AHF Podcast
AHF Podcast
Revision Roundtable Part I
AHF Podcast: Insights from Expert Surgeons on Anterior Hip Revision Techniques
In this episode of the AHF podcast, hosts Dr. Joe Schwab and Dr. Charles Lawrie dive into the intriguing world of anterior approach hip revision surgeries with notable guests: Dr. Kris Alden, Dr. Aldo Riesgo, Dr. John Horberg, and Dr. Jonathan Yerasimides. The panel discusses their backgrounds, experiences, and tips for tackling hip revisions using the anterior approach. Highlights include the benefits of using the HANA table, strategies for consistent exposure and stability, and advice for surgeons looking to venture into anterior hip revisions. The episode is packed with expert insights on advancing surgical practice and achieving optimal patient outcomes.
00:00 Introduction and Guest Introductions
01:03 Guest Backgrounds and Experiences
05:55 Discussion on Traction Tables
11:56 Tips for Surgeons New to Anterior Revisions
20:49 Equipment and Setup for Anterior Revisions
22:50 Conclusion and Next Episode Teaser
Meet our guest surgeons:
Dr. Kris Alden - https://www.krisalden.com/
Dr. John Horberg - https://www.premierboneandjoint.com/meet-dr-horberg
Dr. Aldo Riesgo - https://my.clevelandclinic.org/staff/22587-aldo-riesgo
Dr. Jonathan Yerasimides - https://www.louisvillehip.com/
Dr. Charles Lawrie - https://baptisthealth.net/doctors/charles-m-lawrie/1888379
Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/
Check out Dr. Yerasimides Anterior Approach Masterclass (including episodes on Acetabular and Femoral Revision) on YouTube! Find the playlist at https://www.youtube.com/playlist?list=PLDzGqZUR760dlZ8i9H78ZQuKRfBW5pXe7
Welcome to another episode of the AHF podcast. Today, we get to talk about a topic that makes some surgeons cringe while others can't get enough of it, revisions. From simple and straightforward to complex and daunting, today's guests are excited to tackle them all. My guests today are Dr. Kris Alden of the Steadman Philippon Clinic in Aspen, Colorado, Dr. Aldo Riesgo of the Cleveland Clinic, Florida, Dr. John Horberg of Premier Bone and Joint Center in Wyoming and Jonathan Yerasimides of the Louisville Hip and Knee Institute in Louisville, Kentucky. Jonathan is also the immediate past president of the Anterior Hip Foundation and a pretty amazing surgeon. But don't let his website fool you, his hair is definitely gray now. And because this is such a big group, I've asked Dr. Charles Lawrie vice president of the Anterior Hip Foundation to join me today as co host. Gentlemen, Welcome to the revision round table. Let's start by having each of you briefly tell our listeners a little bit about yourself, a little bit about your training and your practice. And Aldo, why don't we start with you?
Aldo M. Riesgo:Yeah, so I grew up in Miami, Florida. studied here for undergrad. went up to New York for, medical school and my orthopedic surgery training. and then spent a year in Charlotte, during fellowship. And that's really where, I really kinda, I guess my anterior hip experience and exposure really took off. and then I did back home in South Florida. Yeah. Ever since my practice is mostly revisions, somewhere between 50 and 70%, depending on the seasons and how things go. And as far as hip exposures and, approach, I'm almost exclusively, direct anterior for all my revisions now and obviously on my, primaries.
Joseph M. Schwab:Dr. Kris Alden. How about you?
Kris Alden:Sure. I, I grew up in Illinois. I went to, undergrad, and, medical school in Chicago. I did, an MD PhD program there. And then I went to, Johns Hopkins hospital in Baltimore for my residency. And then I did a fellowship in adult reconstruction at the Mayo clinic. it's interesting. I didn't have any exposure to anterior hip and residency or fellowship. I finished my fellowship in 2008. And then In 2011, I got, I was chatting with one of my, friends from residency and he had dabbled and went to a course. And so I actually reached out to Joel Matta and went out and saw him and, jumped on the anterior hip bandwagon. And, 2011 was, the last time I did a posterior hip revision. I've been a hundred percent anterior since, since that time. So it's been fun.
Joseph M. Schwab:John Horberg, tell us a little bit about yourself.
John Horberg:Yeah, I grew up in Illinois, as well. I grew up in downstate Illinois and farm country and I did my undergraduate and my medical school, in downstate Illinois. And that's where I was first exposed to the anterior approach. I had a couple of mentors that were just completing their learning curve. And then I, became fairly passionate about it and chose a fellowship that was almost entirely anterior, at, Virginia tech and Roanoke, Virginia. And I started practice and, I'm a part of that younger generation, maybe that decided that I was going to go a hundred percent anterior from day one. And, I'm about five years into practice now and have never done an approach other than the anterior for primaries or revisions. I've found it to be, quite rewarding and I actually feel as though I'm probably a little bit more comfortable with the anterior approach than any other, exposure at this point.
Joseph M. Schwab:Dr. Why, or as we like to say, Dr. Why not, how about we have you, tell us a little bit about yourself.
Jonathan Yerasimides:Yeah. Jonathan, Yerasimides. I grew up, just outside Kansas city, Missouri. a small town, went to my undergrad in medical school, in Kansas city at the university of Missouri, Kansas city, residency at university of Louisville. then I went out to LA for spent one year with, with Joel Matta because I thought, I was going to be a a traumatologist. This is 2005 and, Joel was, at the top of his field and pelvis and acetabular, fracture, reconstruction. and I went out there not knowing anything about anterior approach, never even heard of it. And, I saw him doing these anterior approach hips and thought, yeah, that's pretty cool. Went back to Louisville, became, full time faculty, trauma faculty. I was doing pelvis and acetabular fractures, but I started doing these anterior approach hips, 2006, in Louisville and nobody. There wasn't anybody within probably three or 400 miles of Louisville doing them at that time. And the prac, that part of my practice started growing so quickly. that, after about four or five years, I gave up the entire trauma side and, and became a, Hip arthroplasty surgeon essentially. I think I did my first revision in 2007. and now I do all my revisions, minus things that need, augmentation of the retroracetabular surface, I'll do through an anterior approach.
Joseph M. Schwab:So just to give our listeners a little bit of background, how many of you are using a traction table, with your setup and how many of you are using a, a standard orthopedic table?
Jonathan Yerasimides:I'm on the HANA table. I think I'd be, I think I'd be disowned from my orthopedic daddy if I didn't use it. I'm on the HANA table.
Kris Alden:Yeah, I am as well. I've been 100 percent table since the inception. I just find it easier. No disrespect to the off table guys, by any means.
Aldo M. Riesgo:Same table HANA table.
John Horberg:Yep, I use the HANA table as well, especially practicing in a rural environment out in Wyoming. Sometimes it's nice to have a free assistant, when you don't necessarily have the staff you want to have available.
Joseph M. Schwab:So four of you on traction tables on the HANA table, have any of you ever done, revisions off the table or is it, has it been exclusively HANA table?
Jonathan Yerasimides:I've never done a revision off the table. I've done primaries off table. but I've never done a revision, off table.
John Horberg:I did dabble a little bit early in my practice and off table, and I've done a couple of headliner exchanges, but, nothing more complicated than that off the table.
Aldo M. Riesgo:some of my partners do off table for their primaries and their revisions and I'll scrub in with them on the tougher ones. And every time I'm not liking that experience. I'm always happy that I think they made the right choice with the HANA table.
Charles Lawrie:What is it about using the HANA table that makes revision anterior approach surgery easier for you guys?
Kris Alden:I would say it's basically like having an extra assistant. you can manipulate the extremity and rotate it, apply axial traction or distraction and not have somebody, get tired holding the leg. So it just basically allows you to mobilize things much easier.
John Horberg:There's more precision and control as well. You can pull traction and that traction is consistent. you can apply rotation, that rotation is consistent. You don't have to worry about, exactly like Kris said, the assistant getting tired or fidgeting or moving. The, leg stays where you put it.
Jonathan Yerasimides:For me, not ever having done it off the table, the femoral elevation that I get, using the hook, again, I'm speaking from a, from a ignorant, point of the point of view inside of the argument, but, I don't know if I can get that elevation with, with just a retractor behind the trochanter. for me, it's knowing I'm going to get the femur up. So I've got a straight shot down the femur. I'm not gonna, destroy the femur. doing a long revision stem
Aldo M. Riesgo:yeah, I think the femur is easier, but also what, Y mentioned about getting like retroacetabular I've done now, if you posterior column augments, and I think the HANA table by having the, the, basically the butt be unsupported, It's just floating there. It allows that soft tissue to fall back a little bit when I come down the outer table, the pelvis, and I can get a little easier exposure there. So that's, I think it's a no brainer. if you do really complex. revision work from the front.
John Horberg:think adding to that as well, leg length discrepancies are more easier to deal with. if you have scarring or proximal migration of the femur on the operative when you're going off table, you don't have the ability to apply counter traction. So having a post in the center, having the other leg tethered, and then you pull traction on the operative leg, it's easier to pull the femur down distal in those cases where the leg wants to be, riding more
Joseph M. Schwab:Do you ever get worried about traction injuries in those circumstances, John?
John Horberg:I, I haven't, it usually the portion of the operation where I'm actually applying traction is fairly limited. it's nice to be able to have counter traction on the contralateral leg and get need it. But the majority of the case, especially the acetabular exposure, the leg is off traction and then it's only, during reduction and specific portions of the
Joseph M. Schwab:Do you, find that you approach draping differently in your revision scenarios or have you done enough revisions on the HANA table that you're pretty much draping both revisions and primaries the same way?
John Horberg:I personally do it the same way. leg and I err on the side of clear overall, I haven't made any major changes on my, my draping aside from edging proximal or distal if I know I'm going to expose
Jonathan Yerasimides:Yeah, I think just like any revision for me, it's just, I get a little, maybe wider, wider, field of view on a primary. I'm probably prepping the two thirds down the thigh. On a revision, I'll typically prep all the way down to the knee and on a primary, my proximal part of my draping is roughly the belly button, the umbilicus. I tell the nurses, straight from the belly button down to two thirds on the knee on a revision. Especially if I need access to the inner table, the pelvis, or I'm planning on extending this to like a Smith, Pete, I'm prepping above the, umbilicus.
Aldo M. Riesgo:Same.
Kris Alden:yeah, and I think it's harder for OR staff to really contemplate different, draping protocols. So I just drape everybody the same, which is similar to what Jonathan was saying.
Charles Lawrie:So you guys are all very experienced anterior hip surgeons. and it sounds like all of you basically figured this out on your own. y'all are really the pioneers behind a lot of this anterior revision work that we're seeing pop up in courses. Now, do you have any tips for surgeons who are experienced primary anterior approach surgeons, but haven't taken the plunge into the revision world yet. Tips for getting started, any particular cases you would try to tackle first.
Kris Alden:Sure, I would probably start with the easier, headliner exchanges. And that's a easy, simple. low stress kind of environment. also go slow, debulk the capsule because there can be a lot of scarring. Even if it was a prior posterior approach, there can still be a very robust capsule and that can very much limit your exposure, but debulking the capsule and getting the appropriate exposure starting with a simple, relatively easy, headliner exchange, I think can be a very rewarding experience. And then obviously work up from there.
Jonathan Yerasimides:When I did my first revision in 2007, I'd never heard of anybody doing a revision from an anterior approach. And even when I was with Joel, we did some. complex extended like hardware removal, total hips, but I'd never seen, total hip implants removed or put back in through an anterior approach, but I just got to the point from the primary where I said, I'm comfortable enough to, do a revision. So if a surgeon that's let's do in primaries. It's shit, I'm still unsure that I'm ready to do a revision. You probably ain't ready. wait till you feel like, hell, I got this. because, you'll tell yourself if you're confident enough to, jump into the revision pool.
Aldo M. Riesgo:For me, I never really, I didn't see any DA revision. I think I saw one in Fellowship, and it was a triflange, and, so the reconstructive part wasn't that hard, it was just the exposure stuff. I think, if you see that once, right? You have all the tools as a hip surgeon to just put it all together. And it, it's just more mentally daunting than it is. I think challenging from a, from an execution standpoint. I saw a lot of PAOs as a chief in, in my residency. So to me, it always felt very natural, Hey, if, I need to get revision exposure for, from a direct anterior approach, just start doing a PAO, start getting access to the pelvis, get, sorry, you're doing osteotomy, flip that ASIS over things like that. So to me, it really helped to see it like once or twice. And then from the primary side, I think getting, being committed. To always doing everything DA. I think that really helps you get your exposures. And I think if you can do really tough primaries, get those tough exposures, and then you've seen some of these maneuvers before you can all put it together. So yeah, I agree. Start with cups, headliners, work your way up to there. And then probably last is femoral work. Like femoral work is probably what I've, was the last part of my kind of that last threshold in my practice, like kind of crossover. so now I'll take out whatever stem from the front.
John Horberg:Yeah, I couldn't agree more with what everybody said. I think, maybe the last two pearls for someone who's wanting to jump into anterior revision would be just like selecting the appropriate case, also selecting the appropriate patient. You don't have to be a hero and have a large muscular male with a wide pelvis as your first case. You can choose a. Okay. A slender, elderly person with a forgiving body habitus, large working space. make the case that was your first primary case the exact same patient that's revision case. Someone who's easy to work on and I think the other thing to think about when we're doing revisions is it is a different animal than, A primary anterior approach. We always focus on limiting releases to the pubofemoral and a certain extent around the capsule. You can get as much exposure as you need after excising that redundant Kris talked about. You can take your releases further on a revision case because it's a different operation. Just like with a posterior approach, it's a
Jonathan Yerasimides:Yeah, I agree with that, John. A hundred percent. I think that, Talking to guys, over the past decade plus about revisions. when I'm describing to them or in a cadaver lab showing them, my exposures, they're always taken aback a little bit by how much I'm releasing, especially around the femur. because in their brains, they're thinking that, this primary side, we're, trying to limit all these releases of the rotators and all that stuff. In a revision, it's no holds barred. You need to, release everything, revisions, completely different surgery, don't think about it as. we're doing this, limited release, minimally invasive thing. It is, like, Wayne Proprosky says, he does MIS surgery every day, maximally invasive surgery. And, and that's what you need to have in your brain in a revision.
Joseph M. Schwab:That actually raises an interesting question. So anterior approach has really, one of the things from a primary standpoint, it's forced us to think differently about how we do our reconstructions. we talk less about adding leg length and offset and more about anatomic reconstruction. how has that changed the way you view, how you do a revision, what's successful, what are the things you need to do, the things you don't need to do, how has it changed the way you approach revisions in general?
John Horberg:I think even though we've just discussed how important it is to take as much release and as much tissue need in order to get your exposure, the anterior approach is still, in some ways internally a minimally evasive approach from a revision in that you're not cutting any of the muscles. off of the femur, aside from perhaps releasing some of the rotators and the conjoined tendon, you still have dynamic stability around the hip. And for me, seen patients that mobilize faster. I have fewer about stability and my concerns about stability based on what's the bony anatomy and what's the, soft tissue injury prior to my operation, rather than what am I doing to the that might be causing them to become unstable. And I'll use alternate bearings and other techniques to improve my. stability, but I don't go chasing it through or
Jonathan Yerasimides:Yeah, I think I've learned that, that stability over the years, Stability does have a lot to do with releases, of the muscles around the proximal femur, but as I've done this more and more years, starting to look at things like, maybe, a lot of our enhanced stability has to do with just proper implant placement, because from a posterior approach, it's so hard to get consistent implant positioning from the hip center rotation to the anteversion abduction on the cup with an anterior approach, it's very, easy. And I really think that the, that one of the things that gives us. Stability that's, heads and shoulders above, opposed to your approach is the fact that the, implants are going to be in the correct position every single time. and with the addition of alternative bearings, like dual mobility, it's, ridiculous. I never put people on hip precautions after. A revision surgery, with my 32 and 36 heads and certainly now with dual mobility, I don't. and it's not because I don't do massive releases, but my implants are always in a good position and that's just more reliable in a supine, positioning and having fluoro available.
Aldo M. Riesgo:Yeah, to me, with the anterior approach, like when I was doing posterior hip revisions and just in my training, you get that post op x ray, you're not using, usually intraoperative imaging, anything short of a disaster, you'll accept, while the anterior approach, you accept nothing short of perfection in terms of your component placement. And you're actually like, you know exactly what's going to look like. You've recreated that offset, that length, you've put your hip center where you need it to be. So there's a, there's a lot more precision, at least in my hands. And I think it's a more ergonomic approach for, me as a surgeon, I'm standing up, I'm not hunched over. I'm not exhausted at the end of the case. Like I would on a hard, posterior approach. And I think hard hips are hard hips regardless of what approach you do. So I like having that kind of precision with the supine direct anterior approach.
Charles Lawrie:Thinking about people getting started with anterior revisions, is there anything extra or special equipment wise that you guys need for the exposure, retractors, et cetera?
Kris Alden:I actually use all the same retractors on a primary that I do on a revision. I wouldn't say there's anything, necessarily extra that I would use on a revision.
Jonathan Yerasimides:Yeah, I agree with Kris. I have the exact same retractor set, whether I'm doing a revision or a primary, it might change if I'm doing like an osteotomy, the femur, I might get some extra retractors, but, for 90 percent of my revisions, it's the exact same tray, and I think that also, it helps a ton with, with your staff in the hospital, with nurses, with scrub techs, my trays, my draping are all the same. patient to patient. and there's no like guesswork, on the staff side, trying to set something up on, M is this going to be different than the last, thing we just, the last case we just prepped. So it's consistency. I think consistency, equates to efficiency, as well. I think being consistent and learning to use the same things. For all the cases, we'll help you as a surgeon and it'll help your efficiency in the operating room.
Aldo M. Riesgo:Yeah, I agree with that. I think that's part of the mental, eliminating that mental roadblock to doing revisions is, hey, this is the same trays, same retractors, it's the same surgery, I'm just doing maybe a touch more here, a touch more there.
John Horberg:Yeah, the only equipment issue differences I see at all are just the same differences in equipment you would need for revision regardless of approach having the availability of burrs and extraction equipment and things like that, but there's no, no change at all in my setup, my exposure, my draping,
Joseph M. Schwab:Thank you for joining us for part one of the AHF revision round table. Join us again next week to hear more tips, tricks, and pearls from our panel of expert revision surgeons, and also keep your eye on our channel for some bonus revision surgery, content coming soon. Do you have any anterior approach, revision, tips, or tricks that you want to share? Leave a comment below, we would love to hear from you. And if you enjoy the content we're bringing you, remember to like and subscribe so that we can deliver even more, and reach a wider audience. If you have an idea for a topic, you can also drop that in the comments. Remember, you can find us in audio podcast form in your favorite podcast app, as well as in video form on YouTube slash@anteriorhipfoundation, all one word. Remember to visit us on the web at anteriorhipfoundation.com where registration for the AHF 2025 meeting is already open. Reserve your seat today. And we'll see you next week for part two of the AHF revision round table. Until then keep those hips happy and healthy.
