AHF Podcast
AHF Podcast
Revision Roundtable BONUS - ASIS/AIIS Double Osteotomy
Find the video version here: https://youtu.be/VvwETRRkQxc
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
Exploring Advanced Osteotomies with Dr. Aldo Riesgo
In this bonus episode of the AHF podcast, host Joe Schwab welcomes Dr. Aldo Riesgo to discuss the intricacies of anterior superior iliac spine (ASIS) osteotomies and the combination of ASIS and AIIS osteotomies. Dr. Riesgo delves into the technical details and benefits of these approaches, particularly in challenging cases involving infection, significant bone lengthening, and complex pelvic reconstructions. Throughout the discussion, emphasis is placed on bone-to-bone healing, reducing morbidity, and continuous improvement in surgical practices. Additionally, the episode highlights the value of collaboration and innovation in orthopedic surgery.
00:00 Introduction and Episode Overview
00:44 Discussion on ASIS Osteotomy
01:38 Double Iliac Osteotomy Technique
02:31 Case Study: Cadaveric Dissection
03:46 Managing Complex Defects
07:16 Innovations and Future Directions
This is Joe Schwab host of the AHF podcast. The response to our revision round table series has been tremendously positive. So this week, just like last week, we have another bonus episode with content that just couldn't make it into the original episodes. This week, we've got Dr. Aldo Riesgo talking about anterior superior iliac spine osteotomies, and combined ASIS and AIIS osteotomies. And just like last week, you can check the show notes for links to the video. Now let's get on with the AHF revision round table.
Jonathan Yerasimides:Aldo what do you think the ASIS osteotomy, gains you as far as, access? And are you taking that, are you taking that bone fragment medially?
Aldo M. Riesgo:look, I think it allows me to start going down the slide, I like to call it. Go down the anterior column, go into the pelvis, I flip that tissue medial, right? And then I start working. I do a lateral window kind of exposure and then walk it down the anterior column to get to, to my pubis. I think it's a, I think it's a low morbidity thing. I like bone on bone healing. I like to leave some of that attached. I've set them up now where they're angled. So if I have a shortening case like John's mentioned before, you can slide the osteotomy down so you can still get bone to bone healing. You don't want to completely flat cut. yeah, so I've been messing around with a double kind of a double Iliac osteotomy, ASIS and AIIS. Cause I had some of my younger patients, when I needed more access and I was always doing a femoral rectus femoris tenotomy. So I've started, doing it, this double osteotomy to leave the rectus attached. So here's a good case, I got to get into the pelvis, extremely short, I'm gonna have to lengthen this patient, so this person's another infection case, bilateral primary hip some many years ago. So I'm going in, if you see the initial exposure, I have a picture there, You're never going to get to the trunnion. That's the anterior coding of his femur, right? So that's where his ASIS is before I decided to do any work. So I need to access the inner table to even get this dislocated. This is a cadaveric picture, but if you see here, this is what it looks like. So there's a, if you click ahead, that's where my ASIS osteotomy would be. That piece of bone right above it is the superior spine. And then you angle it like a 45 degree or 60 degree angle, and then you don't want to extend it till you get into your dome, right? So this is a cadaveric dissection where we've put a cup in and we've already marked that. And then if we keep going, I'll mark it there, ASIS, AIIS. And then in patients where you don't have a lot of shortening, you can actually get a bone to bone. Repair that. So this is back to that case. There's that, pseudoacetabulum that's formed at the top and the inner table. that's where I did the osteotomy. You can see that right there. That's the piece of bone right there. and then I can then hook retractors underneath that. I use a Charnley. So that Charnley's hooked around the AIIS and then I can walk down the column. My sucker tip is pointing at that osteotomy. so there I went ahead and, unroof the socket from the inside. and then, yeah, I was able to, I was able to, dissociate the trunnion and the head ball
Jonathan Yerasimides:Say, cause that, that looked like contained defect. Like when you show me that AP pelvis, I wasn't thinking the anterior column was going to be out. I thought this looked like just a giant superior contained defect, that picture there, so did you create like an anterior column hole then so you could get
Aldo M. Riesgo:Yes, yeah, so this is an infected case. I had to get a really good debridement and I couldn't even access that thing was not that thing was socked in he was up and in that for years This guy was a neglected pji case it took over a year and a half to get him on my schedule not the best social situation for him so there's no way I was gonna even be able to get that cup and trunnion even out of the pelvis without doing this. So yeah, whenever I have to get inside to the, yeah, I think recreating a column defect, that's a great indication for it. But for me, this is just getting the parts out. I had to get the parts out.
Jonathan Yerasimides:Yeah, no, and I've done that before where I've had these giant contained defects. And then just to get the implants out, I ended up creating an anterior column, anterior wall defect, just to get the parts out and then fix them later.
Aldo M. Riesgo:yeah, a case like this where he was short five centimeters. I think direct anterior is the way to go because. I can do an extensive release off the outer table. I think the abductor mass and the TFL will slide down to a new position. And then I, if you angle these osteotomies, you can, slide them down a bit. for this guy, getting him back four or five centimeters, you're probably not going to get bone to bone contact when you repair it, but I do have a, a picture coming up and an X ray of, that's what we did for this guy. you can actually put those plates on the inner table. If you have incredible access to it. So that's a good, that's a good functional spacer for him. He's a pretty low demand guy, but then in my, more functional patients where I've had to do it, I do fix it. Yeah. If you show that next picture, you can see those screws where the ASIS and the AIIS are, you can get great bone to bone. Healing right there of the kind of double osteotomy. So this guy's, this patient here that I showed different patient obviously, but this guy is 42 years old, I would, tenotomize the rectus on most of these patients and I think they would have some persistent. Hip flexor strength. So I've started doing this and I've been pretty happy with the results so far.
Jonathan Yerasimides:Have, do you always double osteotomy or is it possible? And I'm asking just cause I've not done it. I don't know. but taking, taking them both in one osteotomy, the ASIS and the AIIS and just making it one large fragment because you might be getting down into a little bit of the dome, but you're still, you're posterior column where we bear our weight and where we're loading our implants and still be intact. I don't know if you've ever tried to take one piece or not. Yeah,
Aldo M. Riesgo:yeah I think that's the that's the next iteration of this if I can do it and obviously everyone's pelvis morphology You look at it like their angles are a little bit different in terms of you Obviously don't want to compromise the bone that you need for reconstruction. I think that's the number one key and you mentioned that So for right now, I've just been doing Double. but I think then if I could do it all as one big piece, that would probably be better and easier, truthfully. But I think that what that just goes to show is every year I'm doing more and more of these. And I think we're all experimenting and pushing the envelope as to what is best for our patients. And so far so good. I've had, on the few patients I've done this on, they haven't really given me the same complaints that I was getting before, in terms of some of that, rectus or hip flexor weakness.
Jonathan Yerasimides:I'll give a shameless plug out to one of your, one of your, old fellows, James Baker. I just did a course with him and, he's, I'll take a little credit. He was my resident, but he was your fellow, but, he, he's, doing some wild stuff down here in Louisville. He's, on the radar.
Aldo M. Riesgo:Yeah. Yeah. I think we're, but again, it's about training that next generation of guys who are, we're, we are not set in our ways of Hey, this is how we did it. And this is how people have always done it. And this is how we need to keep doing it. No, we haven't perfected anything. And I think that's part of the goal of all this is being collaborative. And I've picked up a lot of stuff from, everyone here that I've talked to about, about how I do hips and how I do revisions.
