the table's low, so I can seeI'm cutting out all the superior
and lateral cartilage.
scar tissue, then I'm going toclear the trochanter where I can
(02:27):
get my finger down and hook thetip of my finger around the tip
of the trochanter.
I don't just want to feel it.
I want to be able to get aroundit.
Then I'd go to the, medial sideand excise, I think John said
earlier about, that, pubofemoralligament, that has to be that,
(02:47):
scar tissue at this point,completely, released.
I debulk the anterior scar, thenI'll externally rotate,
dislocate the hip.
Keep it fixed at 90 degrees ofexternal rotation, and then take
my Bovee and bend the tip and goaround the posterior medial
side.
So I'm doing a circumferentialrelease of the femur prior to
(03:10):
even dropping it down.
And it is, it cuts 30, 40minutes off the case and it
makes it guaranteed.
So you're not going to fracturetrochanters as well, because if
you're doing a revision,somebody old and the tropes
caught behind the, theacetabulum and you're dropping
it before you've cleared it andgot that lateral translation,
(03:32):
you're going to fracture thetroch off.
Joseph M. Schwab (03:35):
Are there any tests you're doing, Jonathan, to
verify that you've done, as muchrelease as you need to?
Jonathan Yerasimides (03:42):
if I can't dislocate, if I'm, doing the
femur, and this is the femuronly, if I'm doing the
acetabulum, I don't do anyfemur, barely any femur
releases.
But if I know I'm doing thefemur, if I can't get, At least
90 and preferably over 90degrees of external rotation.
(04:02):
from the very beginning, beforeI drop the leg, I'm not ready to
drop the leg.
Charles Lawrie (04:09):
So what if you release circumferentially around
the femur and you're stillstruggling, any extra maneuvers
or tips,
Jonathan Yerasimides (04:17):
usually what happens.
And it usually means I haven'treleased enough because I'll
think I've done all the releasesI can do on earth.
And then I'd end up dropping theleg and the damn thing still,
stuck.
So if it's not, if it's notrotating enough.
That means I need to go back tostep one, which is looking at
that saddle region and that,that superior lateral portion of
(04:41):
the capsule and scar.
And I need to excise more therebecause the medial side is
usually fairly easy to see.
It's the, it's that superiorlateral portion that, that
you're usually deficient on.
Kris Alden (04:55):
I would just add like Charles, when you said
you're really struggling, justliterally take everything out
and start over for whateverreason that generally just
works, go back to step one andredo your, femoral exposure,
external rotation, thosereleases.
And, usually it just happenseven if you're not, you don't
(05:17):
think you're doing a lot morefor whatever reason, it just
seems to work.
Charles Lawrie (05:21):
any role for a iliac wing osteotomies or a
tensor, fascial auto releasesoff the pelvis.
Aldo M. Riesgo (05:30):
Yeah, so for me when i'm starting a revision I
start off the back with a Tforelease.
Sorry, Kris.
I cut you off there.
Kris Alden (05:38):
know that's okay.
Aldo M. Riesgo (05:39):
question.
Kris Alden (05:41):
Yeah, I've only needed to do a TFL release in
certain, isolated, like if I'mdoing a really complicated
femoral revision and, I'm justreally struggling, then I will
go ahead and release it.
But I haven't found, the Iliacwing osteotomy to be really
something I've needed to go to.
Jonathan Yerasimides (06:00):
Yeah.
I agree with
Kris Alden (06:01):
repair is a very simple thing to do at the end.
Like it's very low morbidity atall.
So it's, it's, very simple todo.
Jonathan Yerasimides (06:11):
Yeah.
John Horberg (06:15):
I think the tensor fascia releases is sometimes
beneficial if you're going to bereaming and broaching for a
straight stem and you havesomebody with a large muscular
TFL that's fibrotic andadherent.
I don't want to tear the muscle.
So that's the indication I have.
And it's usually at the pointwhere I'm instrumenting the
femur as opposed to gettingexposure.
And then speaking to theprevious question, another test
(06:36):
I do to confirm that my releasesare enough is with the hook for
the bed in place, I just liftthe femur and if I can't lift
the femur with traction off sothe grader clears the
Charles Lawrie (06:46):
we've talked a lot about the benefits that we
see as surgeons doing thesecases from the anterior
approach, right?
the anterior approach isfantastic, extensile exposure in
particular to the acetabulum.
What benefits have you seen inyour patients, do you think,
doing these cases from ananterior approach instead of a
posterior approach?
John Horberg (07:11):
I think just looking at patients, in the
hospital after a revision, we'veall seen those simple socket
revisions from a posteriorapproach where the patient's
laying in bed, they've got apillow strapped between their
legs, they're miserable, they'renot get wanting to get up and
mobilize.
And, the first time I did a,femoral osteotomy for a revision
(07:32):
stem.
I dreading going in and roundingon the patient the next morning
because I figured they be,incision halfway down their leg,
moping, painful, going to be fewdays.
And it amazes me how quicklythese people mobilize.
I had a, the patient I'mthinking of got up, sitting at
the edge of the bedside I hadn'trounded earlier because they
(07:54):
were wanting to go home.
And it's not always the case,but you see these people walk
into clinic and you'll havepartners who do posterior
approach primaries andrevisions, have people with a
walker hobbling in there andeven sometimes fairly complex
reconstructive revision casesor, walking into the clinic,
they're doing well, they'remobilizing faster, they're
living their
Kris Alden (08:13):
Now I would add that, I've adapted the anterior
approach revision to theoutpatient setting.
And so I've had lots of patientsgo home from the ASC, And I
think the recovery is justquicker.
and obviously in my opinion,much less pain.
So I think they just mobilizefaster and, just lends itself
(08:36):
well to a quicker recovery,probably longterm, not a lot
different, but I would say shortterm, definitely, all the
advantages of the anteriorapproach primary applied to the
post, the anterior approachrevision.
Joseph M. Schwab (08:49):
Talk more about that, Kris.
What types of revisions are youdoing in the ASC setting?
Kris Alden (08:55):
I've done almost everything.
So I've done, full revisions,usually not, I'm, able to like,
obviously like shorter stems.
Like I w I've had, for example,like a primary stem that's,
(09:15):
loosened, and I've gone backwith a more, robust primary
stem, like a cry revision, forexample, done those in the,
outpatient setting.
converted, like a resurfacingtotal hip, like taking
everything out and put inprimary implants, done that
(09:37):
type.
so lots of different options,for patients, usually it's the
younger, healthier andmotivated.
So if you have somebody that'solder and sicker, obviously.
That type of revision surgerywould be more applicable to the
hospital setting.
But, if the patient is excitedabout it, they're motivated,
(09:59):
then, the outpatient revision iscertainly something been done
doing for a long time.
Joseph M. Schwab (10:05):
Anybody else doing revisions in the
outpatient setting?
Jonathan Yerasimides (10:09):
I've done some, it just, You can't, do
Medicare in the outpatient inASC yet.
So it has to be a non Medicarepatient with, something
straightforward.
certainly heads and liners,although, you're not finding a
whole lot of, under Medicare.
Age people that need headlinerexchanges.
(10:33):
but certainly conversions, andsimple things like cup revision.
I've not done any femoralrevisions yet through an ASC.
I think it's certainly possible.
it's just finding the peoplebecause, Revision codes are
still inpatient only on theMedicare side of things.
(10:54):
I
John Horberg (10:59):
Yeah, I would echo what Jonathan said.
We've done the exact same thing.
patients, plenty of conversions.
I have removed a stem or two,surgery center for people who
had a posterior approach and agrowth discrepancy.
but the, biggest limiting factorfor me doing them at our
ambulatory Medicare payer statuswon't allow us to do most
(11:21):
revision codes.
yeah.
Most of my revisions that arenon infected or major
reconstructions go home the sameday, from the hospital as well,
or at least have the option to,but, I'd like to do more in our
surgery center,
Aldo M. Riesgo (11:37):
I think obviously the payer stuff is
important for if you're doingoutpatient revision work for me
from an orthopedic standpoint,if I don't do an osteotomy
femoral or pelvic, I think thepatient can go home, especially
if they're motivated.
I think your EBL is cut downtremendously, right?
Your surgical time, everything'scut down.
I think the biggest advantage ofthe anterior approach revisions
(11:58):
is i've never had to take theglute max tendon off a femur
I've never had to take theposterior septum off a femur to
do my work.
All my work is anterior to theseptum to the intermuscular
septum and the gluteal sling.
So to me, in a posteriorapproach, you have to separate
that cause you have to move yourfemur forward to get your
exposure and you're parting thered sea in the wrong direction.
(12:18):
I like to, if you keep all thatback, the patient's obviously
going to do better.
They're going to get up and gothe next day better.
Their gluteal sling and tendonare.
Intact and attached to the femurand all of our osteotomies in
some way or another are allanterior to that right for
femoral work So for me, that'sbeen the biggest advantage for
me And I've done DA revisionsfor my partners who do posterior
(12:40):
on patients who requested it andwe scrub in together and they
round the next day They'rethey're amazed.
Joseph M. Schwab (12:47):
from your guy's perspective, you're at the
forefront of doing theseanterior approach revision
surgeries.
What are the big unsolvedproblems right now in anterior
approach revision surgery?
Jonathan Yerasimides (12:59):
augments that were created to fit on the
inner table of the pelvis for meIs the biggest thing because all
the, the acetabular augmentsthat we use, down on the inner
table of the pelvis, weren'tcreated to, go there.
(13:20):
you always have to have a burrand manipulate the bone a little
bit to get these things to fit.
Now, anterior columnaugmentation is not, It's not
going to be a big moneymaker forimplant companies, frankly,
cause there's not a whole ton ofthem being put in.
So it's probably relatively lowon the list of, of importance,
(13:43):
but hopefully with, 3d printingand stuff of that, like that,
where they're making, 3d printedcustom augments, maybe we can
start getting some implantsthat, there are some augments
that actually fit where we'reoperating.
Kris Alden (13:59):
I would say that, in addition to what Jonathan said,
I completely agree with that.
But I think also, for complexfemoral revisions, the
instrumentation to do thefemoral implant is generally
more posterior approachfriendly.
And, I think there's ways toadapt the instrumentation to the
(14:19):
anterior approach that wouldenable and facilitate anterior
approach revision on the femoralside.
I, think that's something thatwe really need to focus on and
that hasn't really been, on theforefront of a lot of the
implant companies, radar, and asanterior approach, the primary
(14:41):
side, exceeds, posteriorapproach.
I think we're going to see themore ubiquitous, adoption of
anterior approach revisions.
And so hopefully theinstrumentation will play catch
up.
Aldo M. Riesgo (14:53):
I think a lot of surgeons who Would like to maybe
take the leap into directanterior revisions, but don't
feel quite comfortable orworried about things like
assessing femoral version.
How do they do that with the legdown and across and, the
stability testing, right?
It's a, it's an inexact science.
So I think as we move forwardand we incorporate technology
(15:14):
and robotics and augmentedreality and navigation, things
like that, that can help give alittle more, confidence for some
of those surgeons who feel thatwould be a limiting step.
they, a lot of surgeons justlike to get their hands on the
leg and trowel it around.
And it's going to be a littlebit different, with the anterior
approach.
So there's, that little bit of,helping them get used to the new
(15:36):
learning curve.
Jonathan Yerasimides (15:38):
I will say the new, not to spill any beans,
but the new HANA table comingout is going to allow people to
do a full, range of motion test,with the foot still, connected
to the table.
Joseph M. Schwab (15:54):
We'll have to get a OSI on here to give us a
demo.
Jonathan Yerasimides (15:58):
rumor.
It's a rumor.
Yeah.
I don't know.
I have no knowledge.
No, no agreements have beenbroken, but, but yes, that's
what I've heard.
Joseph M. Schwab (16:10):
level six evidence, rumors, and innuendo.
gentlemen, thank you.
really, this is a pleasure forgiving us your time today.
thank you for helping to educateour listeners.
And of course, thank you for allyou do, for your patients.
If you're interested in learningmore about today's guests, you
can check out our show notes fortheir practice links.
(16:32):
we'll also link to some of theanterior approach masterclass
videos that we have on the AHFYouTube channel.
Do you have any anteriorapproach, revision, tips, or
tricks that you want to share?
Leave a comment below.
We would love to hear from you.
And if you enjoy the contentwe're bringing remember to like
and subscribe so that we candeliver even more and reach a
(16:54):
wider audience.
If you have an idea for a topic,you can also drop that in the
comments.
Remember, you can find us anaudio podcast form in your
favorite podcast app.
As well as in video form onYouTube/@anteriorhipfoundation
all one word.
Remember also to visit us on theweb at anteriorhipfoundation.com
(17:17):
where registration for the AHF2025 meeting is already open.
Reserve your seat today.
And we'll see you next week foranother episode of the AHF
podcast.
Until then I'm your host, JoeSchwab, asking you to keep those
hips happy and healthy.
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