Latest / AHF Podcast / Revision Roundtable BONUS - ASIS/AIIS Double Osteotomy

Transcript

Revision Roundtable BONUS - ASIS/AIIS Double Osteotomy · AHF Podcast

• 0:00
  Joseph M. Schwab: This is Joe Schwab host of the AHF podcast.
• 0:03
  Joseph M. Schwab: The response to our revision round table series has been tremendously positive.
• 0:07
  Joseph M. Schwab: So this week, just like last week, we have another bonus episode with content that just couldn't make it into the original episodes.
• 0:16
  Joseph M. Schwab: This week, we've got Dr.
• 0:17
  Joseph M. Schwab: Aldo Riesgo talking about anterior superior iliac spine osteotomies, and combined ASIS and AIIS osteotomies.
• 0:29
  Joseph M. Schwab: And just like last week, you can check the show notes for links to the video.
• 0:33
  Joseph M. Schwab: Now let's get on with the AHF revision round table.
• 0:44
  Jonathan Yerasimides: Aldo what do you think the ASIS osteotomy, gains you as far as, access?
• 0:49
  Jonathan Yerasimides: And are you taking that, are you taking that bone fragment medially?
• 0:55
  Aldo M. Riesgo: look, I think it allows me to start going down the slide, I like to call it.
• 1:01
  Aldo M. Riesgo: Go down the anterior column, go into the pelvis, I flip that tissue medial, right?
• 1:06
  Aldo M. Riesgo: And then I start working.
• 1:07
  Aldo M. Riesgo: I do a lateral window kind of exposure and then walk it down the anterior column to get to, to my pubis.
• 1:16
  Aldo M. Riesgo: I think it's a, I think it's a low morbidity thing.
• 1:18
  Aldo M. Riesgo: I like bone on bone healing.
• 1:22
  Aldo M. Riesgo: I like to leave some of that attached.
• 1:24
  Aldo M. Riesgo: I've set them up now where they're angled.
• 1:26
  Aldo M. Riesgo: So if I have a shortening case like John's mentioned before, you can slide the osteotomy down so you can still get bone to bone healing.
• 1:35
  Aldo M. Riesgo: You don't want to completely flat cut.
• 1:38
  Aldo M. Riesgo: yeah, so I've been messing around with a double kind of a double Iliac osteotomy, ASIS and AIIS.
• 1:44
  Aldo M. Riesgo: Cause I had some of my younger patients, when I needed more access and I was always doing a femoral rectus femoris tenotomy.
• 1:52
  Aldo M. Riesgo: So I've started, doing it, this double osteotomy to leave the rectus attached.
• 1:57
  Aldo M. Riesgo: So here's a good case, I got to get into the pelvis, extremely short, I'm gonna have to lengthen this patient, so this person's another infection case, bilateral primary hip some many years ago.
• 2:14
  Aldo M. Riesgo: So I'm going in, if you see the initial exposure, I have a picture there, You're never going to get to the trunnion.
• 2:21
  Aldo M. Riesgo: That's the anterior coding of his femur, right?
• 2:24
  Aldo M. Riesgo: So that's where his ASIS is before I decided to do any work.
• 2:28
  Aldo M. Riesgo: So I need to access the inner table to even get this dislocated.
• 2:31
  Aldo M. Riesgo: This is a cadaveric picture, but if you see here, this is what it looks like.
• 2:35
  Aldo M. Riesgo: So there's a, if you click ahead, that's where my ASIS osteotomy would be.
• 2:39
  Aldo M. Riesgo: That piece of bone right above it is the superior spine.
• 2:43
  Aldo M. Riesgo: And then you angle it like a 45 degree or 60 degree angle, and then you don't want to extend it till you get into your dome, right?
• 2:52
  Aldo M. Riesgo: So this is a cadaveric dissection where we've put a cup in and we've already marked that.
• 2:58
  Aldo M. Riesgo: And then if we keep going, I'll mark it there, ASIS, AIIS.
• 3:02
  Aldo M. Riesgo: And then in patients where you don't have a lot of shortening, you can actually get a bone to bone.
• 3:07
  Aldo M. Riesgo: Repair that.
• 3:07
  Aldo M. Riesgo: So this is back to that case.
• 3:09
  Aldo M. Riesgo: There's that, pseudoacetabulum that's formed at the top and the inner table.
• 3:15
  Aldo M. Riesgo: that's where I did the osteotomy.
• 3:17
  Aldo M. Riesgo: You can see that right there.
• 3:18
  Aldo M. Riesgo: That's the piece of bone right there.
• 3:20
  Aldo M. Riesgo: and then I can then hook retractors underneath that.
• 3:23
  Aldo M. Riesgo: I use a Charnley.
• 3:25
  Aldo M. Riesgo: So that Charnley's hooked around the AIIS and then I can walk down the column.
• 3:29
  Aldo M. Riesgo: My sucker tip is pointing at that osteotomy.
• 3:32
  Aldo M. Riesgo: so there I went ahead and, unroof the socket from the inside.
• 3:37
  Aldo M. Riesgo: and then, yeah, I was able to, I was able to, dissociate the trunnion and the head ball
• 3:44
  Jonathan Yerasimides: Say, cause that, that looked like contained defect.
• 3:46
  Jonathan Yerasimides: Like when you show me that AP pelvis, I wasn't thinking the anterior column was going to be out.
• 3:51
  Jonathan Yerasimides: I thought this looked like just a giant superior contained defect, that picture there, so did you create like an anterior column hole then so you could get
• 4:00
  Aldo M. Riesgo: Yes, yeah, so this is an infected case.
• 4:04
  Aldo M. Riesgo: I had to get a really good debridement and I couldn't even access that thing was not that thing was socked in he was up and in that for years This guy was a neglected pji case it took over a year and a half to get him on my schedule not the best social situation for him so there's no way I was gonna even be able to get that cup and trunnion even out of the pelvis without doing this.
• 4:28
  Aldo M. Riesgo: So yeah, whenever I have to get inside to the, yeah, I think recreating a column defect, that's a great indication for it.
• 4:35
  Aldo M. Riesgo: But for me, this is just getting the parts out.
• 4:38
  Aldo M. Riesgo: I had to get the parts out.
• 4:39
  Jonathan Yerasimides: Yeah, no, and I've done that before where I've had these giant contained defects.
• 4:44
  Jonathan Yerasimides: And then just to get the implants out, I ended up creating an anterior column, anterior wall defect, just to get the parts out and then fix them later.
• 4:54
  Aldo M. Riesgo: yeah, a case like this where he was short five centimeters.
• 4:57
  Aldo M. Riesgo: I think direct anterior is the way to go because.
• 5:01
  Aldo M. Riesgo: I can do an extensive release off the outer table.
• 5:04
  Aldo M. Riesgo: I think the abductor mass and the TFL will slide down to a new position.
• 5:08
  Aldo M. Riesgo: And then I, if you angle these osteotomies, you can, slide them down a bit.
• 5:14
  Aldo M. Riesgo: for this guy, getting him back four or five centimeters, you're probably not going to get bone to bone contact when you repair it, but I do have a, a picture coming up and an X ray of, that's what we did for this guy.
• 5:26
  Aldo M. Riesgo: you can actually put those plates on the inner table.
• 5:29
  Aldo M. Riesgo: If you have incredible access to it.
• 5:32
  Aldo M. Riesgo: So that's a good, that's a good functional spacer for him.
• 5:35
  Aldo M. Riesgo: He's a pretty low demand guy, but then in my, more functional patients where I've had to do it, I do fix it.
• 5:41
  Aldo M. Riesgo: Yeah.
• 5:42
  Aldo M. Riesgo: If you show that next picture, you can see those screws where the ASIS and the AIIS are, you can get great bone to bone.
• 5:53
  Aldo M. Riesgo: Healing right there of the kind of double osteotomy.
• 5:56
  Aldo M. Riesgo: So this guy's, this patient here that I showed different patient obviously, but this guy is 42 years old, I would, tenotomize the rectus on most of these patients and I think they would have some persistent.
• 6:11
  Aldo M. Riesgo: Hip flexor strength.
• 6:12
  Aldo M. Riesgo: So I've started doing this and I've been pretty happy with the results so far.
• 6:17
  Jonathan Yerasimides: Have, do you always double osteotomy or is it possible?
• 6:22
  Jonathan Yerasimides: And I'm asking just cause I've not done it.
• 6:24
  Jonathan Yerasimides: I don't know.
• 6:26
  Jonathan Yerasimides: but taking, taking them both in one osteotomy, the ASIS and the AIIS and just making it one large fragment because you might be getting down into a little bit of the dome, but you're still, you're posterior column where we bear our weight and where we're loading our implants and still be intact.
• 6:47
  Jonathan Yerasimides: I don't know if you've ever tried to take one piece or not.
• 6:50
  Jonathan Yerasimides: Yeah,
• 6:51
  Aldo M. Riesgo: yeah I think that's the that's the next iteration of this if I can do it and obviously everyone's pelvis morphology You look at it like their angles are a little bit different in terms of you Obviously don't want to compromise the bone that you need for reconstruction.
• 7:03
  Aldo M. Riesgo: I think that's the number one key and you mentioned that So for right now, I've just been doing Double.
• 7:10
  Aldo M. Riesgo: but I think then if I could do it all as one big piece, that would probably be better and easier, truthfully.
• 7:16
  Aldo M. Riesgo: But I think that what that just goes to show is every year I'm doing more and more of these.
• 7:21
  Aldo M. Riesgo: And I think we're all experimenting and pushing the envelope as to what is best for our patients.
• 7:29
  Aldo M. Riesgo: And so far so good.
• 7:31
  Aldo M. Riesgo: I've had, on the few patients I've done this on, they haven't really given me the same complaints that I was getting before, in terms of some of that, rectus or hip flexor weakness.
• 7:43
  Jonathan Yerasimides: I'll give a shameless plug out to one of your, one of your, old fellows, James Baker.
• 7:49
  Jonathan Yerasimides: I just did a course with him and, he's, I'll take a little credit.
• 7:54
  Jonathan Yerasimides: He was my resident, but he was your fellow, but, he, he's, doing some wild stuff down here in Louisville.
• 8:02
  Jonathan Yerasimides: He's, on the radar.
• 8:04
  Aldo M. Riesgo: Yeah.
• 8:05
  Aldo M. Riesgo: Yeah.
• 8:05
  Aldo M. Riesgo: I think we're, but again, it's about training that next generation of guys who are, we're, we are not set in our ways of Hey, this is how we did it.
• 8:14
  Aldo M. Riesgo: And this is how people have always done it.
• 8:15
  Aldo M. Riesgo: And this is how we need to keep doing it.
• 8:16
  Aldo M. Riesgo: No, we haven't perfected anything.
• 8:19
  Aldo M. Riesgo: And I think that's part of the goal of all this is being collaborative.
• 8:22
  Aldo M. Riesgo: And I've picked up a lot of stuff from, everyone here that I've talked to about, about how I do hips and how I do revisions.