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Revision Roundtable Part II · AHF Podcast

• 0:07
  Joseph M. Schwab: Welcome back for part two of the AHF's revision roundtable.
• 0:11
  Joseph M. Schwab: If you missed the first part of the roundtable, you can click here to start at the beginning.
• 0:17
  Joseph M. Schwab: Let's rejoin the conversation with our panel, Dr.
• 0:20
  Joseph M. Schwab: Jonathan Yerasimides, Dr.
• 0:22
  Joseph M. Schwab: Aldo Riesgo, Dr.
• 0:24
  Joseph M. Schwab: John Horberg, and Dr.
• 0:26
  Joseph M. Schwab: Kris Alden, as well as my co host, Dr.
• 0:29
  Joseph M. Schwab: Charles Lawrie.
• 0:31
  Charles Lawrie: while we're talking about femoral side of revisions, when we think about primary anterior approach surgery, we all have this sort of ladder of releases that we do to get the femur exposed well enough to do our broaching.
• 0:43
  Charles Lawrie: Obviously need a little bit more exposure in the revision setting.
• 0:46
  Charles Lawrie: can you all walk us through, what that ladder of releases looks like and any extensile maneuvers you may have to do if you're really struggling to get the straight shot down the femur you need for those revision style implants.
• 1:00
  Jonathan Yerasimides: So for me, I'm doing, the lion's share of my releases before I even try to dislocate or drop the hip.
• 1:11
  Jonathan Yerasimides: I went through a.
• 1:15
  Jonathan Yerasimides: when I first started doing these of treating it like a primary where I would drop the leg and then try to do my releases after I dropped the leg, it's very difficult because the femur gets pinned behind the acetabulum.
• 1:29
  Jonathan Yerasimides: and now when I know I'm doing a femoral revision, I get down to the capsule and the old scar and.
• 1:37
  Jonathan Yerasimides: First, I'll find the interval between scar and minimus and medius, because I want to clear off the superior and lateral portion of that capsule first.
• 1:51
  Jonathan Yerasimides: So I excise all scar while the hip is still reduced, the legs are still up in a neutral position.
• 1:57
  Jonathan Yerasimides: I'm excising.
• 1:58
  Jonathan Yerasimides: All the scar back to muscle in that superior and lateral portion.
• 2:04
  Jonathan Yerasimides: Then I'm going to take my bovie and I'm going to bend the tip of it.
• 2:09
  Jonathan Yerasimides: And I'm going to get around the posterior aspect of the trochanter, prior to doing anything else.
• 2:17
  Jonathan Yerasimides: So the table's low, so I can see I'm cutting out all the superior and lateral cartilage.
• 2:23
  Jonathan Yerasimides: scar tissue, then I'm going to clear the trochanter where I can get my finger down and hook the tip of my finger around the tip of the trochanter.
• 2:32
  Jonathan Yerasimides: I don't just want to feel it.
• 2:33
  Jonathan Yerasimides: I want to be able to get around it.
• 2:36
  Jonathan Yerasimides: Then I'd go to the, medial side and excise, I think John said earlier about, that, pubofemoral ligament, that has to be that, scar tissue at this point, completely, released.
• 2:50
  Jonathan Yerasimides: I debulk the anterior scar, then I'll externally rotate, dislocate the hip.
• 2:56
  Jonathan Yerasimides: Keep it fixed at 90 degrees of external rotation, and then take my Bovee and bend the tip and go around the posterior medial side.
• 3:05
  Jonathan Yerasimides: So I'm doing a circumferential release of the femur prior to even dropping it down.
• 3:12
  Jonathan Yerasimides: And it is, it cuts 30, 40 minutes off the case and it makes it guaranteed.
• 3:19
  Jonathan Yerasimides: So you're not going to fracture trochanters as well, because if you're doing a revision, somebody old and the tropes caught behind the, the acetabulum and you're dropping it before you've cleared it and got that lateral translation, you're going to fracture the troch off.
• 3:35
  Joseph M. Schwab: Are there any tests you're doing, Jonathan, to verify that you've done, as much release as you need to?
• 3:42
  Jonathan Yerasimides: if I can't dislocate, if I'm, doing the femur, and this is the femur only, if I'm doing the acetabulum, I don't do any femur, barely any femur releases.
• 3:51
  Jonathan Yerasimides: But if I know I'm doing the femur, if I can't get, At least 90 and preferably over 90 degrees of external rotation.
• 4:02
  Jonathan Yerasimides: from the very beginning, before I drop the leg, I'm not ready to drop the leg.
• 4:09
  Charles Lawrie: So what if you release circumferentially around the femur and you're still struggling, any extra maneuvers or tips,
• 4:17
  Jonathan Yerasimides: usually what happens.
• 4:19
  Jonathan Yerasimides: And it usually means I haven't released enough because I'll think I've done all the releases I can do on earth.
• 4:24
  Jonathan Yerasimides: And then I'd end up dropping the leg and the damn thing still, stuck.
• 4:29
  Jonathan Yerasimides: So if it's not, if it's not rotating enough.
• 4:32
  Jonathan Yerasimides: That means I need to go back to step one, which is looking at that saddle region and that, that superior lateral portion of the capsule and scar.
• 4:43
  Jonathan Yerasimides: And I need to excise more there because the medial side is usually fairly easy to see.
• 4:49
  Jonathan Yerasimides: It's the, it's that superior lateral portion that, that you're usually deficient on.
• 4:55
  Kris Alden: I would just add like Charles, when you said you're really struggling, just literally take everything out and start over for whatever reason that generally just works, go back to step one and redo your, femoral exposure, external rotation, those releases.
• 5:13
  Kris Alden: And, usually it just happens even if you're not, you don't think you're doing a lot more for whatever reason, it just seems to work.
• 5:21
  Charles Lawrie: any role for a iliac wing osteotomies or a tensor, fascial auto releases off the pelvis.
• 5:30
  Aldo M. Riesgo: Yeah, so for me when i'm starting a revision I start off the back with a Tfo release.
• 5:36
  Aldo M. Riesgo: Sorry, Kris.
• 5:36
  Aldo M. Riesgo: I cut you off there.
• 5:38
  Kris Alden: know that's okay.
• 5:39
  Aldo M. Riesgo: question.
• 5:41
  Kris Alden: Yeah, I've only needed to do a TFL release in certain, isolated, like if I'm doing a really complicated femoral revision and, I'm just really struggling, then I will go ahead and release it.
• 5:54
  Kris Alden: But I haven't found, the Iliac wing osteotomy to be really something I've needed to go to.
• 6:00
  Jonathan Yerasimides: Yeah.
• 6:00
  Jonathan Yerasimides: I agree with
• 6:01
  Kris Alden: repair is a very simple thing to do at the end.
• 6:05
  Kris Alden: Like it's very low morbidity at all.
• 6:08
  Kris Alden: So it's, it's, very simple to do.
• 6:11
  Jonathan Yerasimides: Yeah.
• 6:15
  John Horberg: I think the tensor fascia releases is sometimes beneficial if you're going to be reaming and broaching for a straight stem and you have somebody with a large muscular TFL that's fibrotic and adherent.
• 6:25
  John Horberg: I don't want to tear the muscle.
• 6:26
  John Horberg: So that's the indication I have.
• 6:28
  John Horberg: And it's usually at the point where I'm instrumenting the femur as opposed to getting exposure.
• 6:33
  John Horberg: And then speaking to the previous question, another test I do to confirm that my releases are enough is with the hook for the bed in place, I just lift the femur and if I can't lift the femur with traction off so the grader clears the
• 6:46
  Charles Lawrie: we've talked a lot about the benefits that we see as surgeons doing these cases from the anterior approach, right?
• 6:53
  Charles Lawrie: the anterior approach is fantastic, extensile exposure in particular to the acetabulum.
• 6:58
  Charles Lawrie: What benefits have you seen in your patients, do you think, doing these cases from an anterior approach instead of a posterior approach?
• 7:11
  John Horberg: I think just looking at patients, in the hospital after a revision, we've all seen those simple socket revisions from a posterior approach where the patient's laying in bed, they've got a pillow strapped between their legs, they're miserable, they're not get wanting to get up and mobilize.
• 7:27
  John Horberg: And, the first time I did a, femoral osteotomy for a revision stem.
• 7:33
  John Horberg: I dreading going in and rounding on the patient the next morning because I figured they be, incision halfway down their leg, moping, painful, going to be few days.
• 7:43
  John Horberg: And it amazes me how quickly these people mobilize.
• 7:47
  John Horberg: I had a, the patient I'm thinking of got up, sitting at the edge of the bedside I hadn't rounded earlier because they were wanting to go home.
• 7:55
  John Horberg: And it's not always the case, but you see these people walk into clinic and you'll have partners who do posterior approach primaries and revisions, have people with a walker hobbling in there and even sometimes fairly complex reconstructive revision cases or, walking into the clinic, they're doing well, they're mobilizing faster, they're living their
• 8:13
  Kris Alden: Now I would add that, I've adapted the anterior approach revision to the outpatient setting.
• 8:19
  Kris Alden: And so I've had lots of patients go home from the ASC, And I think the recovery is just quicker.
• 8:29
  Kris Alden: and obviously in my opinion, much less pain.
• 8:32
  Kris Alden: So I think they just mobilize faster and, just lends itself well to a quicker recovery, probably longterm, not a lot different, but I would say short term, definitely, all the advantages of the anterior approach primary applied to the post, the anterior approach revision.
• 8:49
  Joseph M. Schwab: Talk more about that, Kris.
• 8:50
  Joseph M. Schwab: What types of revisions are you doing in the ASC setting?
• 8:55
  Kris Alden: I've done almost everything.
• 8:58
  Kris Alden: So I've done, full revisions, usually not, I'm, able to like, obviously like shorter stems.
• 9:09
  Kris Alden: Like I w I've had, for example, like a primary stem that's, loosened, and I've gone back with a more, robust primary stem, like a cry revision, for example, done those in the, outpatient setting.
• 9:30
  Kris Alden: converted, like a resurfacing total hip, like taking everything out and put in primary implants, done that type.
• 9:38
  Kris Alden: so lots of different options, for patients, usually it's the younger, healthier and motivated.
• 9:46
  Kris Alden: So if you have somebody that's older and sicker, obviously.
• 9:48
  Kris Alden: That type of revision surgery would be more applicable to the hospital setting.
• 9:52
  Kris Alden: But, if the patient is excited about it, they're motivated, then, the outpatient revision is certainly something been done doing for a long time.
• 10:05
  Joseph M. Schwab: Anybody else doing revisions in the outpatient setting?
• 10:09
  Jonathan Yerasimides: I've done some, it just, You can't, do Medicare in the outpatient in ASC yet.
• 10:16
  Jonathan Yerasimides: So it has to be a non Medicare patient with, something straightforward.
• 10:23
  Jonathan Yerasimides: certainly heads and liners, although, you're not finding a whole lot of, under Medicare.
• 10:29
  Jonathan Yerasimides: Age people that need headliner exchanges.
• 10:33
  Jonathan Yerasimides: but certainly conversions, and simple things like cup revision.
• 10:41
  Jonathan Yerasimides: I've not done any femoral revisions yet through an ASC.
• 10:43
  Jonathan Yerasimides: I think it's certainly possible.
• 10:46
  Jonathan Yerasimides: it's just finding the people because, Revision codes are still inpatient only on the Medicare side of things.
• 10:54
  Jonathan Yerasimides: I
• 10:59
  John Horberg: Yeah, I would echo what Jonathan said.
• 11:01
  John Horberg: We've done the exact same thing.
• 11:03
  John Horberg: patients, plenty of conversions.
• 11:06
  John Horberg: I have removed a stem or two, surgery center for people who had a posterior approach and a growth discrepancy.
• 11:14
  John Horberg: but the, biggest limiting factor for me doing them at our ambulatory Medicare payer status won't allow us to do most revision codes.
• 11:23
  John Horberg: yeah.
• 11:23
  John Horberg: Most of my revisions that are non infected or major reconstructions go home the same day, from the hospital as well, or at least have the option to, but, I'd like to do more in our surgery center,
• 11:37
  Aldo M. Riesgo: I think obviously the payer stuff is important for if you're doing outpatient revision work for me from an orthopedic standpoint, if I don't do an osteotomy femoral or pelvic, I think the patient can go home, especially if they're motivated.
• 11:50
  Aldo M. Riesgo: I think your EBL is cut down tremendously, right?
• 11:52
  Aldo M. Riesgo: Your surgical time, everything's cut down.
• 11:55
  Aldo M. Riesgo: I think the biggest advantage of the anterior approach revisions is i've never had to take the glute max tendon off a femur I've never had to take the posterior septum off a femur to do my work.
• 12:04
  Aldo M. Riesgo: All my work is anterior to the septum to the intermuscular septum and the gluteal sling.
• 12:09
  Aldo M. Riesgo: So to me, in a posterior approach, you have to separate that cause you have to move your femur forward to get your exposure and you're parting the red sea in the wrong direction.
• 12:18
  Aldo M. Riesgo: I like to, if you keep all that back, the patient's obviously going to do better.
• 12:23
  Aldo M. Riesgo: They're going to get up and go the next day better.
• 12:25
  Aldo M. Riesgo: Their gluteal sling and tendon are.
• 12:26
  Aldo M. Riesgo: Intact and attached to the femur and all of our osteotomies in some way or another are all anterior to that right for femoral work So for me, that's been the biggest advantage for me And I've done DA revisions for my partners who do posterior on patients who requested it and we scrub in together and they round the next day They're they're amazed.
• 12:47
  Joseph M. Schwab: from your guy's perspective, you're at the forefront of doing these anterior approach revision surgeries.
• 12:53
  Joseph M. Schwab: What are the big unsolved problems right now in anterior approach revision surgery?
• 12:59
  Jonathan Yerasimides: augments that were created to fit on the inner table of the pelvis for me Is the biggest thing because all the, the acetabular augments that we use, down on the inner table of the pelvis, weren't created to, go there.
• 13:20
  Jonathan Yerasimides: you always have to have a burr and manipulate the bone a little bit to get these things to fit.
• 13:26
  Jonathan Yerasimides: Now, anterior column augmentation is not, It's not going to be a big moneymaker for implant companies, frankly, cause there's not a whole ton of them being put in.
• 13:39
  Jonathan Yerasimides: So it's probably relatively low on the list of, of importance, but hopefully with, 3d printing and stuff of that, like that, where they're making, 3d printed custom augments, maybe we can start getting some implants that, there are some augments that actually fit where we're operating.
• 13:59
  Kris Alden: I would say that, in addition to what Jonathan said, I completely agree with that.
• 14:04
  Kris Alden: But I think also, for complex femoral revisions, the instrumentation to do the femoral implant is generally more posterior approach friendly.
• 14:15
  Kris Alden: And, I think there's ways to adapt the instrumentation to the anterior approach that would enable and facilitate anterior approach revision on the femoral side.
• 14:26
  Kris Alden: I, think that's something that we really need to focus on and that hasn't really been, on the forefront of a lot of the implant companies, radar, and as anterior approach, the primary side, exceeds, posterior approach.
• 14:44
  Kris Alden: I think we're going to see the more ubiquitous, adoption of anterior approach revisions.
• 14:50
  Kris Alden: And so hopefully the instrumentation will play catch up.
• 14:53
  Aldo M. Riesgo: I think a lot of surgeons who Would like to maybe take the leap into direct anterior revisions, but don't feel quite comfortable or worried about things like assessing femoral version.
• 15:03
  Aldo M. Riesgo: How do they do that with the leg down and across and, the stability testing, right?
• 15:08
  Aldo M. Riesgo: It's a, it's an inexact science.
• 15:10
  Aldo M. Riesgo: So I think as we move forward and we incorporate technology and robotics and augmented reality and navigation, things like that, that can help give a little more, confidence for some of those surgeons who feel that would be a limiting step.
• 15:25
  Aldo M. Riesgo: they, a lot of surgeons just like to get their hands on the leg and trowel it around.
• 15:29
  Aldo M. Riesgo: And it's going to be a little bit different, with the anterior approach.
• 15:33
  Aldo M. Riesgo: So there's, that little bit of, helping them get used to the new learning curve.
• 15:38
  Jonathan Yerasimides: I will say the new, not to spill any beans, but the new HANA table coming out is going to allow people to do a full, range of motion test, with the foot still, connected to the table.
• 15:54
  Joseph M. Schwab: We'll have to get a OSI on here to give us a demo.
• 15:58
  Jonathan Yerasimides: rumor.
• 15:59
  Jonathan Yerasimides: It's a rumor.
• 15:59
  Jonathan Yerasimides: Yeah.
• 16:00
  Jonathan Yerasimides: I don't know.
• 16:01
  Jonathan Yerasimides: I have no knowledge.
• 16:02
  Jonathan Yerasimides: No, no agreements have been broken, but, but yes, that's what I've heard.
• 16:10
  Joseph M. Schwab: level six evidence, rumors, and innuendo.
• 16:14
  Joseph M. Schwab: gentlemen, thank you.
• 16:16
  Joseph M. Schwab: really, this is a pleasure for giving us your time today.
• 16:20
  Joseph M. Schwab: thank you for helping to educate our listeners.
• 16:22
  Joseph M. Schwab: And of course, thank you for all you do, for your patients.
• 16:27
  Joseph M. Schwab: If you're interested in learning more about today's guests, you can check out our show notes for their practice links.
• 16:32
  Joseph M. Schwab: we'll also link to some of the anterior approach masterclass videos that we have on the AHF YouTube channel.
• 16:40
  Joseph M. Schwab: Do you have any anterior approach, revision, tips, or tricks that you want to share?
• 16:44
  Joseph M. Schwab: Leave a comment below.
• 16:46
  Joseph M. Schwab: We would love to hear from you.
• 16:47
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• 16:55
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• 16:59
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• 17:04
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• 17:12
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• 17:21
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• 17:24
  Joseph M. Schwab: And we'll see you next week for another episode of the AHF podcast.
• 17:29
  Joseph M. Schwab: Until then I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.