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Management of Valgus Knee for Orthopaedic Exams
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Management of Valgus Knee for Orthopaedic Exams
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Language: EN.
Segment:0 .
Evening, everyone, and welcome to the FRCS mentors group webinar. Thank you for joining us today. My name is Abdullah Hanoun. We have a show up of mentis today. The topic is approaches to the vulgar knee osteoarthritis, and our presenter today is GQ Hannibal.
He is a specialist orthopedics working in Singapore. He passed the exam in November 2018, and he has special interest in arthroplasty. As usual, the routine. This talk is recorded and you will be able to get to see the copy of it from our YouTube channel. You are more than welcome to ask questions, and me and Dave will keep an eye on the questions you ask and then present it to gq, who will be happy to answer it at the end of the talk.
After that, we will move to the Viva sessions, and we have some nice questions for you today at this 500 hour session. Again, as you know, will not be recorded, so please feel free to join in chipping. Have courage and practice. If you have any questions related to the setting, you can put it on the telegram group, which you can find some more discussions about the topic and other topics.
Just to remind you, recently we have published the FRC book again, we are not trying to give you a headaches about it. It is just like a contribution from all the mentors. Every one of US has tried to put their best in summarizing what comes in the exam, what are the main topics that can be asked and explained in a nice way with references to the resources which are linked really easily for you to use?
None of the cost of the book comes to us at all. It is just to cover the cost. We are not gaining from it financially at all. In fact, it was just a headache for us. We hope that you will find it useful. And please give us feedback on the book on because it is a continuous, continuously updated. And the third version is we are starting already editing for the third edition, so please give us feedback.
Any mistakes, anything you would like to add, anything you find was not explained well. Let us know. But that was a long introduction, without further ado, I would invite GQ to present a to volarly. Good evening, everyone. Thank you, Abdullah, for the introduction.
Regenerative just knee is a common topic that comes in the FRC as trauma and Orthopedics exam. It can come as come in the clinicals, most commonly as a short case or also even as an intermediate case, and also in the waiver section. An early pattern identification is required. 10% of patients undergoing totally arthroplasty have religous knees, although general welcome is common in inflammatory arthritis.
Vast majority of degenerative Wilder's knee arthritis is due to primary osteoarthritis. It is commonly seen in females with unresolved physiological Vargas and also with persistence of childhood Bulger's secondary to metabolic disorders like rickets. Or you lost your dystrophy. In inflammatory arthritis. Think about rheumatoid arthritis as a lead, psoriatic arthritis and gout.
Romantic causes include tibial plateau fracture. Uh, tibial shaft fracture and fischel arrest. I totally. Kos is due to overcorrection of high tibial osteotomy. Start your clinical evaluation by making the patient stand and observing the alignment of the lower limb. Which will reveal the deformity.
Gate is the best way to assess dynamic instability and look for Vargas trust and the team in the stands face. Measure the values deformity in supine with a goal your meter and check whether it is correctable or whether it is fixed. Look for any recovered item and collection contracture and assess the range of motion. Check the competency of ligaments, especially the ACL and the ACL.
Look for any systemic features of inflammatory property and document the status of the company ulnar nerve. Other than the standard mixed reviews, if realignment osteotomy and unique compartmented arthroplasty are options considered, then ask for Rosenburg view and virus rescues. Egawa standing long leg.
The mechanical and the anatomical axis is critical in planning the distal femoral and the proximal tibial dissections. The metaphor is in Vargas. In the distal femur and approximate tibia is best appreciated in the long leg limbs, and when you are planning the vets for the osteotomy is done on it. I will come to that a little later.
General deformity Allen can be classified according to the clinical radiological classification by Iran over in the long leak classified from grade 1 to 3. With increasing severity of deformities, grade 1 consists of 80% of the cases, with mild less than 10 degrees of correctable deformity, with intact epimysium grade to 10 to 20 degrees with attenuation of the ACL, but functionally intact and grade 3 with severe more than 20 degree deformity with a known epimysium.
In the AP view, look for lateral femoral container hyperplasia. And which is which affects the distal femur bone cuts. The bone defects in the lateral tibial plateau and the medial opening are important in determining the proximal tibial dissections. In the lateral view, look for the lateral posterior container hyperplasia and location and the presence of lateral tibia bone loss.
Also, look for the patella height as Baja is commonly associated with knees. In the skyline, you look for the severity and breeding of arthritis and for tracking subluxation and dislocation of the. Virus stress radiographs are mandatory when considering lateral compartment and knee arthroplasty to assess the presence of full thickness cartilage loss in the medial compartment and the conforme.
Whether the deformity is fully correctable to improve, which is one of the prerequisites for that, will you? Rosenberg view is the best radiological view to evaluate lateral and medial tibial cartilage where critical when considering an osteotomy or a unique compartment in the arthroplasty. Surgical options other than totally arthroplasty includes lateral unit compartment arthroplasty and distal femoral osteotomy.
The aims of broadening arthroplasty in balcony is similar to other indications of arthroplasty. The depending upon mainly the surgeon preference, totally arthroplasty in Bulger's knee can be carried out either by a median or a lateral approach. Middleborough Butler is the standard approach, which is familiar for the most orthopedic surgeon you version of the patella in this approach is easier due to a combination of deformity and localization of the tibial tubercle.
Disadvantages of this approach includes limited access to the lateral structures, especially the post-war posterolateral corner for soft tissue release. This approach would lead to be vascularization if additional data release is required to improve that tracking. Lateral approach allows for better surgical view, better direct surgical view for the lateral contracted elements, which facilitates this release.
There is no risk of Kessler devascularization as the latter release is a part of the approach and the medial vascular supply for the extensor mechanism is untouched. If tibial osteotomy is done as a part of the approach, it is possible to neutralize and improve the tracking. The collateral better Butler approach there, there is a difficulty, there is difficulty in particular abortion.
And there is limited middle compartment exposure if people tubercle osteotomy is not done. After adequate releases laterally to achieve balance, there may be a defect in the lateral retinaculum during the retinacular closure, which requires advancement of the fat part, or is it plastic of the capsule to facilitate the closure? Let us now talk about the bone cuts in the valgus knee the Vegas angle cut reference both the anatomical axis is reduced from the normal 5 to 7 degrees of algos to three degrees.
So as to compensate for the metaphor is your diaphragm while this remodeling and to avoid under correction. Caution is taken, nor to all risk the lateral epicondyle to avoid marked elevation of the join line. The proposed femoral dissection is kept minimal, usually around eight AM from the medial epicondyle and no more than 10.
This is usually this may result only in minimal or no lateral resection in severe while this deformity cases. People protection is kept to the minimum, usually around only around 5 to eight am or from the medial tibial plateau with minimal or no bone removed from the lateral side. In severe, well, just needs.
With regard to funeral component rotation and sizing, lateral condyle hyperplasia makes for speedier fontella referencing inaccurate. There is a tendency to put the moral component into internal rotation with excessive resection of the already hypoplastic lateral posterior epicondyle. This internal rotation of the component increases the hue anchor by obligate medial placement of the group.
And results in abnormal satellite tracking, this also results in trapezoidal flexion gap, wider lateral. Recreational referencing should be done on the proposed posted of eyesight's line or with the slap epicondyle line in valgus city. You've posted a container referencing is used by more external rotation. About 5 to 7 degrees.
From the normal three degrees to build up or build up on the positive aspect of the latter contained within your tone during sizing and determining the location. In Sibile Vargas mi, the structures there are light. There are tight little structures, there will be laxity of the skin and the PCL. The title battles factors can be of two types.
That there are structures which are inserted at the flexion extension axis at the lateral epicondyle. That that is the lateral collateral ligament and the completist tendon, which is isometric, really tension in both extension and flexion of the knee. And the structures inserting away from the axis, like the IT band and the post-war little capsule and the lateral head of the muscles, which actually in extension.
After executing the bone cuts, there are two possibilities. One is to 1 is a symmetrical, rectangular flexion extension gap. When no further release is necessary. And the other possibility is that the gaps are trapezoidal. Then further soft tissue releases are necessary. The best sequence and the technique to perform the lateral release in Vegas is debatable.
One popular technique is the what's inside out technique. In this technique, the knee is extended. And spread out with the spreader. Brad Pitt for the tight structures laterally, which Hinders the balancing of the gaps in this technique, the first structure to be released is the posterior cruciate ligament. Then after that, the post-war posterolateral corner is released from the surface of the tibia, from the PCL to the posterior border of the band.
And then we release the IT band by multiple stab incision, centimeter proximal and higher to the tibial cut surface. If the need continues to be tight, inflection rarely complete, completely standing can also be released. After the lateral structure release, if the gaps are not balanced.
One might consider 1 May consider emcee an advancement that is the epicondyle origin of the lax emcee is advanced proximally and secured with a suture anchor or a staple. The other option for MQL tightening is improvisation, where the substance of the ACL is divided and implicated to equalize the doing gaps. After taking after.
Check the tracking of the Petrella after releasing the tourniquet. If the Butler lateral male tracking persists. After confirming the optimal component position, the lateral release is to be performed in the inside out technique. The lateral return column is exposed. And the red column is incised. From the mid Bachelor level to the upper DBL border, centimeter lateral to the patella.
For the proximal retina, regular release endangers the superior lateral artery and. Usually it's not required to extend it, so really. Email deformities where soft tissue balance can be restored without PCL release, a minimally constrained seizure component could be implanted.
In Vegas knees. Most surgeons prefer a penis implant as the PCL is going functional. The implant also allows greater liberalization of the component with better particular tracking, although the PSA component provides some degree of posterior stabilization due to compose mechanism and also some translation the post-raw medial and the posterior lateral direction, it will not protect against residual medial laxity.
In severe deformities where there is significant collateral laxity, the virus well in plan may be necessary. Component augmentation may be required if there is bone loss and to restore the join line. The Krakow in his review article noticed increased incidents of instability, recurrent wildfires, deformity and patellar complications with Walt Disney totally arthroplasty, the common perennial no policy incidents was.
Found to be three to four percent, which was attributed to the attraction of the nerve during the lateral lengthening or. The direct injury while performing the pipe casting technique. With the common perennial, no policy is discovered for stock. The compression, the sinks are removed and the knee is flexed to relax the tension of the nerve and then expectant management is advised.
This femur osteotomy is the osteotomy of choice in while gives me an ideal candidate for this femur, osteotomy is a younger, active patient who is able to comply with post-operative rehabilitation, which includes non weight bearing walking for a period of time. In the presence of wagga's malalignment associated with isolated early little compartment arthritis.
This femoral osteotomy is contraindicated in Tri compartment in osteoarthritis. Inflammatory arthritis or severe articular disruption of the battery compartment. Well, this deformity more than 20 degrees flexion contractions, more than 15 degrees and knee flexion more less than 90 degrees are also contraindications for distal femoral osteotomy. Relative contraindications include ligament instability, which needs one or two stage reconstruction along with the osteotomy.
In case of associated ACL injury. Emcee laxity seemed to improve after this femur osteotomy. Even though they still femoral osteotomy is favorable with regards to alignment in patients with high BMI because of improved thigh clearance because of increased complications. BMI, more than 30 is a relative contraindication. Yes, battle of articulation improves after the still femoral osteotomy mild to moderate battle of arthritis is not a contraindication for those tenotomy severe osteoporosis and nicotine use.
Is related to delayed wounding at the osteotomy site. The two main types of distal femur osteotomy are the. Natural opening with the osteotomy and the medial closing windows tenotomy. The tape of the osteotomy is mainly based on the surgeon preference, but the general consensus is that moderate corrections up to 1 degree of correction is better obtained by a natural closing width.
And for larger correction. More than 12 degree immediate closing with Freeman osteotomy could be a better choice. Advantages of lateral opening with osteotomy include better control of distraction when optimizing the mechanical access. It's a more familiar approach to the lateral distal femur for most surgeons. Advantages of the medial crossing with the osteotomy is direct bone to bone healing and avoidance of bone grafting in the open wedge technique.
Correction is achieved. Correction achieved is better maintained. Although nicotine use and osteoporosis are relative contraindications in osteotomy, posing with those tenotomy is preferred over lateral opening within these situations, because of that, a healing. There is less hardware because of the plate not being directly under the bed.
Rosenberg view is a mandatory view in this femur osteotomy surgeon believe that either an MRI or an intraoperative r-truth should be performed in diagnosing control and ligament alterations before the post-mortem is performed. The osteotomy planning is done on Long Lake films by the dovedale method, the correction angle is calculated by the angle form between two lines.
The first line drawn from the center of the head to the 50% Coordinate in the medial tibial plateau and the second line drawn from the center of the handle to the same point. By measuring the width of the femur at the level of the proposed osteotomy surgeon can convert the angular correction into the size required. Back steam in a series demonstrate a 10 year survival ship of 82 percent, with a significant decline to 45% at 50 years after the was reopened.
Lateral combat, mental arthroplasty E10 is 10 times less perform, then medial unit compartment. Arthroplasty that's representing less than 1% of all totally arthroplasty, 1% of all knee arthroplasty because of the low numbers, limited long term results are available for lateral.
An ideal candidate for a UK is a patient with isolated bone to bone arthritis in the lateral compartment with preserved medial peel-back with intact anterior cruciate ligament. Fully, passively correctable pelvis deformity. Other than, like environmental and inflammatory arthritis, while there's more than 15 degrees, any known correctable this range of movement less than 100 degrees and any flexion contractors are absolute contraindications for that unique compartment arthroplasty.
Recent studies have shown that. Lateral UK, where is more related to activity than to be a mine? Ligament instability needs to be corrected before the. Natalie and previous was tenotomy, or any surgery altering the knee biomechanics. It totally arthroplasty should be considered. Over that unique compartment, lots of plastic.
Lateral UK is technically more challenging than medial UK due to anatomy and biomechanical differences between the two compartments. The main differences are the relative lateral ligament laxity. That being more divergent and convex medial peel-back and the lateral fontella rollback and the whole mechanism in extension. Due to these factors, there is more chance of component dislocation and femoral component impingement on the patella inflection and the tibial spine extension.
You overcome the dislocation risk. Some voters suggested fixed bearing implants for lateral. Impeachment can be minimized by catalyzing and avoiding oversight of the funeral component. You may reason systemic review on the survivorship. Even though the lateral. UK is more challenging technically. Both the UK and the UK was found to have similar survivorship with no statistical difference in the survivorship and UK survival at five, 10 and 15 years respectively.
95 percent, 93% and 89 percent, respectively. Thank you. For the other questions, I have a couple of questions for you. Does age play any part in choosing which one to you go for? Do you go for, you know, do you have a cut off where you say, definitely, I'll go for total knee replacement rather than a uni or osteotomy or age doesn't play any part in it? Yes so more than age in natural uni compartment, the knee arthroplasty, it is the activity level of the patient that decides the decides the choice of the surgery in case of distal femoral osteotomy the patient.
Should be relatively young patient who is able to. Cooperate with rehabilitation. Use of walking aids and non weight bearing walking in case of unique bombardment. There is no age limitations. You can do unique combat mental knee replacement in any age group. But the survivorship is less if the patient is more active, so activity level determines which.
Is the surgery of choice for a particular patient? Mm-hmm OK. The other question is now do you have an algorithm or a guide on which one to choose? For example, you've got a 50-year-old office worker who is coming with a vacation? Would you go for a total? Would you go for uni or would you go for osteotomy? This is the exam scenario.
They present you with that and they ask you, which one do you go for? How do you choose? And how do you phrase your answer in the exam? Right so a 50 year old, 50-year-old patient like we, we will be more inclined to doing this. Freeman osteotomy. So my answer will be that I will be taking a detailed history, especially looking at the activity level of the patient and the functional limitations of the condition.
But what the condition, what functional restrictions the patient is having. I would ask about. We make whether the patient is a smoker, what is whether what is the medical comorbidities of the patient, whether the patient will be able to. They cooperate with rehabilitate we whether the patient has got rehabilitated potential to avoid, to cooperate with non weight bearing walking post-operative.
Then I will be basing my decision based on these factors. Absolutely fine. Another question from Barry Vann. He asked about how do you differentiate between Rosenberg and tunnel views? The talk, the Rosalba view is the it's another name of the tunnel view. It is actually it's supposed to a view of the knee taken in 45 degrees of flexion with 10 degrees of caudal and motion of the X-ray beam.
So according to my knowledge, the tunnel view is same as the Rosenberg view. Anybody else? I looked into that one as well. But yeah, so I have a tunnel view is looking at the intercom, the notch more so than Rosenberg view and the one big specific differences. Rozenberg is generally weight bearing and a Pas view. A true tunnel view is non weight bearing and AP view.
OK, so that's my understanding, but I mean, what we might consider a tunnel view and what a radiologist might consider a tunnel view is completely different. That's the problem sometimes. In reality, I think both are interchangeable and people use one for the other. So as long as basically what you are looking for, I think it's in real life in the exam.
They will forget, they will forgive you. I think if you mention it, unless you've got a really are unlucky and you've got a particular examiner who would want you to know the difference between the two. I don't think that matters. No, I would say to you, be prepared. If you're going to say Rosenberg for you and avivah, just have a quick I say, just if they say, what's a Rosenberg for you to say quickly?
Oh, it's a few weight bearing 30 degrees or 40 to five degrees, they'll be fine. Perfect no one will ask you, what's the difference between that and the tunnel view unless you mention both. That's the thing. The technique of the exam is the examiners are not there to take you. They will ask you and they will ask you based on what you say.
So if you say rozenberg, they may ask you what Rosenberg is. They will never ask you, how do you differentiate between that and the tunnel view? Yeah, OK, fine. I just want to add something for the age regarding whether to use only comportamento or total replacement. There is a nice paper published last year in the BMJ. Actually, it's the age is not a factor.
So whatever the indication for the patients and x-ray, if it's suitable for unit comportamento will do that. However, you may like discuss that with the patients, according to the pros and cons of every one. Yes, like the rate of revision is a much more in the unit compartment than the total knee replacement. But the age itself, it is not a factor, and sometimes it irritates the examiner to say I will do the compartment in young patients and do two to any replacement in all the patients.
Sometimes not. It's not a better answer to say. Yeah OK. So you can mention it's a physiological age rather than chronological age for this age. Yeah OK, next question. Mohamed egawa, I may have to ask you to explain it. The question is written how do you differentiate between vulgar need due to osteoarthritis.
And that due to rheumatoid if due to osteoarthritis, you will deal with it in a different way? So I'm guessing because you mentioned that osteoarthritis is a contra indication, how do you differentiate between the two? Is that what you wanted? Mohammed, I mean, if you have an advanced degree of osteoarthritis. And you are going to replace the knee, how you differentiate from the ideology that this is due to advanced osteoarthritis or it is or is him Flipper arthritis?
So again, with its surgical tips and tricks that the hypoplastic clutter and bas status female epicondyle. OK, so in case of radiological differentiating between an inflammatory arthritis and osteoarthritis in inflammatory arthritis, there will be a distinct, symmetrical collapse of the joint space and osteoarthritis likely it will be an asymmetrical collapse of the joint space with opening up of one.
Compartment with the obliteration of the space on the other side, the other features of inflammatory arthritis will be evidence of soft tissue swelling. The associated articular osteopenia and paucity of osteoarthritis. That is how you both are. The radiological differences between inflammatory arthritis and osteoarthritis.
In addition, the patient normally can tell you because, as you know, inflammatory arthritis is multi joint, so they will usually come with more than one joint at the same time, including it's a systemic disease, so bilateral symmetrical arthroplasty usually. In addition, if you have three compartments, then by definition you can whether the reason is osteoarthritis or rheumatoid because you can't apply Vargas technique if it's dry compartmentalized.
And that's the reason for the rheumatoid arthritis being excluded because it affects all compartments at the same time. So, for example, if you do osteotomy, it will fail very quickly because the disease is progressive. The same thing about unit compartment on only does that answer your question, mohammed? Yes, to some extent, yeah, I because I suppose to avoid Disney, we were replacing the but.
We don't know. You don't. You cannot detect from the preoperative X-ray if a lot of female epicondyle is really hyperplastic as inflammatory arthritis, and in this case, you have to depend on the Enter epicondyle or the right side line. Or you can or you will deal it, deal with it as a conventional osteoarthritis with no tips and tricks.
I think going to it was confusing theology, whether it is because of osteoarthritis or inflammatory arthritis or hyperplasia, is likely to be present in this league. So in case of Bulger's knee, like one way, while you're determining the femoral rotation and sizing, if you observe the disparity between the epicondyle Allen and the Whiteside's line with regards to the posterior referencing, then you have to be careful.
You usually depends on either the apex line or in the Gondola in the epicondyle line for your professional reference. Yeah, it's always a good technique, but not rely on only one method. I know many surgeons who would rely on the posterior referencing and white side lines, and they measure both. And if there is a discrepancy, they will dial it like an external rotation in the matter. It's just a matter of making sure that you are doing it correctly.
Fine moving on. So the next question is from nabard and and he says in general for Vargas knee, which approach is considered the standard one medial or lateral? Yeah, so basically, like, you know, I have seen in my practice like hardly one or two like lateral approaches to the well with me, even in mild.
So basically when you consider mild, moderate and severe mild cases accounts for around 80% of the cases. So there is no ambiguity that we should be going. Usually we'll be going with the like a medial approach. But the question comes when in very severe needs, very severe needs. Yes, even with the middle propeller approach, what I find is your exposure is adequate because as I mentioned, your Kessler evolution is easier and you have got reasonably good, generalized better exposure of the knee and you have an access to the access to the lateral structures.
Even with the middle propeller approach, but there are so few less lateral therapies for very severe needs. But for me, I always go. We've begun answering the exam. The key thing is to say, in my practice, I will use the medial patella approach because that's what I know. That's what I'm comfortable with.
However, I understand the principles behind the lateral approach and say it that way. Get out of jail. They want you. You want to demonstrate that you're a safe, competent surgeon, not someone who's going to dry. If you suddenly just say, I'm going to do the lateral approach that might go. How many times have you done a lateral approach?
I think I've worked with many of these surgeons, and I do think that they would say they're probably only done it. Well, 10 times in the whole career out, 1,000 times are done the medial approach. So it is a very rare approach. But as long as you can say, I understand the principles behind that will get you through. Another scenario that may come in the exam is if it is severe Vargas and the decision tree led you to doing a knee replacement, then it is safe to say in this case, it is significantly severe Vargas knee and I anticipate that the ligaments will would have contracted and all of that.
I draw the a arthroplasty surgeon who does this frequently deals with that because this may need a lateral para patella approach, which I know the principles of, but I haven't done enough. So again, this is another get out of jail card, which you can use. But that is only if it is severe because, as GQ has mentioned, it is 80% of the cases is mild where medial approach is enough.
Another question. He was asking and that's a sum I think he was asking. Should we prefer to use bee's knees and inflammatory arthritis? I think I got that right. Islam, if that is the wrong. A question, if I didn't get it right, please correct us.
Mason Yes. I'm asking about the state of stabilizing or sacrificing, I think it's sacrificing because people will not be competent. That's right. Jacob, Yeah. So inflammatory arthritis like it is one of the described the previously described the indications for his knee, but but there have been papers which suggest suggested the seizure implants or anterior stabilized or condylar stabilized implants for inflammatory arthritis.
So recently, there is more of a trend in using the Greek cruciate retaining implants, even in rheumatoid arthritis. But for the exam, I think we can still stick with the answer that the inflammatory arthritis? You will go for. Excellent. Thank you.
Thank you. Thanks may I ask everyone else is not asking the question to mute, please and I will ask the next question. But while we are waiting, anyone who is interested in doing the Viva, please raise your hands. I have got three people who have raised their hands. So far. We have got many Viva nice Viva questions today for you guys, so please contribute.
If anyone is interested, raise your hand by clicking on the Raise Hand button underneath your name. So next question is for Mohammad egawa again. Do we have a limit in the Vargas angle when we do digital cut? Limit, yes, usually like, you know, when in your general practice, you usually cut a five degrees. Between a 5 and seven, that is your normal standard virus or any cut will be in case of taller people and in case of this deformity.
Are your femoral the femoral fontella cut should be reduced to. Up to around three degrees, so this in Vegas means is because there will be a Vegas remodeling of the metaphors or their facial. When you do, when you put in your operatively guide, you are there is a bit of in-built well. Or in Bidwell goes in that measurement itself.
So you reduce your well, guess, cut to around 3 degrees. But the more critical question that you are asking is how to get a neutral mechanical alignment, which is we got by cutting perpendicular to the mechanical axis. So as long as you do your templating. Of the distal Vargas cut borrowing a mechanical axis on the long leg, Williams, you will get an idea about how much well guess cut you require, but hardly ever you go.
Uh, less than three degrees while gas cut in Texas. OK another question, which is about the rehab post, Australia Post the osteotomy, what is your protocol for rehabilitation after a femoral osteotomy? Yeah, so my protocol for this femur osteotomy after. It depends on the type of osteotomy that I do, I usually do a lateral opening with the osteotomy, with the lateral opening, with the osteotomy, you definitely wear non weight bearing to attach weight bearing for at least four weeks with a meter closing the doors to your tummy with the more stability of the osteotomy with bone to bone contact.
I don't do middle closing with your osteotomy, but even if you do middle crossing with osteotomy, we can allow a bit more weight bearing around 50% weight bearing can be. Hello So usually around four weeks of non weight bearing weight bearing that will be the range of movement to begin immediate posture. Excellent good. Thank you very much, GQ.
I know that you have other things to attend to the time difference. I think it's time for you to go be somewhere. Any other questions, guys? OK, thank you very much, GQ. It was very good, very comprehensive and clear answers, thank you very much for all the people who stood questions.
It will now. The recording and then we will move to the Viva session.
Segment:0 .
Evening, everyone, and welcome to the FRCS mentors group webinar. Thank you for joining us today. My name is Abdullah Hanoun. We have a show up of mentis today. The topic is approaches to the vulgar knee osteoarthritis, and our presenter today is GQ Hannibal.
He is a specialist orthopedics working in Singapore. He passed the exam in November 2018, and he has special interest in arthroplasty. As usual, the routine. This talk is recorded and you will be able to get to see the copy of it from our YouTube channel. You are more than welcome to ask questions, and me and Dave will keep an eye on the questions you ask and then present it to gq, who will be happy to answer it at the end of the talk.
After that, we will move to the Viva sessions, and we have some nice questions for you today at this 500 hour session. Again, as you know, will not be recorded, so please feel free to join in chipping. Have courage and practice. If you have any questions related to the setting, you can put it on the telegram group, which you can find some more discussions about the topic and other topics.
Just to remind you, recently we have published the FRC book again, we are not trying to give you a headaches about it. It is just like a contribution from all the mentors. Every one of US has tried to put their best in summarizing what comes in the exam, what are the main topics that can be asked and explained in a nice way with references to the resources which are linked really easily for you to use?
None of the cost of the book comes to us at all. It is just to cover the cost. We are not gaining from it financially at all. In fact, it was just a headache for us. We hope that you will find it useful. And please give us feedback on the book on because it is a continuous, continuously updated. And the third version is we are starting already editing for the third edition, so please give us feedback.
Any mistakes, anything you would like to add, anything you find was not explained well. Let us know. But that was a long introduction, without further ado, I would invite GQ to present a to volarly. Good evening, everyone. Thank you, Abdullah, for the introduction.
Regenerative just knee is a common topic that comes in the FRC as trauma and Orthopedics exam. It can come as come in the clinicals, most commonly as a short case or also even as an intermediate case, and also in the waiver section. An early pattern identification is required. 10% of patients undergoing totally arthroplasty have religous knees, although general welcome is common in inflammatory arthritis.
Vast majority of degenerative Wilder's knee arthritis is due to primary osteoarthritis. It is commonly seen in females with unresolved physiological Vargas and also with persistence of childhood Bulger's secondary to metabolic disorders like rickets. Or you lost your dystrophy. In inflammatory arthritis. Think about rheumatoid arthritis as a lead, psoriatic arthritis and gout.
Romantic causes include tibial plateau fracture. Uh, tibial shaft fracture and fischel arrest. I totally. Kos is due to overcorrection of high tibial osteotomy. Start your clinical evaluation by making the patient stand and observing the alignment of the lower limb. Which will reveal the deformity.
Gate is the best way to assess dynamic instability and look for Vargas trust and the team in the stands face. Measure the values deformity in supine with a goal your meter and check whether it is correctable or whether it is fixed. Look for any recovered item and collection contracture and assess the range of motion. Check the competency of ligaments, especially the ACL and the ACL.
Look for any systemic features of inflammatory property and document the status of the company ulnar nerve. Other than the standard mixed reviews, if realignment osteotomy and unique compartmented arthroplasty are options considered, then ask for Rosenburg view and virus rescues. Egawa standing long leg.
The mechanical and the anatomical axis is critical in planning the distal femoral and the proximal tibial dissections. The metaphor is in Vargas. In the distal femur and approximate tibia is best appreciated in the long leg limbs, and when you are planning the vets for the osteotomy is done on it. I will come to that a little later.
General deformity Allen can be classified according to the clinical radiological classification by Iran over in the long leak classified from grade 1 to 3. With increasing severity of deformities, grade 1 consists of 80% of the cases, with mild less than 10 degrees of correctable deformity, with intact epimysium grade to 10 to 20 degrees with attenuation of the ACL, but functionally intact and grade 3 with severe more than 20 degree deformity with a known epimysium.
In the AP view, look for lateral femoral container hyperplasia. And which is which affects the distal femur bone cuts. The bone defects in the lateral tibial plateau and the medial opening are important in determining the proximal tibial dissections. In the lateral view, look for the lateral posterior container hyperplasia and location and the presence of lateral tibia bone loss.
Also, look for the patella height as Baja is commonly associated with knees. In the skyline, you look for the severity and breeding of arthritis and for tracking subluxation and dislocation of the. Virus stress radiographs are mandatory when considering lateral compartment and knee arthroplasty to assess the presence of full thickness cartilage loss in the medial compartment and the conforme.
Whether the deformity is fully correctable to improve, which is one of the prerequisites for that, will you? Rosenberg view is the best radiological view to evaluate lateral and medial tibial cartilage where critical when considering an osteotomy or a unique compartment in the arthroplasty. Surgical options other than totally arthroplasty includes lateral unit compartment arthroplasty and distal femoral osteotomy.
The aims of broadening arthroplasty in balcony is similar to other indications of arthroplasty. The depending upon mainly the surgeon preference, totally arthroplasty in Bulger's knee can be carried out either by a median or a lateral approach. Middleborough Butler is the standard approach, which is familiar for the most orthopedic surgeon you version of the patella in this approach is easier due to a combination of deformity and localization of the tibial tubercle.
Disadvantages of this approach includes limited access to the lateral structures, especially the post-war posterolateral corner for soft tissue release. This approach would lead to be vascularization if additional data release is required to improve that tracking. Lateral approach allows for better surgical view, better direct surgical view for the lateral contracted elements, which facilitates this release.
There is no risk of Kessler devascularization as the latter release is a part of the approach and the medial vascular supply for the extensor mechanism is untouched. If tibial osteotomy is done as a part of the approach, it is possible to neutralize and improve the tracking. The collateral better Butler approach there, there is a difficulty, there is difficulty in particular abortion.
And there is limited middle compartment exposure if people tubercle osteotomy is not done. After adequate releases laterally to achieve balance, there may be a defect in the lateral retinaculum during the retinacular closure, which requires advancement of the fat part, or is it plastic of the capsule to facilitate the closure? Let us now talk about the bone cuts in the valgus knee the Vegas angle cut reference both the anatomical axis is reduced from the normal 5 to 7 degrees of algos to three degrees.
So as to compensate for the metaphor is your diaphragm while this remodeling and to avoid under correction. Caution is taken, nor to all risk the lateral epicondyle to avoid marked elevation of the join line. The proposed femoral dissection is kept minimal, usually around eight AM from the medial epicondyle and no more than 10.
This is usually this may result only in minimal or no lateral resection in severe while this deformity cases. People protection is kept to the minimum, usually around only around 5 to eight am or from the medial tibial plateau with minimal or no bone removed from the lateral side. In severe, well, just needs.
With regard to funeral component rotation and sizing, lateral condyle hyperplasia makes for speedier fontella referencing inaccurate. There is a tendency to put the moral component into internal rotation with excessive resection of the already hypoplastic lateral posterior epicondyle. This internal rotation of the component increases the hue anchor by obligate medial placement of the group.
And results in abnormal satellite tracking, this also results in trapezoidal flexion gap, wider lateral. Recreational referencing should be done on the proposed posted of eyesight's line or with the slap epicondyle line in valgus city. You've posted a container referencing is used by more external rotation. About 5 to 7 degrees.
From the normal three degrees to build up or build up on the positive aspect of the latter contained within your tone during sizing and determining the location. In Sibile Vargas mi, the structures there are light. There are tight little structures, there will be laxity of the skin and the PCL. The title battles factors can be of two types.
That there are structures which are inserted at the flexion extension axis at the lateral epicondyle. That that is the lateral collateral ligament and the completist tendon, which is isometric, really tension in both extension and flexion of the knee. And the structures inserting away from the axis, like the IT band and the post-war little capsule and the lateral head of the muscles, which actually in extension.
After executing the bone cuts, there are two possibilities. One is to 1 is a symmetrical, rectangular flexion extension gap. When no further release is necessary. And the other possibility is that the gaps are trapezoidal. Then further soft tissue releases are necessary. The best sequence and the technique to perform the lateral release in Vegas is debatable.
One popular technique is the what's inside out technique. In this technique, the knee is extended. And spread out with the spreader. Brad Pitt for the tight structures laterally, which Hinders the balancing of the gaps in this technique, the first structure to be released is the posterior cruciate ligament. Then after that, the post-war posterolateral corner is released from the surface of the tibia, from the PCL to the posterior border of the band.
And then we release the IT band by multiple stab incision, centimeter proximal and higher to the tibial cut surface. If the need continues to be tight, inflection rarely complete, completely standing can also be released. After the lateral structure release, if the gaps are not balanced.
One might consider 1 May consider emcee an advancement that is the epicondyle origin of the lax emcee is advanced proximally and secured with a suture anchor or a staple. The other option for MQL tightening is improvisation, where the substance of the ACL is divided and implicated to equalize the doing gaps. After taking after.
Check the tracking of the Petrella after releasing the tourniquet. If the Butler lateral male tracking persists. After confirming the optimal component position, the lateral release is to be performed in the inside out technique. The lateral return column is exposed. And the red column is incised. From the mid Bachelor level to the upper DBL border, centimeter lateral to the patella.
For the proximal retina, regular release endangers the superior lateral artery and. Usually it's not required to extend it, so really. Email deformities where soft tissue balance can be restored without PCL release, a minimally constrained seizure component could be implanted.
In Vegas knees. Most surgeons prefer a penis implant as the PCL is going functional. The implant also allows greater liberalization of the component with better particular tracking, although the PSA component provides some degree of posterior stabilization due to compose mechanism and also some translation the post-raw medial and the posterior lateral direction, it will not protect against residual medial laxity.
In severe deformities where there is significant collateral laxity, the virus well in plan may be necessary. Component augmentation may be required if there is bone loss and to restore the join line. The Krakow in his review article noticed increased incidents of instability, recurrent wildfires, deformity and patellar complications with Walt Disney totally arthroplasty, the common perennial no policy incidents was.
Found to be three to four percent, which was attributed to the attraction of the nerve during the lateral lengthening or. The direct injury while performing the pipe casting technique. With the common perennial, no policy is discovered for stock. The compression, the sinks are removed and the knee is flexed to relax the tension of the nerve and then expectant management is advised.
This femur osteotomy is the osteotomy of choice in while gives me an ideal candidate for this femur, osteotomy is a younger, active patient who is able to comply with post-operative rehabilitation, which includes non weight bearing walking for a period of time. In the presence of wagga's malalignment associated with isolated early little compartment arthritis.
This femoral osteotomy is contraindicated in Tri compartment in osteoarthritis. Inflammatory arthritis or severe articular disruption of the battery compartment. Well, this deformity more than 20 degrees flexion contractions, more than 15 degrees and knee flexion more less than 90 degrees are also contraindications for distal femoral osteotomy. Relative contraindications include ligament instability, which needs one or two stage reconstruction along with the osteotomy.
In case of associated ACL injury. Emcee laxity seemed to improve after this femur osteotomy. Even though they still femoral osteotomy is favorable with regards to alignment in patients with high BMI because of improved thigh clearance because of increased complications. BMI, more than 30 is a relative contraindication. Yes, battle of articulation improves after the still femoral osteotomy mild to moderate battle of arthritis is not a contraindication for those tenotomy severe osteoporosis and nicotine use.
Is related to delayed wounding at the osteotomy site. The two main types of distal femur osteotomy are the. Natural opening with the osteotomy and the medial closing windows tenotomy. The tape of the osteotomy is mainly based on the surgeon preference, but the general consensus is that moderate corrections up to 1 degree of correction is better obtained by a natural closing width.
And for larger correction. More than 12 degree immediate closing with Freeman osteotomy could be a better choice. Advantages of lateral opening with osteotomy include better control of distraction when optimizing the mechanical access. It's a more familiar approach to the lateral distal femur for most surgeons. Advantages of the medial crossing with the osteotomy is direct bone to bone healing and avoidance of bone grafting in the open wedge technique.
Correction is achieved. Correction achieved is better maintained. Although nicotine use and osteoporosis are relative contraindications in osteotomy, posing with those tenotomy is preferred over lateral opening within these situations, because of that, a healing. There is less hardware because of the plate not being directly under the bed.
Rosenberg view is a mandatory view in this femur osteotomy surgeon believe that either an MRI or an intraoperative r-truth should be performed in diagnosing control and ligament alterations before the post-mortem is performed. The osteotomy planning is done on Long Lake films by the dovedale method, the correction angle is calculated by the angle form between two lines.
The first line drawn from the center of the head to the 50% Coordinate in the medial tibial plateau and the second line drawn from the center of the handle to the same point. By measuring the width of the femur at the level of the proposed osteotomy surgeon can convert the angular correction into the size required. Back steam in a series demonstrate a 10 year survival ship of 82 percent, with a significant decline to 45% at 50 years after the was reopened.
Lateral combat, mental arthroplasty E10 is 10 times less perform, then medial unit compartment. Arthroplasty that's representing less than 1% of all totally arthroplasty, 1% of all knee arthroplasty because of the low numbers, limited long term results are available for lateral.
An ideal candidate for a UK is a patient with isolated bone to bone arthritis in the lateral compartment with preserved medial peel-back with intact anterior cruciate ligament. Fully, passively correctable pelvis deformity. Other than, like environmental and inflammatory arthritis, while there's more than 15 degrees, any known correctable this range of movement less than 100 degrees and any flexion contractors are absolute contraindications for that unique compartment arthroplasty.
Recent studies have shown that. Lateral UK, where is more related to activity than to be a mine? Ligament instability needs to be corrected before the. Natalie and previous was tenotomy, or any surgery altering the knee biomechanics. It totally arthroplasty should be considered. Over that unique compartment, lots of plastic.
Lateral UK is technically more challenging than medial UK due to anatomy and biomechanical differences between the two compartments. The main differences are the relative lateral ligament laxity. That being more divergent and convex medial peel-back and the lateral fontella rollback and the whole mechanism in extension. Due to these factors, there is more chance of component dislocation and femoral component impingement on the patella inflection and the tibial spine extension.
You overcome the dislocation risk. Some voters suggested fixed bearing implants for lateral. Impeachment can be minimized by catalyzing and avoiding oversight of the funeral component. You may reason systemic review on the survivorship. Even though the lateral. UK is more challenging technically. Both the UK and the UK was found to have similar survivorship with no statistical difference in the survivorship and UK survival at five, 10 and 15 years respectively.
95 percent, 93% and 89 percent, respectively. Thank you. For the other questions, I have a couple of questions for you. Does age play any part in choosing which one to you go for? Do you go for, you know, do you have a cut off where you say, definitely, I'll go for total knee replacement rather than a uni or osteotomy or age doesn't play any part in it? Yes so more than age in natural uni compartment, the knee arthroplasty, it is the activity level of the patient that decides the decides the choice of the surgery in case of distal femoral osteotomy the patient.
Should be relatively young patient who is able to. Cooperate with rehabilitation. Use of walking aids and non weight bearing walking in case of unique bombardment. There is no age limitations. You can do unique combat mental knee replacement in any age group. But the survivorship is less if the patient is more active, so activity level determines which.
Is the surgery of choice for a particular patient? Mm-hmm OK. The other question is now do you have an algorithm or a guide on which one to choose? For example, you've got a 50-year-old office worker who is coming with a vacation? Would you go for a total? Would you go for uni or would you go for osteotomy? This is the exam scenario.
They present you with that and they ask you, which one do you go for? How do you choose? And how do you phrase your answer in the exam? Right so a 50 year old, 50-year-old patient like we, we will be more inclined to doing this. Freeman osteotomy. So my answer will be that I will be taking a detailed history, especially looking at the activity level of the patient and the functional limitations of the condition.
But what the condition, what functional restrictions the patient is having. I would ask about. We make whether the patient is a smoker, what is whether what is the medical comorbidities of the patient, whether the patient will be able to. They cooperate with rehabilitate we whether the patient has got rehabilitated potential to avoid, to cooperate with non weight bearing walking post-operative.
Then I will be basing my decision based on these factors. Absolutely fine. Another question from Barry Vann. He asked about how do you differentiate between Rosenberg and tunnel views? The talk, the Rosalba view is the it's another name of the tunnel view. It is actually it's supposed to a view of the knee taken in 45 degrees of flexion with 10 degrees of caudal and motion of the X-ray beam.
So according to my knowledge, the tunnel view is same as the Rosenberg view. Anybody else? I looked into that one as well. But yeah, so I have a tunnel view is looking at the intercom, the notch more so than Rosenberg view and the one big specific differences. Rozenberg is generally weight bearing and a Pas view. A true tunnel view is non weight bearing and AP view.
OK, so that's my understanding, but I mean, what we might consider a tunnel view and what a radiologist might consider a tunnel view is completely different. That's the problem sometimes. In reality, I think both are interchangeable and people use one for the other. So as long as basically what you are looking for, I think it's in real life in the exam.
They will forget, they will forgive you. I think if you mention it, unless you've got a really are unlucky and you've got a particular examiner who would want you to know the difference between the two. I don't think that matters. No, I would say to you, be prepared. If you're going to say Rosenberg for you and avivah, just have a quick I say, just if they say, what's a Rosenberg for you to say quickly?
Oh, it's a few weight bearing 30 degrees or 40 to five degrees, they'll be fine. Perfect no one will ask you, what's the difference between that and the tunnel view unless you mention both. That's the thing. The technique of the exam is the examiners are not there to take you. They will ask you and they will ask you based on what you say.
So if you say rozenberg, they may ask you what Rosenberg is. They will never ask you, how do you differentiate between that and the tunnel view? Yeah, OK, fine. I just want to add something for the age regarding whether to use only comportamento or total replacement. There is a nice paper published last year in the BMJ. Actually, it's the age is not a factor.
So whatever the indication for the patients and x-ray, if it's suitable for unit comportamento will do that. However, you may like discuss that with the patients, according to the pros and cons of every one. Yes, like the rate of revision is a much more in the unit compartment than the total knee replacement. But the age itself, it is not a factor, and sometimes it irritates the examiner to say I will do the compartment in young patients and do two to any replacement in all the patients.
Sometimes not. It's not a better answer to say. Yeah OK. So you can mention it's a physiological age rather than chronological age for this age. Yeah OK, next question. Mohamed egawa, I may have to ask you to explain it. The question is written how do you differentiate between vulgar need due to osteoarthritis.
And that due to rheumatoid if due to osteoarthritis, you will deal with it in a different way? So I'm guessing because you mentioned that osteoarthritis is a contra indication, how do you differentiate between the two? Is that what you wanted? Mohammed, I mean, if you have an advanced degree of osteoarthritis. And you are going to replace the knee, how you differentiate from the ideology that this is due to advanced osteoarthritis or it is or is him Flipper arthritis?
So again, with its surgical tips and tricks that the hypoplastic clutter and bas status female epicondyle. OK, so in case of radiological differentiating between an inflammatory arthritis and osteoarthritis in inflammatory arthritis, there will be a distinct, symmetrical collapse of the joint space and osteoarthritis likely it will be an asymmetrical collapse of the joint space with opening up of one.
Compartment with the obliteration of the space on the other side, the other features of inflammatory arthritis will be evidence of soft tissue swelling. The associated articular osteopenia and paucity of osteoarthritis. That is how you both are. The radiological differences between inflammatory arthritis and osteoarthritis.
In addition, the patient normally can tell you because, as you know, inflammatory arthritis is multi joint, so they will usually come with more than one joint at the same time, including it's a systemic disease, so bilateral symmetrical arthroplasty usually. In addition, if you have three compartments, then by definition you can whether the reason is osteoarthritis or rheumatoid because you can't apply Vargas technique if it's dry compartmentalized.
And that's the reason for the rheumatoid arthritis being excluded because it affects all compartments at the same time. So, for example, if you do osteotomy, it will fail very quickly because the disease is progressive. The same thing about unit compartment on only does that answer your question, mohammed? Yes, to some extent, yeah, I because I suppose to avoid Disney, we were replacing the but.
We don't know. You don't. You cannot detect from the preoperative X-ray if a lot of female epicondyle is really hyperplastic as inflammatory arthritis, and in this case, you have to depend on the Enter epicondyle or the right side line. Or you can or you will deal it, deal with it as a conventional osteoarthritis with no tips and tricks.
I think going to it was confusing theology, whether it is because of osteoarthritis or inflammatory arthritis or hyperplasia, is likely to be present in this league. So in case of Bulger's knee, like one way, while you're determining the femoral rotation and sizing, if you observe the disparity between the epicondyle Allen and the Whiteside's line with regards to the posterior referencing, then you have to be careful.
You usually depends on either the apex line or in the Gondola in the epicondyle line for your professional reference. Yeah, it's always a good technique, but not rely on only one method. I know many surgeons who would rely on the posterior referencing and white side lines, and they measure both. And if there is a discrepancy, they will dial it like an external rotation in the matter. It's just a matter of making sure that you are doing it correctly.
Fine moving on. So the next question is from nabard and and he says in general for Vargas knee, which approach is considered the standard one medial or lateral? Yeah, so basically, like, you know, I have seen in my practice like hardly one or two like lateral approaches to the well with me, even in mild.
So basically when you consider mild, moderate and severe mild cases accounts for around 80% of the cases. So there is no ambiguity that we should be going. Usually we'll be going with the like a medial approach. But the question comes when in very severe needs, very severe needs. Yes, even with the middle propeller approach, what I find is your exposure is adequate because as I mentioned, your Kessler evolution is easier and you have got reasonably good, generalized better exposure of the knee and you have an access to the access to the lateral structures.
Even with the middle propeller approach, but there are so few less lateral therapies for very severe needs. But for me, I always go. We've begun answering the exam. The key thing is to say, in my practice, I will use the medial patella approach because that's what I know. That's what I'm comfortable with.
However, I understand the principles behind the lateral approach and say it that way. Get out of jail. They want you. You want to demonstrate that you're a safe, competent surgeon, not someone who's going to dry. If you suddenly just say, I'm going to do the lateral approach that might go. How many times have you done a lateral approach?
I think I've worked with many of these surgeons, and I do think that they would say they're probably only done it. Well, 10 times in the whole career out, 1,000 times are done the medial approach. So it is a very rare approach. But as long as you can say, I understand the principles behind that will get you through. Another scenario that may come in the exam is if it is severe Vargas and the decision tree led you to doing a knee replacement, then it is safe to say in this case, it is significantly severe Vargas knee and I anticipate that the ligaments will would have contracted and all of that.
I draw the a arthroplasty surgeon who does this frequently deals with that because this may need a lateral para patella approach, which I know the principles of, but I haven't done enough. So again, this is another get out of jail card, which you can use. But that is only if it is severe because, as GQ has mentioned, it is 80% of the cases is mild where medial approach is enough.
Another question. He was asking and that's a sum I think he was asking. Should we prefer to use bee's knees and inflammatory arthritis? I think I got that right. Islam, if that is the wrong. A question, if I didn't get it right, please correct us.
Mason Yes. I'm asking about the state of stabilizing or sacrificing, I think it's sacrificing because people will not be competent. That's right. Jacob, Yeah. So inflammatory arthritis like it is one of the described the previously described the indications for his knee, but but there have been papers which suggest suggested the seizure implants or anterior stabilized or condylar stabilized implants for inflammatory arthritis.
So recently, there is more of a trend in using the Greek cruciate retaining implants, even in rheumatoid arthritis. But for the exam, I think we can still stick with the answer that the inflammatory arthritis? You will go for. Excellent. Thank you.
Thank you. Thanks may I ask everyone else is not asking the question to mute, please and I will ask the next question. But while we are waiting, anyone who is interested in doing the Viva, please raise your hands. I have got three people who have raised their hands. So far. We have got many Viva nice Viva questions today for you guys, so please contribute.
If anyone is interested, raise your hand by clicking on the Raise Hand button underneath your name. So next question is for Mohammad egawa again. Do we have a limit in the Vargas angle when we do digital cut? Limit, yes, usually like, you know, when in your general practice, you usually cut a five degrees. Between a 5 and seven, that is your normal standard virus or any cut will be in case of taller people and in case of this deformity.
Are your femoral the femoral fontella cut should be reduced to. Up to around three degrees, so this in Vegas means is because there will be a Vegas remodeling of the metaphors or their facial. When you do, when you put in your operatively guide, you are there is a bit of in-built well. Or in Bidwell goes in that measurement itself.
So you reduce your well, guess, cut to around 3 degrees. But the more critical question that you are asking is how to get a neutral mechanical alignment, which is we got by cutting perpendicular to the mechanical axis. So as long as you do your templating. Of the distal Vargas cut borrowing a mechanical axis on the long leg, Williams, you will get an idea about how much well guess cut you require, but hardly ever you go.
Uh, less than three degrees while gas cut in Texas. OK another question, which is about the rehab post, Australia Post the osteotomy, what is your protocol for rehabilitation after a femoral osteotomy? Yeah, so my protocol for this femur osteotomy after. It depends on the type of osteotomy that I do, I usually do a lateral opening with the osteotomy, with the lateral opening, with the osteotomy, you definitely wear non weight bearing to attach weight bearing for at least four weeks with a meter closing the doors to your tummy with the more stability of the osteotomy with bone to bone contact.
I don't do middle closing with your osteotomy, but even if you do middle crossing with osteotomy, we can allow a bit more weight bearing around 50% weight bearing can be. Hello So usually around four weeks of non weight bearing weight bearing that will be the range of movement to begin immediate posture. Excellent good. Thank you very much, GQ.
I know that you have other things to attend to the time difference. I think it's time for you to go be somewhere. Any other questions, guys? OK, thank you very much, GQ. It was very good, very comprehensive and clear answers, thank you very much for all the people who stood questions.
It will now. The recording and then we will move to the Viva session.
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