Latest / AHF Podcast / Interview: Alfonso Alias, MD
Transcript
- 0:24Joseph M Schwab: Hello and welcome to the AHF Podcast.
- 0:26Joseph M Schwab: I'm your host, Joe Schwab.
- 0:29Joseph M Schwab: Our episode today features my conversation with Dr.
- 0:31Joseph M Schwab: Alfonso Alias, a consultant hip surgeon from the hip unit at the Orthopedic Surgery and Traumatology service at Clinic Barcelona in Spain.
- 0:41Joseph M Schwab: Dr.
- 0:41Joseph M Schwab: Alias has been instrumental in growing anterior approach in Barcelona, and through his efforts and the efforts of his partners, patients are recovering quicker and spending less time in the hospital.
- 0:53Joseph M Schwab: As a side note, I was recovering from laryngitis when we talked, so my voice is a little raspy.
- 0:58Joseph M Schwab: Nevertheless, I was fascinated to hear how much growth anterior approach had undergone in Barcelona thanks to Dr.
- 1:05Joseph M Schwab: Alias and his partners.
- 1:07Joseph M Schwab: Let's listen in on a portion of our conversation.
- 1:12Joseph M Schwab: Dr.
- 1:13Joseph M Schwab: Alias welcome to the podcast.
- 1:16Alfonso Alías: Thank you so much for having me.
- 1:17Alfonso Alías: It was honor for me.
- 1:20Alfonso Alías: I.
- 1:21Joseph M Schwab: so my understanding is you're in practice in Barcelona, Spain.
- 1:25Alfonso Alías: Is correct?
- 1:25Alfonso Alías: Yeah.
- 1:26Alfonso Alías: I'm in hospital clinic in Barcelona.
- 1:28Alfonso Alías: Right.
- 1:29Joseph M Schwab: when you began there, was anterior approach, hip replacement, something that was common, or did you bring that, into the practice where you're at?
- 1:38Alfonso Alías: So when I started in the hospital, my chief was, already performing anterior approach.
- 1:43Alfonso Alías: That was in 2019 at the end of 2019, I started with my first approaches and now as my regular approach, like I said, it's like five years from now, three of us are performing anterior approach
- 1:59Joseph M Schwab: And so what motivated you to take up anterior approach when you got into practice?
- 2:05Alfonso Alías: So I've seen the difference, between my patient and the from my chief who was, he was doing anterior approach.
- 2:14Alfonso Alías: I, since 2013, I think.
- 2:18Alfonso Alías: And I've seen for, in terms of rapid recovery or, to get early with, physiotherapy also because of the length of the stay.
- 2:27Alfonso Alías: And something was kind of a difference between the, his patient and my patient.
- 2:32Alfonso Alías: That's why I wanted to start it.
- 2:34Alfonso Alías: Also, also maybe to, I wanted to all the unit to see, to do the things in the same way, because otherwise I was doing the posterior approach.
- 2:45Alfonso Alías: Another colleague was doing a direct lateral approach.
- 2:48Alfonso Alías: My chief was doing the anterior approach.
- 2:50Alfonso Alías: Then that's why I felt, it makes sense just that everybody does the same
- 2:55Joseph M Schwab: What was it that you noticed that made you think the entire team should be doing it all the same way?
- 3:03Alfonso Alías: You have no restrictions at all.
- 3:05Alfonso Alías: So when I was doing the posterior approach, we had.
- 3:08Alfonso Alías: some kind of restriction.
- 3:10Alfonso Alías: Yeah, you have to take care you're standing up or when you're moving.
- 3:14Alfonso Alías: This kind of movements.
- 3:15Alfonso Alías: If you go to the toilet, maybe you have to have a height in there in when you're sitting for the first weeks.
- 3:22Alfonso Alías: Maybe it was just me that I was maybe very careful in the beginning, and, but the, the patients who were having the anterior approach, were no restrictions at all.
- 3:33Alfonso Alías: We actually, they can do whatever they want.
- 3:35Alfonso Alías: We have no restriction in, in terms of, restriction of movements it's like they can do whatever they feel good to do.
- 3:44Joseph M Schwab: Was it a ward type situation where patients from multiple surgeons might be in one room?
- 3:49Joseph M Schwab: Room or, did have individual rooms?
- 3:53Joseph M Schwab: How much were they seeing ways that they were being treated differently?
- 3:57Alfonso Alías: Usually we have single rooms and double rooms and yeah, that happens a lot that you have in the same room people from posterior approach or for lateral approach together with, with the people from anterior approach.
- 4:09Alfonso Alías: Nowadays we are doing almost all our cases in anterior approach, like I said, and, we have not so much ref difference.
- 4:18Alfonso Alías: Really the difference is between the direct lateral approach and the anterior approach, for me.
- 4:24Alfonso Alías: With the posterior approach, it's not so much the difference, but with the lateral approach, this is something like, you can really really feel that the patient is moving faster.
- 4:33Alfonso Alías: The pain is less.
- 4:35Alfonso Alías: It's very, very common that in the first day they want to leave the crutches and work without crutches sometimes.
- 4:42Alfonso Alías: And that is a, a big difference, I think.
- 4:46Joseph M Schwab: And the system that you're in, is it a public system in Spain?
- 4:51Alfonso Alías: Yeah.
- 4:51Alfonso Alías: I work in a university hospital and in a public system, yeah.
- 4:55Joseph M Schwab: So tell me a little bit about how setup of the medical system and the public hospital system in Spain plays into your decision about what you choose to do for patients.
- 5:08Alfonso Alías: Usually we have to say that the patient that we get in our hospital are the patient that are living in a, in a zone in Barcelona.
- 5:18Alfonso Alías: But I think we have about 350,000 people we have to take care of, and, they are, they're gonna be referred to our hospital.
- 5:28Alfonso Alías: So it's not that the people can decide which hospital you want to choose, it's just that's the public system just allows you to go in the hospital that is near your, your home
- 5:41Joseph M Schwab: With all of you and your partners the same, surgical at this point, getting the teams, on getting the nurses physiotherapists on board, are you able to work on efficiency or is that something that's difficult to, maneuver the health system you're in?
- 6:01Alfonso Alías: It is very difficult.
- 6:03Alfonso Alías: It is one of, our challenge, I think, and because here it is like, Your team, or even the doctors, everybody's gonna get paid the same amount of money at the end of the month no matter if you do two hips or two hundred.
- 6:20Alfonso Alías: Okay.
- 6:21Alfonso Alías: starting from that point, it is something that is difficult to talk about efficiency.
- 6:28Alfonso Alías: I was trained in Germany where, you know, the system is very different and everybody wants to be more efficient and everybody wants to operate more patients because it's better for the hospital, it's better for the society also, but it's better also for, the directors of the hospital just to get the, the system moving, you know.
- 6:50Alfonso Alías: but here it's kind of different.
- 6:52Alfonso Alías: I think we're getting better and we are trying to get better in terms of efficiency, but, we have a lot of things to, to improve I was with, I was visiting Kristoff Corten and seeing him doing 12 to 16 hips in a day.
- 7:10Joseph M Schwab: Yeah.
- 7:11Alfonso Alías: it's not something that's gonna happen.
- 7:13Alfonso Alías: It's gonna happen in my hospital overnight, you know, so you are gonna have to work a lot.
- 7:19Alfonso Alías: And maybe we are never gonna hit, hit these numbers, but, But for sure we are working on, on getting better.
- 7:28Joseph M Schwab: Is efficiency one of the biggest challenges that you've come across in your practice or as you've, anterior approach, what, say has been one of the biggest challenges?
- 7:40Alfonso Alías: I think that is nowadays my biggest challenge.
- 7:44Alfonso Alías: here, for example, I work in Barcelona.
- 7:46Alfonso Alías: a patient comes to me in my, in my outpatient clinic and wants to be, want to have his or her hip done, they're gonna have to wait almost six months.
- 8:00Joseph M Schwab: Wow.
- 8:00Alfonso Alías: We are working in kind of, I think the NHS had some kind of a more or less same system and we have this waiting list that is what moves me to get better in terms of efficiency because, you know, you can optimize the patient in this time for example, people that said I am, I'm BMI over 35.
- 8:22Alfonso Alías: They're gonna be in a different clinic to, to, to get the, the weight reduced before.
- 8:28Alfonso Alías: So you can do a lot of things in these six months.
- 8:33Alfonso Alías: it is something we don't want to, and we would like to, to have something shorter, like one month or something like that.
- 8:40Joseph M Schwab: And how long after the surgeries are patients staying in the hospital, in your clinic?
- 8:46Alfonso Alías: One night.
- 8:47Alfonso Alías: Usually we do outpatient.
- 8:49Joseph M Schwab: Oh, you do.
- 8:50Alfonso Alías: Yeah.
- 8:51Alfonso Alías: But we were, we were the first hospital in Spain starting with, with the outpatient.
- 8:57Joseph M Schwab: Great.
- 8:58Alfonso Alías: we have done not so much cases and that is, also something that, we want to improve I think we want to.
- 9:08Alfonso Alías: Yeah, I hope that in the next couple years we can do maybe 20% or 25% of our patients with, in like outpatients.
- 9:20Alfonso Alías: You know, we are working in a hospital that is a high level hospital.
- 9:24Alfonso Alías: We get all complicated cases, not because, not just because of the surgery, but also because of, I don't know, liver transplantation or.
- 9:34Alfonso Alías: people that are really sick, we're not a clinic who is doing just ASA one or two.
- 9:40Alfonso Alías: So we have complicated cases and that allows you not to do an outpatient center where everybody's gonna go home the same day.
- 9:51Joseph M Schwab: so how did your patients respond when you started offering them basically outpatient, total hip arthroplasty?
- 9:57Joseph M Schwab: Was that something they were excited about?
- 9:59Joseph M Schwab: Were they hesitant?
- 10:00Joseph M Schwab: How was, what was their response?
- 10:02Joseph M Schwab: I.
- 10:03Alfonso Alías: Yeah, we have started with the, with the, the first patient was in 2018, was a patient who had already a hip done in the other side.
- 10:12Alfonso Alías: So it's a patient who knows all the process and knows everything is gonna happen to him.
- 10:19Alfonso Alías: And then we started doing slowly more and more.
- 10:22Alfonso Alías: And the patient, usually they don't want to sleep in the hospital.
- 10:27Alfonso Alías: They have to share a room with another, with another patient.
- 10:31Alfonso Alías: but that is something that I think the oldest, patient we have done is 77 years old.
- 10:39Alfonso Alías: And usually it's something you do for the 60 years old, healthy people.
- 10:48Alfonso Alías: we like, to have at the, at the first, the first patient, they were all living around the hospital, so not so far away.
- 10:58Joseph M Schwab: Yeah.
- 10:59Alfonso Alías: the hospital.
- 10:59Alfonso Alías: We were scared in the first, in the first cases, but till till today, we had no problems at all with all the patient that went home.
- 11:07Alfonso Alías: And, and after you speak with the patient and say, how was the experience for you, and the answer is always, it was okay.
- 11:14Alfonso Alías: It was nice.
- 11:15Alfonso Alías: I think everybody wa everything was under control.
- 11:18Alfonso Alías: And and I felt, I felt great going home same day.
- 11:22Alfonso Alías: So that's why we wanted to do more.
- 11:25Joseph M Schwab: This episode of the A HF podcast is brought to you by Mizuho, OSI, the way a surgical tool like the HA table has enabled the adoption of the anterior approach has made a real difference.
- 11:39Joseph M Schwab: It's been about 20 years since the HA table first began revolutionizing our ability to perform anterior approach consistently.
- 11:48Joseph M Schwab: Since then, we've seen the growth of hip preservation techniques like arthroscopy and PAO.
- 11:54Joseph M Schwab: The team at Mizuho OSI is taking that 20 years of learning and experience to prepare for the next innovation, which will further push forward what we can accomplish in the operating room.
- 12:07Joseph M Schwab: What they have coming up is gonna take what you know about the HA table to a whole new level experience, the difference innovation makes for yourself by visiting Mizuho OSI at this year's Anterior Hip Foundation annual meeting.
- 12:23Joseph M Schwab: Who knows what solution they might bring out next, but you're gonna want to be the first to see it.
- 12:29Joseph M Schwab: And now back to our podcast.
- 12:33Joseph M Schwab: So your patients have been fairly satisfied with the outpatient experience at this point.
- 12:37Joseph M Schwab: Yeah.
- 12:38Joseph M Schwab: Talking a little bit about how you do anterior approach and a little bit specifically about table versus tableless, use of fluoroscopy or robotics.
- 12:50Joseph M Schwab: additional navigation.
- 12:51Joseph M Schwab: What your, implant choice is and, and things that.
- 12:56Joseph M Schwab: Tell me a little bit about what your setup is.
- 12:59Alfonso Alías: So in our setup, we operate on regular table.
- 13:04Alfonso Alías: Okay, that's, we do the anterior approach.
- 13:07Alfonso Alías: We use, the bikini approach for, I would say all of our patients.
- 13:14Alfonso Alías: We do like a, with a table.
- 13:17Alfonso Alías: we have been using, at the beginning we were for retraction, we were using the Gelpi from Anelli.
- 13:26Alfonso Alías: And nowadays, is like 18 months, I think we started with, the Gripper.
- 13:33Joseph M Schwab: From medEnvision?
- 13:34Alfonso Alías: From medEnvision, yeah.
- 13:35Alfonso Alías: Right.
- 13:36Alfonso Alías: And we're pretty happy with that, so.
- 13:38Alfonso Alías: We'll, we love it.
- 13:41Alfonso Alías: yeah, so we are, we are doing the, the approach, think we are doing kind of different things sometimes in terms of how you treat the, the capsule, for example.
- 13:54Joseph M Schwab: Yeah.
- 13:55Alfonso Alías: but, I will say that the approach is more or less the same we are using the fluoroscopy at, once we have put the cup in, so we don't use the fluoroscopy to put the cup, but, but to take a look to the stem, to take a look to the length and to take a look to the offset usually.
- 14:14Joseph M Schwab: I see.
- 14:15Joseph M Schwab: So you're putting the cup in with anatomic landmarks.
- 14:18Alfonso Alías: Yeah.
- 14:19Alfonso Alías: and now also because I have started with the robotics, with, the Rosa
- 14:23Joseph M Schwab: Mm-hmm.
- 14:24Alfonso Alías: from Zimmer and we are doing our first cases and then, yeah, we are using the more fluoroscopy because of the Rosa.
- 14:34Alfonso Alías: And then maybe we're gonna do it in the future.
- 14:37Alfonso Alías: We'll see.
- 14:38Joseph M Schwab: so you mentioned Kristoff Corten, and you mentioned your training in Germany.
- 14:44Joseph M Schwab: tell me a little bit about your, who your mentors have been and what influences, they've, they've had to help, shape your approach to direct anterior approach.
- 14:59Alfonso Alías: So when I was, when I was a resident, I was doing a Watson-Jones in supine position.
- 15:05Alfonso Alías: Okay.
- 15:06Alfonso Alías: is what, that was my approach when I was finished, with the residency.
- 15:10Alfonso Alías: And I have started my practice, but, I've been, I was, it was the classic one.
- 15:17Alfonso Alías: You know, with a, you know, with this Bend shape incision,
- 15:20Joseph M Schwab: Yeah.
- 15:22Alfonso Alías: but it was, I was not so happy because usually even from the beginning, you have to remove or to detach the first fibers of the gluteus medius.
- 15:35Alfonso Alías: In order to get the stem down, and, sometimes you get it, you can do it without touching the gluteus, but that was something that in my hands and in the hands from the people from when, from, from whom I am learned.
- 15:51Alfonso Alías: Always the first fibers.
- 15:53Alfonso Alías: I will say not, not one third of the gluteus, but maybe, 20% of the gluteus in the front side is, get detached from, from the insertion of the stem, that was in our hands.
- 16:07Alfonso Alías: Now, after that you can do the, your sutures, you can do whatever.
- 16:11Alfonso Alías: And that's why I didn't like it so much
- 16:14Joseph M Schwab: if you could go back five years, in, into the beginning of your practice, what would be something you wish you would've known, or wish you would've had available to you when starting your, anterior approach journey?
- 16:31Alfonso Alías: Yeah, like to really understand the releases.
- 16:36Alfonso Alías: For me, at the beginning it was like, I haven't, that's really clear at the beginning.
- 16:43Alfonso Alías: Maybe I haven't visit so much.
- 16:45Alfonso Alías: maybe, yeah.
- 16:48Alfonso Alías: wasn't in, I was just in a ca in one cadaver lab I haven't seen that.
- 16:53Alfonso Alías: Well, really, and I, in the beginning, I was always struggling with, with the lift of the femur, like everybody at the beginning.
- 17:03Alfonso Alías: And, and now it's something that I've really understand, and I say hope be possible before, but yeah, this is a learning program beginning, always, I don't know if how was for you, but
- 17:19Joseph M Schwab: It.
- 17:19Joseph M Schwab: It was just time and experience for you that taught you those releases.
- 17:23Alfonso Alías: Yeah.
- 17:24Alfonso Alías: Yeah.
- 17:24Alfonso Alías: And also I have to say, I have to thank really from the help to Kristoff, to Kristoff Corten.
- 17:31Alfonso Alías: in the, in this month I was spending with him.
- 17:35Alfonso Alías: I've seen everything so clear and everything was so easy.
- 17:39Alfonso Alías: And, yeah, it was like a real change in my practice.
- 17:45Joseph M Schwab: Tell me a little bit about those adjustments you've made based on going to see, for instance, Kristoff.
- 17:52Joseph M Schwab: is it adjustments in your instrumentation, in your positioning, in your team coordination?
- 17:58Joseph M Schwab: are the changes you're making?
- 18:01Alfonso Alías: So in the position of the instruments.
- 18:04Alfonso Alías: So I really like it that I was kind of a, a little bit more random position of the instrument from, depending on, on every patient.
- 18:18Alfonso Alías: And at the beginning, but, after ep, I've been with, professor Corten.
- 18:24Alfonso Alías: So everything was the same.
- 18:26Alfonso Alías: Every step was really the same.
- 18:29Alfonso Alías: And, and you don't have to to change the way you do the things, depending on how big is the patient, how muscular is the patient, or you can, you can do, I, I've learned that you can do always the same.
- 18:46Alfonso Alías: And no matter if it's a lady with 60, years old or a young guy, muscular big and, and difficult to do.
- 18:57Joseph M Schwab: And so it, it feels more like what you're describing is a joint replacement, hip replacement, specifically in this case becoming, a, bit more assembly line.
- 19:09Joseph M Schwab: E everything done the same way each time.
- 19:12Alfonso Alías: I think that every patient is different.
- 19:16Alfonso Alías: You can do it the same way, but in my opinion, maybe.
- 19:23Alfonso Alías: Sometimes it's not the same 87 years old Dorr C femur, are gonna put a cemented stem in, or young lady with, I don't know, 35 years old, I'm gonna put a short stem in, not a, not a regular one, for we change things, but I mean, I meant yes, in the way you do the approach.
- 19:48Joseph M Schwab: Yeah.
- 19:48Joseph M Schwab: So if you were able to give some advice, to surgeons who are considering switching to anterior approach or are maybe hesitant because of the learning curve, what, would you share either about your experience or what advice would you give, to those surgeons who are thinking about the change in their practice?
- 20:10Alfonso Alías: So first step, cadaver lab.
- 20:13Alfonso Alías: That is very, very, very important.
- 20:16Alfonso Alías: Just to see, to have to, because it's not the same if I'm doing, I'm seeing you to do the approach in a video, and I say, well, it looks very, very easy.
- 20:27Joseph M Schwab: Yeah.
- 20:28Alfonso Alías: you don't have the idea hold, you have to put the retractors, the, this, this, they, you have a lot of tiny details that can make your life really easier.
- 20:40Alfonso Alías: And, the second.
- 20:43Alfonso Alías: to visit somebody who is doing the anterior approach and can, and you can see really in real patient are they performing an anterior approach.
- 20:52Alfonso Alías: And the third step is, to start with your fair case, with your, with your first cases, with somebody you who can help you in just in case you struggle with, with, with approach.
- 21:08Joseph M Schwab: Alfonso, I've really enjoyed talking to you today.
- 21:10Joseph M Schwab: I really appreciate having you on the AHF podcast
- 21:14Alfonso Alías: Thank you so much for having me.
- 21:15Alfonso Alías: Like I said, it was really a pleasure and I hope to see you again maybe in London.
- 21:20Joseph M Schwab: Thank you for listening to this episode of the AHF podcast.
- 21:24Joseph M Schwab: Remember to like and subscribe so we can reach a wider audience.
- 21:28Joseph M Schwab: If you have an idea for a topic, leave it in the comments.
- 21:31Joseph M Schwab: Remember, you can find us in audio podcast form in your favorite podcast app.
- 21:36Joseph M Schwab: As well as in video form on YouTube slash at Anterior Hip Foundation, all one word.
- 21:44Joseph M Schwab: New episodes of the AHF Podcast come out on Fridays.
- 21:48Joseph M Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.