Interview: Alfonso Alias, MD

Revolutionizing Hip Surgery in Barcelona: Anterior Approach Insights with Dr. Alfonso Alias

In this episode of the AHF Podcast, host Joe Schwab chats with Dr. Alfonso Alias, a consultant hip surgeon from Clinic Barcelona, about the transformative impact of the anterior approach to hip replacement surgeries. Learn how Dr. Alias and his team have improved patient recovery times and hospital stays, and gain insights on the differences between anterior, posterior, and lateral approaches. Discover the challenges and solutions in optimizing efficiency within the public healthcare system, as well as Dr. Alias's advice for surgeons considering a switch to the anterior method. Tune in to hear about his experiences, mentorship, and his journey to adopting advanced surgical techniques.

Transcript

Joseph M Schwab: 0:24

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. Our episode today features my conversation with Dr. Alfonso Alias, a consultant hip surgeon from the hip unit at the Orthopedic Surgery and Traumatology service at Clinic Barcelona in Spain. Dr. 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. As a side note, I was recovering from laryngitis when we talked, so my voice is a little raspy. Nevertheless, I was fascinated to hear how much growth anterior approach had undergone in Barcelona thanks to Dr. Alias and his partners. Let's listen in on a portion of our conversation. Dr. Alias welcome to the podcast.

Alfonso Alías: 1:16

Thank you so much for having me. It was honor for me. I.

Joseph M Schwab: 1:21

so my understanding is you're in practice in Barcelona, Spain.

Alfonso Alías: 1:25

Is correct? Yeah. I'm in hospital clinic in Barcelona. Right.

Joseph M Schwab: 1:29

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?

Alfonso Alías: 1:38

So when I started in the hospital, my chief was, already performing anterior approach. 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

Joseph M Schwab: 1:59

And so what motivated you to take up anterior approach when you got into practice?

Alfonso Alías: 2:05

So I've seen the difference, between my patient and the from my chief who was, he was doing anterior approach. I, since 2013, I think. And I've seen for, in terms of rapid recovery or, to get early with, physiotherapy also because of the length of the stay. And something was kind of a difference between the, his patient and my patient. That's why I wanted to start it. 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. Another colleague was doing a direct lateral approach. My chief was doing the anterior approach. Then that's why I felt, it makes sense just that everybody does the same

Joseph M Schwab: 2:55

What was it that you noticed that made you think the entire team should be doing it all the same way?

Alfonso Alías: 3:03

You have no restrictions at all. So when I was doing the posterior approach, we had. some kind of restriction. Yeah, you have to take care you're standing up or when you're moving. This kind of movements. If you go to the toilet, maybe you have to have a height in there in when you're sitting for the first weeks. 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. We actually, they can do whatever they want. We have no restriction in, in terms of, restriction of movements it's like they can do whatever they feel good to do.

Joseph M Schwab: 3:44

Was it a ward type situation where patients from multiple surgeons might be in one room? Room or, did have individual rooms? How much were they seeing ways that they were being treated differently?

Alfonso Alías: 3:57

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. Nowadays we are doing almost all our cases in anterior approach, like I said, and, we have not so much ref difference. Really the difference is between the direct lateral approach and the anterior approach, for me. 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. The pain is less. It's very, very common that in the first day they want to leave the crutches and work without crutches sometimes. And that is a, a big difference, I think.

Joseph M Schwab: 4:46

And the system that you're in, is it a public system in Spain?

Alfonso Alías: 4:51

Yeah. I work in a university hospital and in a public system, yeah.

Joseph M Schwab: 4:55

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.

Alfonso Alías: 5:08

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. 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. 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

Joseph M Schwab: 5:41

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?

Alfonso Alías: 6:01

It is very difficult. 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. Okay. starting from that point, it is something that is difficult to talk about efficiency. 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. but here it's kind of different. 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.

Joseph M Schwab: 7:10

Yeah.

Alfonso Alías: 7:11

it's not something that's gonna happen. It's gonna happen in my hospital overnight, you know, so you are gonna have to work a lot. And maybe we are never gonna hit, hit these numbers, but, But for sure we are working on, on getting better.

Joseph M Schwab: 7:28

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?

Alfonso Alías: 7:40

I think that is nowadays my biggest challenge. here, for example, I work in Barcelona. 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.

Joseph M Schwab: 8:00

Wow.

Alfonso Alías: 8:00

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. They're gonna be in a different clinic to, to, to get the, the weight reduced before. So you can do a lot of things in these six months. it is something we don't want to, and we would like to, to have something shorter, like one month or something like that.

Joseph M Schwab: 8:40

And how long after the surgeries are patients staying in the hospital, in your clinic?

Alfonso Alías: 8:46

One night. Usually we do outpatient.

Joseph M Schwab: 8:49

Oh, you do.

Alfonso Alías: 8:50

Yeah. But we were, we were the first hospital in Spain starting with, with the outpatient.

Joseph M Schwab: 8:57

Great.

Alfonso Alías: 8:58

we have done not so much cases and that is, also something that, we want to improve I think we want to. Yeah, I hope that in the next couple years we can do maybe 20% or 25% of our patients with, in like outpatients. You know, we are working in a hospital that is a high level hospital. We get all complicated cases, not because, not just because of the surgery, but also because of, I don't know, liver transplantation or. people that are really sick, we're not a clinic who is doing just ASA one or two. So we have complicated cases and that allows you not to do an outpatient center where everybody's gonna go home the same day.

Joseph M Schwab: 9:51

so how did your patients respond when you started offering them basically outpatient, total hip arthroplasty? Was that something they were excited about? Were they hesitant? How was, what was their response? I.

Alfonso Alías: 10:03

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. So it's a patient who knows all the process and knows everything is gonna happen to him. And then we started doing slowly more and more. And the patient, usually they don't want to sleep in the hospital. They have to share a room with another, with another patient. but that is something that I think the oldest, patient we have done is 77 years old. And usually it's something you do for the 60 years old, healthy people. we like, to have at the, at the first, the first patient, they were all living around the hospital, so not so far away.

Joseph M Schwab: 10:58

Yeah.

Alfonso Alías: 10:59

the hospital. 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. And, and after you speak with the patient and say, how was the experience for you, and the answer is always, it was okay. It was nice. I think everybody wa everything was under control. And and I felt, I felt great going home same day. So that's why we wanted to do more.

Joseph M Schwab: 11:25

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. It's been about 20 years since the HA table first began revolutionizing our ability to perform anterior approach consistently. Since then, we've seen the growth of hip preservation techniques like arthroscopy and PAO. 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. 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. Who knows what solution they might bring out next, but you're gonna want to be the first to see it. And now back to our podcast. So your patients have been fairly satisfied with the outpatient experience at this point. Yeah. Talking a little bit about how you do anterior approach and a little bit specifically about table versus tableless, use of fluoroscopy or robotics. additional navigation. What your, implant choice is and, and things that. Tell me a little bit about what your setup is.

Alfonso Alías: 12:59

So in our setup, we operate on regular table. Okay, that's, we do the anterior approach. We use, the bikini approach for, I would say all of our patients. We do like a, with a table. we have been using, at the beginning we were for retraction, we were using the Gelpi from Anelli. And nowadays, is like 18 months, I think we started with, the Gripper.

Joseph M Schwab: 13:33

From medEnvision?

Alfonso Alías: 13:34

From medEnvision, yeah. Right. And we're pretty happy with that, so. We'll, we love it. 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.

Joseph M Schwab: 13:54

Yeah.

Alfonso Alías: 13:55

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.

Joseph M Schwab: 14:14

I see. So you're putting the cup in with anatomic landmarks.

Alfonso Alías: 14:18

Yeah. and now also because I have started with the robotics, with, the Rosa

Joseph M Schwab: 14:23

Mm-hmm.

Alfonso Alías: 14:24

from Zimmer and we are doing our first cases and then, yeah, we are using the more fluoroscopy because of the Rosa. And then maybe we're gonna do it in the future. We'll see.

Joseph M Schwab: 14:38

so you mentioned Kristoff Corten, and you mentioned your training in Germany. 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.

Alfonso Alías: 14:59

So when I was, when I was a resident, I was doing a Watson-Jones in supine position. Okay. is what, that was my approach when I was finished, with the residency. And I have started my practice, but, I've been, I was, it was the classic one. You know, with a, you know, with this Bend shape incision,

Joseph M Schwab: 15:20

Yeah.

Alfonso Alías: 15:22

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. 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. Always the first fibers. 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. Now, after that you can do the, your sutures, you can do whatever. And that's why I didn't like it so much

Joseph M Schwab: 16:14

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?

Alfonso Alías: 16:31

Yeah, like to really understand the releases. For me, at the beginning it was like, I haven't, that's really clear at the beginning. Maybe I haven't visit so much. maybe, yeah. wasn't in, I was just in a ca in one cadaver lab I haven't seen that. Well, really, and I, in the beginning, I was always struggling with, with the lift of the femur, like everybody at the beginning. 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

Joseph M Schwab: 17:19

It. It was just time and experience for you that taught you those releases.

Alfonso Alías: 17:23

Yeah. Yeah. And also I have to say, I have to thank really from the help to Kristoff, to Kristoff Corten. in the, in this month I was spending with him. I've seen everything so clear and everything was so easy. And, yeah, it was like a real change in my practice.

Joseph M Schwab: 17:45

Tell me a little bit about those adjustments you've made based on going to see, for instance, Kristoff. is it adjustments in your instrumentation, in your positioning, in your team coordination? are the changes you're making?

Alfonso Alías: 18:01

So in the position of the instruments. 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. And at the beginning, but, after ep, I've been with, professor Corten. So everything was the same. Every step was really the same. 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. And no matter if it's a lady with 60, years old or a young guy, muscular big and, and difficult to do.

Joseph M Schwab: 18:57

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. E everything done the same way each time.

Alfonso Alías: 19:12

I think that every patient is different. You can do it the same way, but in my opinion, maybe. 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.

Joseph M Schwab: 19:48

Yeah. 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?

Alfonso Alías: 20:10

So first step, cadaver lab. That is very, very, very important. 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.

Joseph M Schwab: 20:27

Yeah.

Alfonso Alías: 20:28

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. And, the second. 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. 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.

Joseph M Schwab: 21:08

Alfonso, I've really enjoyed talking to you today. I really appreciate having you on the AHF podcast

Alfonso Alías: 21:14

Thank you so much for having me. Like I said, it was really a pleasure and I hope to see you again maybe in London.

Joseph M Schwab: 21:20

Thank you for listening to this episode of the AHF podcast. Remember to like and subscribe so we can reach a wider audience. If you have an idea for a topic, leave it 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 at Anterior Hip Foundation, all one word. New episodes of the AHF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy and healthy.