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Part II: From Posterior Approach to Anterior Approach · AHF Podcast

• 0:24
  Joseph M Schwab: Hello and welcome back to the AHF Podcast.
• 0:27
  Joseph M Schwab: I'm your host, Joe Schwab.
• 0:29
  Joseph M Schwab: This week we have part two of our AHF Roundtable on moving from posterior approach to anterior approach while already in practice.
• 0:38
  Joseph M Schwab: My guests are Dr.
• 0:39
  Joseph M Schwab: Alex Sah and Dr.
• 0:41
  Joseph M Schwab: Michael Blankstein.
• 0:42
  Joseph M Schwab: This week we discussed their thoughts on revision surgery, and we learned what Mike has been right about and what he's been wrong about.
• 0:50
  Joseph M Schwab: Let's get back to our conversation.
• 0:53
  Joseph M Schwab: you actually raise a really good question, Mike, which is.
• 0:57
  Joseph M Schwab: Um, so where do things go from here?
• 1:00
  Joseph M Schwab: I mean, where does interior approach go from here or where does, uh, total hip arthroplasty go from here?
• 1:06
  Joseph M Schwab: What are the challenges we've left to conquer?
• 1:11
  Alexander Sah: That's a great question, Joe.
• 1:12
  Alexander Sah: Things have gotten very good with the anterior approach, and I think as you see the movement to the ASCs, you see outpatient surgery, I think, I think anterior really lends itself to those types of things.
• 1:23
  Alexander Sah: I think we can still get better in, uh, maybe even more minimally invasive surgery, you know, fewer releases, potentially, uh, better wound healing with our incisions and how we manage the soft tissue.
• 1:34
  Alexander Sah: So I think there are still areas for improvement.
• 1:37
  Alexander Sah: Uh, certainly we're seeing a large increase in revision surgery through the anterior approach.
• 1:42
  Alexander Sah: I think we're going to see more and more of that being developed.
• 1:45
  Alexander Sah: That's, That's, an area where probably tools and other techniques and, and other approaches will, will help us more as we learn how to do larger and more complicated revisions through the anterior approach.
• 1:55
  Alexander Sah: I think there's room for growth there.
• 1:58
  Michael Blankstein: So if you look again at the current day revision rates, according to the American Joint Replacement Registry, three top reasons are infection.
• 2:07
  Michael Blankstein: dislocations and fracture.
• 2:08
  Michael Blankstein: So obviously where we should continue to work, put all our effort is into preventing infection, uh, or again optimizing our patients better.
• 2:17
  Michael Blankstein: So if you had to choose one, I would say better patient selection optimization.
• 2:23
  Michael Blankstein: of a peripatetic fractures, we have gone a long way, and this is my little plug for knowing how to cement a total hip when necessary.
• 2:32
  Michael Blankstein: is some really good data showing that maybe these modern stems These brooch only colored HA coated stems, which happen to be the anterior brooch friendly stems, the next seem to be really decreasing the rates of periprostatic fractures.
• 2:47
  Michael Blankstein: So I actually think that if we can do one thing, we should make sure that we all control tests.
• 2:52
  Michael Blankstein: the right stems.
• 2:53
  Michael Blankstein: to a cement when we need to, monitoring and not a cable when we need to.
• 2:57
  Michael Blankstein: So, track because that complication can be keep an prevented.
• 3:01
  Michael Blankstein: And Um, about respect to actually controls the dislocations, um, traffic.
• 3:05
  Michael Blankstein: I think again, the rates are so low right now, and now we're just finding out the, the final details, which is, hey, if you have somebody who's high risk and they have a abnormal hip spine relationship, should you use enabling technologies?
• 3:19
  Michael Blankstein: Should you use larger, um, Ceramic femoral heads, she used dual mobility components, or maybe it's just the approach.
• 3:26
  Michael Blankstein: And again, the rates are so low, but that's the one thing we're all still chasing, that again, that perfection.
• 3:32
  Michael Blankstein: So I think these are probably the top three things.
• 3:36
  Michael Blankstein: Um, uh, about the revisions to the front, it's interesting.
• 3:39
  Michael Blankstein: That's where I'm going to challenge the anterior approach surgeons.
• 3:42
  Michael Blankstein: I think that, you know, Most of the advantages of the anterior approach are in the early recovery.
• 3:49
  Michael Blankstein: Now, when we're talking about these big revisions, you know, cup cages, a custom tri flange, all that stuff, I think you lose those advantages through the anterior approach for pretty big dissection.
• 4:02
  Michael Blankstein: So I think this is where it still Don't be a one trick pony.
• 4:07
  Michael Blankstein: Be able to do both approaches when necessary.
• 4:10
  Michael Blankstein: If you can, don't feel the pressure.
• 4:13
  Michael Blankstein: I think the pressure to do the anterior approach for a primary hip, I got it, and I was influenced by it.
• 4:18
  Michael Blankstein: To feel the pressure to do revisions to the front, I mean, Show me the data one day, maybe, but sometimes the posterior ports is still the winner, no, these tough complex cases.
• 4:31
  Michael Blankstein: no, again, naturally more extensive.
• 4:34
  Michael Blankstein: And I don't know my opinion.
• 4:36
  Joseph M Schwab: Yeah, I was going to say, Mike, I think you raise a good point.
• 4:39
  Joseph M Schwab: So we just actually finished a conversation with a group of revision surgeons, uh, talking about doing revision anterior approach.
• 4:47
  Joseph M Schwab: And I would say, um, about half the surgeons.
• 4:52
  Joseph M Schwab: incorporate some posterior approach in their revisions and half don't.
• 4:57
  Joseph M Schwab: Um, and that could be a product of the types of revisions that they're seeing or other factors.
• 5:01
  Joseph M Schwab: But, um, there were some anatomic factors that would push one surgeon to go, you for instance, on a posterior approach versus an anterior approach.
• 5:10
  Joseph M Schwab: But was a common theme that they all raised as far as what, how they felt that anterior approach in a revision scenario would continue to benefit or potentially even outperform posterior approach, which is in the reliability of the placement of the components.
• 5:31
  Joseph M Schwab: So in being able to reliably restore hip center, reliably restore leg length and offset and all of the anatomic restoration that we aim for in anterior approach, um, is very facilitated by, um, uh, the, nature of anterior approach surgery being able to be done, um, uh, under guidance of fluoroscopy.
• 5:56
  Joseph M Schwab: Um, now I, I think it's, uh, just like we learned with the development of anterior approach.
• 6:03
  Joseph M Schwab: It's good that there are people out there who are taking those chances and pushing those boundaries and, and learning those things for us.
• 6:10
  Joseph M Schwab: And we'll hope that the, the dissemination of the education, you know, makes us all better surgeons in the end.
• 6:17
  Joseph M Schwab: Uh, once we have the data.
• 6:19
  Joseph M Schwab: to identify what are the best ways to go about But I think that's a really good point is making, um, uh, a surgeon, a, a well rounded surgeon, um, and being able to approach the hip from whatever direction the hip needs to be approached.
• 6:35
  Joseph M Schwab: Um, I do have a, uh, one additional question for you, Alex.
• 6:40
  Joseph M Schwab: Um, tell me a little bit about, I, I, when I talk to people, I, I refer to this as the fit check.
• 6:45
  Joseph M Schwab: Give me a little bit about your fit check.
• 6:47
  Joseph M Schwab: So your, for anterior approach, you mentioned using the HANA table, um, and you mentioned fluoroscopy.
• 6:54
  Joseph M Schwab: Is that, uh, tell me a little bit about what your standard, uh, anterior approach setup is.
• 7:00
  Alexander Sah: Definitely, Joe.
• 7:01
  Alexander Sah: Before I go to that, I am going to just go back for one second, just to highlight something you and Michael were talking about, which is with all the modern day training of anterior approach.
• 7:09
  Alexander Sah: I think there is value of surgeons to learn it.
• 7:12
  Alexander Sah: do courses.
• 7:13
  Alexander Sah: And even if they don't convert their practice to Andrew hip approach, I think there's still this value.
• 7:18
  Alexander Sah: I think by seeing the anatomy, seeing the approach, as Michael said, when you first start, things are upside down and backwards, but I think that's a good thing as a hip surgeon.
• 7:25
  Alexander Sah: I think it's good to understand the anatomy from a different angle and a different place.
• 7:30
  Alexander Sah: And so I I've had other colleagues who.
• 7:33
  Alexander Sah: Go back to their posterior approaches after trainings, but they say they appreciate learning something different.
• 7:38
  Alexander Sah: And I think that highlights what you just said about revision surgery as well.
• 7:42
  Alexander Sah: I think one of those benefits are learning how to do those complex revisions from the front, help you appreciate and just make you a better overall surgeon.
• 7:49
  Alexander Sah: So just wanted to follow up on your comment.
• 7:52
  Michael Blankstein: One thing to say that I still keep the posterior approaches a part of my practice.
• 7:56
  Michael Blankstein: There are cases where I love showing the residents.
• 7:59
  Michael Blankstein: I'm like, do you guys think we should do this to the front?
• 8:03
  Michael Blankstein: And it's the biggest it's people with the anatomy that just would make the interior purchase so challenging.
• 8:09
  Michael Blankstein: And we all know who we're talking about.
• 8:11
  Michael Blankstein: We're talking about these big dudes with huge beer bellies.
• 8:15
  Michael Blankstein: And they have these like skinny little thighs, right?
• 8:18
  Michael Blankstein: And sure, you could do it through the front, but you'll be fighting in that belly the entire time.
• 8:24
  Michael Blankstein: And if you do it through the back, it's significantly easier.
• 8:27
  Michael Blankstein: Any conversion cases, previous hardware, um, cases that you were just, you know, abnormal anatomy, you're worried.
• 8:36
  Michael Blankstein: So, again, I think we should, Um, never be one trick ponies in orthopedics.
• 8:42
  Michael Blankstein: And that's probably been my biggest message, I think, to the community, both in the Okay.
• 8:52
  Michael Blankstein: Yeah.
• 8:58
  Michael Blankstein: Right.
• 9:03
  Michael Blankstein: be able to do at least one other approach for these complex cases.
• 9:09
  Michael Blankstein: And one of the, Sorry, I'm ahead.
• 9:12
  Michael Blankstein: think we should keep it.
• 9:13
  Michael Blankstein: And some people say I've gone all in 100%.
• 9:16
  Michael Blankstein: I'm like, okay, fine.
• 9:18
  Michael Blankstein: But not maintain that previous skill set that you're good at?
• 9:23
  Joseph M Schwab: This episode of the A HF podcast is brought to you by Mizuho, OSI.
• 9:30
  Joseph M Schwab: The Hana table has revolutionized how I perform anterior approach hip replacements.
• 9:36
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• 9:44
  Joseph M Schwab: Orthopedic surgery is always evolving, and tools like the Hana Orthopedic table are what pushes this field forward.
• 9:52
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• 9:59
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• 10:04
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• 10:10
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• 10:18
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• 10:25
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• 10:31
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• 10:37
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• 10:47
  Joseph M Schwab: And now.
• 10:48
  Joseph M Schwab: Back to our podcast.
• 10:51
  Joseph M Schwab: The question that, um, I had posed to Alex, I'll, I'll now pose kind of to both of you guys, which is, what does your, uh, anterior approach set up look like normally in your hospital?
• 11:04
  Joseph M Schwab: Are you using the HANA table?
• 11:05
  Joseph M Schwab: Are you using a standard table?
• 11:07
  Joseph M Schwab: Are you using fluoroscopy?
• 11:09
  Joseph M Schwab: Is there any enabling technologies that they're using on a regular basis?
• 11:12
  Joseph M Schwab: Just give me a rundown.
• 11:13
  Joseph M Schwab: And, and Alex, why don't we start with you?
• 11:17
  Alexander Sah: So for our setup, Joe, we do use the HANA table.
• 11:19
  Alexander Sah: Certainly we like how easy it is to use, how consistent it is for positioning.
• 11:24
  Alexander Sah: Certainly with posterior approach, we're all familiar with the person on the opposite side of the table and how variable their help can be when they're trying to move that leg.
• 11:31
  Alexander Sah: So having a HANA table that will consistently.
• 11:34
  Alexander Sah: position.
• 11:34
  Alexander Sah: The femur where we want it is definitely ideal and not going to give that up, even though people can do it just buying off table as well.
• 11:41
  Alexander Sah: Sea arm, of course, who are highly favorable, favorable for, as we've talked about today, all the advantages of it.
• 11:47
  Alexander Sah: So definitely not giving that up either.
• 11:49
  Alexander Sah: And we do use ortho grid AI technology.
• 11:53
  Alexander Sah: So we did have our reps using the pen and doing outlines, and that worked just fine.
• 11:58
  Alexander Sah: But then Printer paper went away.
• 12:00
  Alexander Sah: So we had to figure out some sort of technology and the A.
• 12:03
  Alexander Sah: I.
• 12:03
  Alexander Sah: And these current technologies are so fast and reproducible.
• 12:06
  Alexander Sah: It gives us great information.
• 12:08
  Alexander Sah: So we've been very happy with how that has worked for us.
• 12:11
  Alexander Sah: And I've started using some of the automated impactors as well.
• 12:15
  Alexander Sah: I didn't think I would.
• 12:16
  Alexander Sah: I was resisting it.
• 12:17
  Alexander Sah: I wanted to think I was still young and that was really only for the older guys with rotator cut problems.
• 12:21
  Alexander Sah: But I've actually seen some potential benefits of it.
• 12:24
  Alexander Sah: So I've been using that as well.
• 12:27
  Michael Blankstein: I like it.
• 12:27
  Michael Blankstein: It's amazing how similar we are.
• 12:29
  Michael Blankstein: Um, I, it's funny, I, I keep a tab with myself of what I was wrong about, what I'm right about.
• 12:35
  Michael Blankstein: An example, I thought that outpatient surgery.
• 12:37
  Michael Blankstein: It was a fad.
• 12:38
  Michael Blankstein: There's no way it's going to be where we're all, where we're all doing.
• 12:42
  Michael Blankstein: And I was clearly wrong, you know.
• 12:44
  Michael Blankstein: It's amazing how, how many patients go home the same day.
• 12:47
  Michael Blankstein: I also thought the automated impactor was just a, whatever, just for Americans who love guns.
• 12:54
  Michael Blankstein: There's no way we need this, you know, and clearly people really, really like it.
• 13:00
  Michael Blankstein: And once you get used to it, yeah, it just makes the operation a bit more fun.
• 13:04
  Michael Blankstein: So, um, so I use a very similar setup.
• 13:06
  Michael Blankstein: I use the Hanna table.
• 13:08
  Michael Blankstein: I use a CRM.
• 13:09
  Michael Blankstein: It's my favorite advantage of the anterior approach.
• 13:12
  Michael Blankstein: use a, a anterior friendly implants and, um, and yeah, that's pretty much the basic setup.
• 13:21
  Michael Blankstein: One of the things that I do, um, Um, think about is the hip spine relationship.
• 13:26
  Michael Blankstein: I used to really say until somebody figures it out, I'm not going to get involved.
• 13:31
  Michael Blankstein: Like somebody, let somebody figure it out and then we'll, um, we'll tackle it.
• 13:36
  Michael Blankstein: But now with the enabling technology, it's actually easy to figure out.
• 13:41
  Michael Blankstein: We have all the tools right now.
• 13:42
  Michael Blankstein: You just have to get a couple of extra x rays with those x rays, we can all start to figure out what's the idea.
• 13:49
  Michael Blankstein: personalized composition for that patient.
• 13:51
  Michael Blankstein: So for my primary basic vanilla cases, I do not use it.
• 13:56
  Michael Blankstein: But when I do see something, it's a bit more complex, where you look at those x rays and you say, well, that's way too much of an inlet or an outlet view.
• 14:05
  Michael Blankstein: Or you see this fusion of the spine.
• 14:10
  Michael Blankstein: I wanted to see whether we should get a different composition, and I use a robot navigation tool that, uh, think it definitely allows you to even improve your accuracy even more.
• 14:22
  Michael Blankstein: idea behind that is that in theory, with this technology, we can get rid of radiation.
• 14:28
  Michael Blankstein: So I'm still, I still have one more phase of learning, which is my favorite tool, which kind of works, but in theory, we may be
• 14:38
  Joseph M Schwab: what pearls do you have for maximizing your time and your education throughout the process of, uh, adopting, uh, anterior approach?
• 14:49
  Joseph M Schwab: Um, and for instance, with a surgeon visitation, how do you maximize your time?
• 14:56
  Alexander Sah: I think what was eye opening for me, Joe, really was attending that Andrew Hitt Foundation meeting.
• 15:01
  Alexander Sah: And I'm saying it truly.
• 15:02
  Alexander Sah: Compared to all the other meetings we go to it really is one that is unique in terms of everyone there Loves the entry hip surgery.
• 15:10
  Alexander Sah: They love helping each other.
• 15:11
  Alexander Sah: They love teaching.
• 15:12
  Alexander Sah: It's not uh, argumentative at all.
• 15:14
  Alexander Sah: You don't see people who are Challenging each other unless they're trying to help each other.
• 15:20
  Alexander Sah: So there's no animosity.
• 15:21
  Alexander Sah: That's really what's great about it There's some other Uh, meetings where it's, it is difficult to people want to show, you know, poor outcomes or, um, show the negative effects of other new technologies or uh, techniques, but really the anterior foundation is very supportive even when I was the only poster hip surgeon in the room.
• 15:38
  Alexander Sah: And I remember that very fondly.
• 15:39
  Alexander Sah: So I think taking advantage of meetings like that, I think getting into the interhip community and knowing your peers, get to know your peers, they are all incredibly friendly and helpful.
• 15:50
  Alexander Sah: I think that helps you in your journey, not just when you're beginning, But when you're getting better or when you're starting to do revisions or when you're in your 10th year of practice, I think there's still huge benefit to learning from your peers.
• 16:02
  Alexander Sah: You don't want to operate in a bubble.
• 16:03
  Alexander Sah: You don't want to try to figure things out for yourself.
• 16:05
  Alexander Sah: There's so many people out there willing to help and, and that's why I can't wait to come to the meeting you're running in Nashville in June.
• 16:11
  Alexander Sah: That's going to be another exciting meeting and each year is different and even better.
• 16:17
  Joseph M Schwab: We're looking forward to having you.
• 16:19
  Joseph M Schwab: Michael, how about you?
• 16:22
  Michael Blankstein: Yeah, I agree again.
• 16:23
  Michael Blankstein: I think that, um, the community.
• 16:26
  Michael Blankstein: is really supportive.
• 16:28
  Michael Blankstein: I would say it's a five step process.
• 16:30
  Michael Blankstein: If you're really considering making that transition, I would say to one of the courses and they're usually industry sponsored courses.
• 16:38
  Michael Blankstein: I actually think you should go to two courses, go to one, see how X does it, take a break, see how company Y does it, then ask yourself, do I still want to do it?
• 16:50
  Michael Blankstein: If that's the case, then you should go see another surgeon, do it live.
• 16:54
  Michael Blankstein: And there with their setup.
• 16:56
  Michael Blankstein: Go see how they do four or five hips.
• 16:59
  Michael Blankstein: Then find a surgeon to come back with you and be there around if you don't have somebody around for the first day you're doing it.
• 17:10
  Michael Blankstein: And then see how those patients do.
• 17:12
  Michael Blankstein: Reflect on it.
• 17:13
  Michael Blankstein: Don't switch 100 percent on.
• 17:16
  Michael Blankstein: See how you do and then reassess.
• 17:18
  Michael Blankstein: And if then you think, you know what, I'm ready, then you dive all in.
• 17:25
  Joseph M Schwab: Well, gentlemen, thank you both for talking to me today, for sharing your stories.
• 17:29
  Joseph M Schwab: I really appreciate hearing it.
• 17:30
  Joseph M Schwab: And, uh, as you're both, uh, I consider good friends.
• 17:35
  Joseph M Schwab: I, uh, I appreciate just the opportunity to see and talk to you.
• 17:39
  Joseph M Schwab: If you're a mid-career surgeon looking to add anterior approach, hip replacement to your practice, we would love to hear from you, drop us a comment below and tell us your story.
• 17:50
  Joseph M Schwab: Or maybe you have a story to tell about your own adoption of anterior approach in your practice.
• 17:56
  Joseph M Schwab: Leave it in the comments to share with others.
• 17:59
  Joseph M Schwab: Thank you for listening to this episode of the AHF podcast.
• 18:03
  Joseph M Schwab: Remember to like and subscribe so we can reach a wider audience.
• 18:07
  Joseph M Schwab: If you have an idea for a topic, leave it in the comments.
• 18:10
  Joseph M Schwab: Remember, you can find us in audio podcast form in your favorite podcast app, as well as in video form on YouTube slash at anterior hip foundation.
• 18:20
  Joseph M Schwab: All one word.
• 18:22
  Joseph M Schwab: New episodes of the AHF Podcast come out on Fridays.
• 18:25
  Joseph M Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.