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

• 0:24
  Joseph M Schwab: Hello and welcome back to the AHF Podcast.
• 0:28
  Joseph M Schwab: I'm your host, Joe Schwab.
• 0:30
  Joseph M Schwab: Most residents coming out of training today will have had some exposure to anterior approach total hip arthroplasty.
• 0:36
  Joseph M Schwab: Adult reconstruction fellows in the United States will often consider surgical approach as a key distinguishing factor when choosing fellowships.
• 0:45
  Joseph M Schwab: All of this is to say our young orthopedic learners are coming into practice with greater and greater levels of experience in anterior total hips.
• 0:54
  Joseph M Schwab: But what do you do if you're already an established surgeon and you're looking to add anterior approach as part of your practice?
• 1:02
  Joseph M Schwab: Has the opportunity already passed you by?
• 1:05
  Joseph M Schwab: How much time do you need to take from your practice to get comfortable with the approach and how steep is the learning curve?
• 1:12
  Joseph M Schwab: Well, my guests today have done just that.
• 1:15
  Joseph M Schwab: They're here to answer those questions for you.
• 1:17
  Joseph M Schwab: Joining me today is Alex Sah of Sah Orthopedic Associates at the Institute for Joint Restoration in Fremont, California and Dr.
• 1:26
  Joseph M Schwab: Michael Blankstein at the University of Vermont Medical Center in Burlington, Vermont.
• 1:31
  Joseph M Schwab: Both Mike and Alex started their practices doing posterior approach and have gone through the process of adopting anterior approach.
• 1:40
  Joseph M Schwab: Let's listen in on the conversation.
• 1:43
  Joseph M Schwab: Mike, Alex, thanks for joining me.
• 1:46
  Alexander Sah: Thank you, Joe.
• 1:47
  Michael Blankstein: for having us.
• 1:49
  Joseph M Schwab: When you were considering this process of changing your practice, moving from posterior approach and adding anterior approach, Um, what factors were you considering?
• 1:59
  Joseph M Schwab: Was it economics?
• 2:01
  Joseph M Schwab: Was it intellectual factors or simply outcomes or, or maybe something completely different, Alex, let's start with you.
• 2:08
  Alexander Sah: Those are all great considerations, Joe, and making that transition from a poster approach or different approach to anterior hip surgery.
• 2:16
  Alexander Sah: When I was in practice about 8 years ago, I was doing exclusively mini posterior approach.
• 2:21
  Alexander Sah: People are doing very well.
• 2:23
  Alexander Sah: People are going home same day already.
• 2:24
  Alexander Sah: And we're doing them at the also.
• 2:27
  Alexander Sah: So, for us, it seemed like we couldn't be doing any better.
• 2:30
  Alexander Sah: We're very happy with it.
• 2:31
  Alexander Sah: And I was looking at some of the other results being published, as we know, early literature on anterior hip replacement is very different than current literature on anterior hip replacement.
• 2:41
  Alexander Sah: So, a combination of factors we can talk about later, but probably because there were surges not, who should not have been doing anterior approach who were doing it.
• 2:48
  Alexander Sah: I think people were not learning appropriately and complications were much higher.
• 2:52
  Alexander Sah: Things being reported in the literature, I think, were not really showing.
• 2:55
  Alexander Sah: How well trained and You have surgeons were performing.
• 2:58
  Alexander Sah: So that kind of literature, that kind of negative backlash of the early growth of entry approach made me hesitant to adopt it.
• 3:06
  Alexander Sah: And again, things were going very well for me with my standard mini posterior approach.
• 3:10
  Alexander Sah: So at least for me, it wasn't about economics or more business or promotion or trying to be different or setting myself apart from others, which are perfectly reasonable ways and reasons for other people to adopt something new.
• 3:22
  Alexander Sah: But for me, it was simply a question that arose, which is, could I be better?
• 3:28
  Alexander Sah: I was very happy with what I was doing already, but the question was simply, was there a way where I could be even better?
• 3:33
  Alexander Sah: And if it wasn't for Joel Matta and Charlie DeCook, who approached me and were willing to teach me and asked me to be involved, I don't know if I would have converted.
• 3:42
  Alexander Sah: So, as You know, I was involved with the Anterior Hip Foundation early on and Charlie and Joel asked me to give a talk on Why I would even consider and your approach, having never done any and being the only post your hip surgeon in the room at the entry of foundation.
• 3:57
  Alexander Sah: Talk about being a black sheep.
• 3:59
  Alexander Sah: So I felt very out of place, but that meeting, as we all have grown to love is just such a amazing environment to learn from others and and ask questions that I quickly.
• 4:11
  Alexander Sah: started to do them myself.
• 4:12
  Alexander Sah: And, um, it was really because of that question.
• 4:15
  Alexander Sah: Could I be better?
• 4:16
  Alexander Sah: And Charlie was kind enough to come out and do with the first three cases with me.
• 4:22
  Alexander Sah: And after those three cases, I never looked back.
• 4:25
  Joseph M Schwab: Transcripts
• 4:28
  Michael Blankstein: heh, heh.
• 4:32
  Michael Blankstein: slight differences.
• 4:33
  Michael Blankstein: This is actually one of my favorite questions that people ask me, um, because I've truly changed my practice.
• 4:39
  Michael Blankstein: So when I graduated in Canada, I finished my fellowship.
• 4:43
  Michael Blankstein: I was very happy with my training, moved to Vermont in 2012.
• 4:47
  Michael Blankstein: And one of my partners, Nathan Elms, who I hope listens to this, started doing the anterior approach at the time.
• 4:53
  Michael Blankstein: We're essentially the same cohort.
• 4:55
  Michael Blankstein: And when I graduated in Canada, I think there was nearly one anterior approach surgeon in the entire country.
• 5:03
  Michael Blankstein: So it wasn't even something I thought about and I was so happy with the way things were going and I actually scrubbed it with my partner in my first year in practice and I literally remember thinking, is crazy.
• 5:14
  Michael Blankstein: There's no way I'm ever going to do this.
• 5:15
  Michael Blankstein: I was disoriented.
• 5:17
  Michael Blankstein: I didn't know what's right, left, you know, posterior, anterior.
• 5:21
  Michael Blankstein: The releases looked so challenging.
• 5:23
  Michael Blankstein: And, um, and as a matter of fact, I, you know, as you know, I love academia and research and science and I could quote it.
• 5:29
  Michael Blankstein: All the papers in the world that talked bad, said bad things about the interior approach, wound problems, the blood loss, the peripatetic fractures, the, uh, the stem loosening, like you name it, you know, the numbness and the curve.
• 5:47
  Michael Blankstein: And it was just like, there's no way I was going to do it.
• 5:50
  Michael Blankstein: Um, things started, actually started changing when I met you.
• 5:53
  Michael Blankstein: Dr.
• 5:54
  Michael Blankstein: Schwab, when we did the Hip Society Traveling Fellowship to the UK and you, we went to many meetings where you literally were the only one who did the anterior approach.
• 6:04
  Michael Blankstein: So I felt very comfortable.
• 6:06
  Michael Blankstein: I was like, okay, what the guys in Canada don't do it.
• 6:08
  Michael Blankstein: The guys in the UK don't do this.
• 6:10
  Michael Blankstein: So I'm good.
• 6:11
  Michael Blankstein: Um, and I kept with my, hard minded approach of, hey, I'm sticking to the posterior approach.
• 6:20
  Michael Blankstein: And then somebody once said to me something interesting, which was, how about you listen to your patients?
• 6:25
  Michael Blankstein: What do they want?
• 6:26
  Michael Blankstein: Why are they asking you for the anterior approach?
• 6:30
  Michael Blankstein: And I'll tell you this one humbling experience that I had that really changed my practice.
• 6:35
  Michael Blankstein: Um, it was one day we were sitting in a meeting and they were just talking about the wait times and access to care in Vermont.
• 6:41
  Michael Blankstein: And they said, well, the waitlist to see Dr.
• 6:43
  Michael Blankstein: Blankson, this is 10, this is five years in, I'm already doing a good job.
• 6:46
  Michael Blankstein: I really don't have dislocations, you know, things are fine.
• 6:51
  Michael Blankstein: to see Dr.
• 6:51
  Michael Blankstein: Blankson is that, oh, you can see him next week.
• 6:53
  Michael Blankstein: The waitlist to see Dr.
• 6:55
  Michael Blankstein: Nelms is like five months.
• 7:00
  Michael Blankstein: I'd rather learn a new approach and do what people want than speak badly about it for the rest of my career.
• 7:06
  Michael Blankstein: Like, I'm a hip surgeon.
• 7:07
  Michael Blankstein: I love doing hip surgery.
• 7:09
  Michael Blankstein: Why not just learn a new approach?
• 7:11
  Michael Blankstein: And this is really what I want to do here and really is compliment the AHF.
• 7:16
  Michael Blankstein: And all the teachers that Alexi just mentioned, DeCook, Schwab, of course, the modern day Charlie, the modern day Charlie, Joe Matta.
• 7:27
  Michael Blankstein: I said, you know, I'm going to go to their courses and the way the courses were taught, which is so responsible, right?
• 7:34
  Michael Blankstein: So as hip surgeons, we've all seen bad things Okay.
• 7:38
  Michael Blankstein: Okay.
• 7:55
  Michael Blankstein: like you guys, I decided I'm gonna bark upon it, and just like, just like Joe, just like Alex said, like, haven't moved back.
• 8:04
  Michael Blankstein: I haven't gone back.
• 8:04
  Michael Blankstein: It's been really rewarding.
• 8:07
  Joseph M Schwab: So you had your partner was able to scrub in with you on your first few cases kind of help you through that process.
• 8:12
  Joseph M Schwab: Alex, what was that like for you?
• 8:15
  Alexander Sah: That was a challenge, Joe, because I was the only surgeon in my institution to be doing anti approach.
• 8:21
  Alexander Sah: So we were starting completely from scratch.
• 8:23
  Alexander Sah: So that means our nurses, our techs, our reps, right?
• 8:27
  Alexander Sah: We didn't, we just got our first Honda table.
• 8:30
  Alexander Sah: All of this was brand new, so that definitely was a challenge because suddenly now, as Michael said, has a surgeon, things are upside down and backwards.
• 8:38
  Alexander Sah: You're looking at the hip from a completely different perspective.
• 8:41
  Alexander Sah: You're trying to learn it yourself, but at the same time in the corner of your eye, you're trying to keep an eye on the person managing the table.
• 8:47
  Alexander Sah: Implant rep, the person running the C arm.
• 8:50
  Alexander Sah: There's a lot more coordination that that's something that is truly different with that approach because it's it's really a coordination of all the team members.
• 8:56
  Alexander Sah: So being the first person in my hospital to do it was a challenge.
• 9:00
  Alexander Sah: But when you asked about learning curve, I would say the learning curve, it depends on how you define it.
• 9:06
  Alexander Sah: Learning curve, you learn a little bit with it.
• 9:09
  Alexander Sah: for many, many cases.
• 9:10
  Alexander Sah: I think we all say we always learn when we do another anterior approach because we're always trying to find ways to be better.
• 9:16
  Alexander Sah: So that learning goes on for quite a long time.
• 9:18
  Alexander Sah: But when you're talking about a learning curve in terms of avoiding complications or problems with modern day training and and Joe has been involved with it a lot and is a great teacher of it.
• 9:29
  Alexander Sah: You can really avoid those complications early.
• 9:31
  Alexander Sah: So I think the learning curve actually can be very short with modern training.
• 9:36
  Joseph M Schwab: Um, that actually raises a question.
• 9:38
  Joseph M Schwab: So the, um, I, I, you I, I think the way that both, um, Alex and, and Mike that you've described your approach to the educational processes, uh, as a very positive one, um, what were the biggest challenges or the biggest, um, the, the biggest difficulties that you encountered during that educational phase or during that growth phase?
• 10:04
  Joseph M Schwab: of anterior approach in your practice.
• 10:08
  Michael Blankstein: I think the thing that was very important for me was not to have these early complications, right?
• 10:14
  Michael Blankstein: I did, because then everyone knows, okay, so this is a posterior part surgeon, and now he's going to do the anterior part, and if he doesn't go well everyone's going to know about it.
• 10:23
  Michael Blankstein: And I actually heard some stories about surgeons trying and things not going bad and reverting back to the posterior approach.
• 10:31
  Michael Blankstein: So I think this is, again, one of the things that I learned from you guys, which is let's choose your first patients appropriately.
• 10:38
  Michael Blankstein: Just in itself, just know when to do it, how to do it, have the support personnel.
• 10:44
  Michael Blankstein: also don't change, another thing that I learned was very interesting, is don't change the implants.
• 10:49
  Michael Blankstein: You have to, so for example, if you wanted to use an anterior friendly stem, then you have to get comfortable with that stem while doing surgery.
• 10:56
  Michael Blankstein: The posterior approach.
• 10:58
  Michael Blankstein: Um, and then it's learning, learning from every single step, everything.
• 11:04
  Michael Blankstein: I'll give you another example was one of the biggest challenges I had in the beginning was cutting the neck through the front.
• 11:10
  Michael Blankstein: And once it was too high, once it was too low, and I brought an extra, I'm like, okay, that's standardized.
• 11:15
  Michael Blankstein: Boom.
• 11:16
  Michael Blankstein: And it's like that every just think is that a whole bunch of little steps, you know,
• 11:20
  Alexander Sah: Early in the learning curve for me, Joe, you know, it really wasn't a challenge to learn the technique or go to a cadaver course, or there was so much opportunity on the web.
• 11:31
  Alexander Sah: There are videos.
• 11:32
  Alexander Sah: I mean, modern day training again is very, very different than early training.
• 11:35
  Alexander Sah: I mean, when I think those.
• 11:37
  Alexander Sah: learning curves were being published and they would be more challenging.
• 11:39
  Alexander Sah: Modern day training has V.
• 11:42
  Alexander Sah: R.
• 11:43
  Alexander Sah: It has web, it has, you know, all kinds of materials on the internet where you can watch videos.
• 11:48
  Alexander Sah: So really the only challenge when first adopting was really going somewhere to go to a course.
• 11:53
  Alexander Sah: It was really more of an inconvenience than a hurdle because you had to take time out of your practice.
• 11:57
  Alexander Sah: You had to go to a course and learn it.
• 11:59
  Alexander Sah: But It is well worth it because the ability to work in a cadaver lab, go to one of these educational courses that are now everywhere from various implant vendors is extremely helpful.
• 12:11
  Alexander Sah: And I think one of the best things for me at least was having that reverse visitation, having someone with you when you do your first, I think probably sped the learning curve up by 10 20 cases.
• 12:22
  Alexander Sah: Honestly,
• 12:24
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• 12:30
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• 13:45
  Joseph M Schwab: So looking back, um, on your educational journey, uh, to, to sort of adopting anterior approach, what would you have done differently?
• 13:56
  Alexander Sah: that's a good question.
• 13:57
  Alexander Sah: You know, if if anything I would have done differently, Joe is I probably would have done it sooner in my career.
• 14:02
  Alexander Sah: I probably waited longer than I needed to.
• 14:04
  Alexander Sah: And really, the reason that prompted me at least was learning from people I trusted.
• 14:09
  Alexander Sah: And I think that's like anything else that we do as surgeons.
• 14:12
  Alexander Sah: We don't adapt or adopt to new technologies until we learn from someone we know who does it.
• 14:18
  Alexander Sah: And that's what really makes the Andrew Hitt Foundation unique.
• 14:21
  Alexander Sah: The faculty and the people who are members, because they're all willing to teach.
• 14:24
  Alexander Sah: It is amazing.
• 14:25
  Alexander Sah: You can ask anyone a question anytime.
• 14:27
  Alexander Sah: They're willing to help.
• 14:28
  Alexander Sah: They know everyone has questions and been through that journey.
• 14:30
  Alexander Sah: I think the support system is really what sets it apart.
• 14:35
  Joseph M Schwab: How about Michael?
• 14:36
  Joseph M Schwab: What would you have done differently?
• 14:39
  Michael Blankstein: I must say, I, I really have no regrets, I'm happy, um, by the time I had done it, I was, you know, I've really mastered the posterior approach, which is nice.
• 14:47
  Michael Blankstein: We actually now have the opposite problem, that so many people are so only with the anterior approach that they lost their posterior approach skills.
• 14:56
  Michael Blankstein: So I've kind of like mastered that, um, and then, uh, you know what I tell my residents, I go, aren't we so lucky that we get to do the surgery after people like Joe Maddow I've already figured everything out for us.
• 15:09
  Michael Blankstein: Like, like, like had I tried it earlier, I probably would have maybe given up on it.
• 15:14
  Michael Blankstein: But by the time that I tried, we had again, everything, all the broaches figured out, all the x rays figured out the stems, the just like also well laid out.
• 15:28
  Michael Blankstein: It was actually a really fun.
• 15:31
  Michael Blankstein: I think that I chose the right time to join, to join the party.
• 15:36
  Joseph M Schwab: For both of you, you mentioned different types of educational opportunities between industry courses and academy style courses, surgeon vision, visitation and online videos.
• 15:48
  Joseph M Schwab: What was your preferred way to learn then?
• 15:51
  Joseph M Schwab: And do you think that would be the same way that you would learn now?
• 15:55
  Joseph M Schwab: Or with your experience, is there a different sort of learning style that you would gravitate towards?
• 16:03
  Alexander Sah: It's a great question, Joe.
• 16:05
  Alexander Sah: I think, you know, when COVID came and we thought everything was going to move onto the Internet and be web based, some things have, but some things have not.
• 16:13
  Alexander Sah: So I was sort of surprised that not everything's gone that route.
• 16:15
  Alexander Sah: Really, What I've learned is you cannot get away from in person training.
• 16:19
  Alexander Sah: There's really nothing better than cadaver training being with your peers.
• 16:24
  Alexander Sah: I think learning from obviously experts in the field has huge value.
• 16:27
  Alexander Sah: I think learning from people you know is also incredibly helpful because then you have a relationship and you can ask them questions later.
• 16:34
  Alexander Sah: You can talk to them when you do your first cases.
• 16:36
  Alexander Sah: And I think The modern technologies such as cameras that can let you watch live surgery or have video recordings that are so prevalent now really help because you're going to go to a cadaver course, you might not do your first case for three to four weeks later.
• 16:51
  Alexander Sah: So to have that refresher, to have something available to review, I think makes it a lot easier doing that first case.
• 16:59
  Michael Blankstein: Yeah, I agree.
• 17:00
  Michael Blankstein: I think again, obviously we have more great videos now and great everything now, but the mentorship model here is, I think it's still the key.
• 17:09
  Michael Blankstein: If you are to transition.
• 17:12
  Michael Blankstein: mid career.
• 17:14
  Michael Blankstein: You need to really have some support around you.
• 17:16
  Michael Blankstein: So just like a yeah, I've flown in to see multiple surges before I did my first one and I asked somebody to be in the or with me for that first one.
• 17:25
  Michael Blankstein: I know, Joe, you guys did your first like 50 together.
• 17:28
  Michael Blankstein: You, you and your partner, something like that.
• 17:30
  Joseph M Schwab: That's correct.
• 17:31
  Michael Blankstein: Yeah.
• 17:32
  Michael Blankstein: So I think that's a, that's a big one.
• 17:33
  Michael Blankstein: Cause what you don't want to do is find yourself in a situation where once I can, I, I can't expose that femur or I, I had a little crack in the calcar and I don't know how to put a cable on through the front.
• 17:46
  Michael Blankstein: So definitely be ready to handle that.
• 17:49
  Alexander Sah: just going to say, Joe, there's no reason to reinvent the wheel when you're starting, right?
• 17:53
  Alexander Sah: There are plenty of people willing to help.
• 17:55
  Alexander Sah: So take advantage of those who want to help you get through it.
• 17:58
  Joseph M Schwab: Have been any surprising moments for you in this journey or since you adopting anterior approach, uh, as sort of the primary approach in your practice?
• 18:11
  Alexander Sah: I think the surprise for me was that I literally never went back to posterior approach after doing those anterior hip replacements, the benefits of it were remarkable.
• 18:21
  Alexander Sah: So when you hear about them being as great as they are, you wonder if it's really just being over popularized or being exaggerated.
• 18:28
  Alexander Sah: But again, my mini posterior approaches were doing very, very well and I was very happy with it.
• 18:33
  Alexander Sah: But the benefits I found from anterior approach, having patients supine, having the ability to use CRM, having the ability to restore leg length offset and have quicker recovery, all these things that are said really you would see in patients in the recovery.
• 18:46
  Alexander Sah: So that's really what surprised me is that I really didn't have any hesitation to just move 100 percent forward with that approach.
• 18:55
  Michael Blankstein: yeah, same again, same benefits.
• 18:57
  Michael Blankstein: One of my earliest day experiences was actually a working with the therapist then I got, thank God you don't have these precautions anymore.
• 19:06
  Michael Blankstein: well, I didn't realize my precautions were such a big deal.
• 19:09
  Michael Blankstein: But to be able to tell patients, hey, whatever you want within reason.
• 19:14
  Michael Blankstein: Just avoid extreme legs of motion, a range of motion, and that's it.
• 19:19
  Michael Blankstein: That was cool.
• 19:19
  Michael Blankstein: Because in the beginning, you know, with the posterior approach, even though we have data showing you probably don't need precautions, most of us still Like some gentle precautions and to be able to just let go of that altogether is, I think is, it means a lot to the patients.
• 19:35
  Michael Blankstein: But again, I want to highlight one of the things that, um, that is really important here in my Okay.
• 19:41
  Michael Blankstein: So again, if you look at the, if you look at the science behind anterior versus posterior approach, the differences are very small still till today, right?
• 19:49
  Michael Blankstein: We're talking about if patients do well at three months, they're probably going to do well with both approaches.
• 19:55
  Michael Blankstein: Because if you have a surgeon Who's able to do a good job, meaning, again, restore the length, length so we're going to go ahead and get started, and we're going to go ahead and get started and feel as natural as I can the first day.
• 20:30
  Michael Blankstein: sure you that.
• 20:32
  Michael Blankstein: Why are we not who that?
• 20:35
  Michael Blankstein: interested Uh, Service.
• 20:37
  Michael Blankstein: Uh, Uh, Based, Of Marketing Of Portfolios.
• 20:42
  Michael Blankstein: Based.
• 20:43
  Michael Blankstein: Um, And of Course, Basearchy.
• 20:47
  Michael Blankstein: Uh, And.
• 20:48
  Michael Blankstein: making the recovery easier.
• 20:50
  Michael Blankstein: And also knowing Yeah.
• 21:19
  Joseph M Schwab: Join me next week for part two of my conversation with Dr.
• 21:22
  Joseph M Schwab: Alex Sah and Dr.
• 21:24
  Joseph M Schwab: Michael Blankstein.
• 21:26
  Joseph M Schwab: Thank you for listening to this episode of the AHF Podcast.
• 21:29
  Joseph M Schwab: Remember to like and subscribe so we can reach a wider audience.
• 21:34
  Joseph M Schwab: I.
• 21:34
  Joseph M Schwab: If you have an idea for a topic, leave it in the comments.
• 21:36
  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, all one word.
• 21:47
  Joseph M Schwab: New episodes of the AHF Podcast come out on Fridays.
• 21:51
  Joseph M Schwab: I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.