AHF Podcast
AHF Podcast
Revision Roundtable Part II
AHF Revision Roundtable Part Two: Advanced Techniques and Patient Outcomes
In this episode of the AHF revision roundtable, Joe Schwab and co-host Dr. Charles Lawrie rejoin the panel of expert orthopedic surgeons, including Dr. Jonathan Yerasimides, Dr. Aldo Riesgo, Dr. John Horberg, and Dr. Kris Alden, to discuss femoral revision techniques. The conversation covers the detailed procedures and strategies for effective femoral exposure and release, the benefits of the anterior approach, and the use of outpatient settings for revision surgeries. Panelists also delve into technology and instrumentation needs, the potential advantages of new advancements, and the current limitations in anterior approach revision practices.
00:00 Welcome Back to AHF's Revision Roundtable
00:30 Techniques for Femoral Side Revisions
03:34 Challenges and Solutions in Femoral Revisions
06:46 Anterior Approach Benefits and Patient Outcomes
08:13 Outpatient Setting for Revisions
12:45 Instrumentation and Future Innovations
16:13 Closing Remarks and Additional Resources
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 back for part two of the AHF's revision roundtable. If you missed the first part of the roundtable, you can click here to start at the beginning. Let's rejoin the conversation with our panel, Dr. Jonathan Yerasimides, Dr. Aldo Riesgo, Dr. John Horberg, and Dr. Kris Alden, as well as my co host, Dr. Charles Lawrie.
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. Obviously need a little bit more exposure in the revision setting. 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.
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. I went through a. 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. and now when I know I'm doing a femoral revision, I get down to the capsule and the old scar and. 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. So I excise all scar while the hip is still reduced, the legs are still up in a neutral position. I'm excising. All the scar back to muscle in that superior and lateral portion. Then I'm going to take my bovie and I'm going to bend the tip of it. And I'm going to get around the posterior aspect of the trochanter, prior to doing anything else. So the table's low, so I can see I'm cutting out all the superior and lateral cartilage. 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. I don't just want to feel it. I want to be able to get around it. 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. I debulk the anterior scar, then I'll externally rotate, dislocate the hip. 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. So I'm doing a circumferential release of the femur prior to even dropping it down. And it is, it cuts 30, 40 minutes off the case and it makes it guaranteed. 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.
Joseph M. Schwab:Are there any tests you're doing, Jonathan, to verify that you've done, as much release as you need to?
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. 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. from the very beginning, before I drop the leg, I'm not ready to drop the leg.
Charles Lawrie:So what if you release circumferentially around the femur and you're still struggling, any extra maneuvers or tips,
Jonathan Yerasimides:usually what happens. And it usually means I haven't released enough because I'll think I've done all the releases I can do on earth. And then I'd end up dropping the leg and the damn thing still, stuck. So if it's not, if it's not rotating enough. 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. And I need to excise more there because the medial side is usually fairly easy to see. It's the, it's that superior lateral portion that, that you're usually deficient on.
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. 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.
Charles Lawrie:any role for a iliac wing osteotomies or a tensor, fascial auto releases off the pelvis.
Aldo M. Riesgo:Yeah, so for me when i'm starting a revision I start off the back with a Tfo release. Sorry, Kris. I cut you off there.
Kris Alden:know that's okay.
Aldo M. Riesgo:question.
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. But I haven't found, the Iliac wing osteotomy to be really something I've needed to go to.
Jonathan Yerasimides:Yeah. I agree with
Kris Alden:repair is a very simple thing to do at the end. Like it's very low morbidity at all. So it's, it's, very simple to do.
Jonathan Yerasimides:Yeah.
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. I don't want to tear the muscle. So that's the indication I have. And it's usually at the point where I'm instrumenting the femur as opposed to getting exposure. 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
Charles Lawrie:we've talked a lot about the benefits that we see as surgeons doing these cases from the anterior approach, right? the anterior approach is fantastic, extensile exposure in particular to the acetabulum. What benefits have you seen in your patients, do you think, doing these cases from an anterior approach instead of a posterior approach?
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. And, the first time I did a, femoral osteotomy for a revision stem. 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. And it amazes me how quickly these people mobilize. 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. 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
Kris Alden:Now I would add that, I've adapted the anterior approach revision to the outpatient setting. And so I've had lots of patients go home from the ASC, And I think the recovery is just quicker. and obviously in my opinion, much less pain. 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.
Joseph M. Schwab:Talk more about that, Kris. What types of revisions are you doing in the ASC setting?
Kris Alden:I've done almost everything. So I've done, full revisions, usually not, I'm, able to like, obviously like shorter stems. 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. converted, like a resurfacing total hip, like taking everything out and put in primary implants, done that type. so lots of different options, for patients, usually it's the younger, healthier and motivated. So if you have somebody that's older and sicker, obviously. That type of revision surgery would be more applicable to the hospital setting. 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.
Joseph M. Schwab:Anybody else doing revisions in the outpatient setting?
Jonathan Yerasimides:I've done some, it just, You can't, do Medicare in the outpatient in ASC yet. So it has to be a non Medicare patient with, something straightforward. certainly heads and liners, although, you're not finding a whole lot of, under Medicare. Age people that need headliner exchanges. but certainly conversions, and simple things like cup revision. I've not done any femoral revisions yet through an ASC. I think it's certainly possible. it's just finding the people because, Revision codes are still inpatient only on the Medicare side of things. I
John Horberg:Yeah, I would echo what Jonathan said. We've done the exact same thing. patients, plenty of conversions. I have removed a stem or two, surgery center for people who had a posterior approach and a growth discrepancy. but the, biggest limiting factor for me doing them at our ambulatory Medicare payer status won't allow us to do most revision codes. yeah. 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,
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. I think your EBL is cut down tremendously, right? Your surgical time, everything's cut down. 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. All my work is anterior to the septum to the intermuscular septum and the gluteal sling. 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. I like to, if you keep all that back, the patient's obviously going to do better. They're going to get up and go the next day better. Their gluteal sling and tendon are. 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.
Joseph M. Schwab:from your guy's perspective, you're at the forefront of doing these anterior approach revision surgeries. What are the big unsolved problems right now in anterior approach revision surgery?
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. you always have to have a burr and manipulate the bone a little bit to get these things to fit. 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. 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.
Kris Alden:I would say that, in addition to what Jonathan said, I completely agree with that. But I think also, for complex femoral revisions, the instrumentation to do the femoral implant is generally more posterior approach friendly. 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. 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. I think we're going to see the more ubiquitous, adoption of anterior approach revisions. And so hopefully the instrumentation will play catch up.
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. How do they do that with the leg down and across and, the stability testing, right? It's a, it's an inexact science. 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. they, a lot of surgeons just like to get their hands on the leg and trowel it around. And it's going to be a little bit different, with the anterior approach. So there's, that little bit of, helping them get used to the new learning curve.
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.
Joseph M. Schwab:We'll have to get a OSI on here to give us a demo.
Jonathan Yerasimides:rumor. It's a rumor. Yeah. I don't know. I have no knowledge. No, no agreements have been broken, but, but yes, that's what I've heard.
Joseph M. Schwab:level six evidence, rumors, and innuendo. gentlemen, thank you. really, this is a pleasure for giving us your time today. thank you for helping to educate our listeners. And of course, thank you for all you do, for your patients. If you're interested in learning more about today's guests, you can check out our show notes for their practice links. we'll also link to some of the anterior approach masterclass videos that we have on the AHF YouTube channel. 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 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 an audio podcast form in your favorite podcast app. As well as in video form on YouTube/@anteriorhipfoundation all one word. Remember also 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 another episode of the AHF podcast. Until then I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.
