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Tibial Tubercle Osteotomy (TTO) in Revision Knee Replacement by Dr. Anoop Jhurani
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Tibial Tubercle Osteotomy (TTO) in Revision Knee Replacement by Dr. Anoop Jhurani
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T00H15M33S
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https://cadmoreoriginalmedia.blob.core.windows.net/1e07d881-12da-4521-853c-0663c97f0676/Tibial tubercle osteotomy (TTO) in Revision Knee Replacement.mp4?sv=2019-02-02&sr=c&sig=COfNrAoLO70z7kY4fqP32z%2BdwVtpruyUq5hoyqbGTXc%3D&st=2024-11-23T09%3A55%3A56Z&se=2024-11-23T12%3A00%3A56Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision decay in an infected knee. So as you can see, this was a 60-year-old gentleman who had a primary total knee about three years back. He got immediately infected and the knee was removed and a spacer put. He grew MRSA and then it still he was infected, so a second spacer was done with extensive debridement.
ANOOP JHURANI: All the three procedures were done elsewhere. So we received the patient, as you can see now. Interestingly, the patient has extra articular deformity, as you can see. So the patient had an extra articular deformity in the revision decay, which makes it very challenging. The patient has got a spacer, three surgeries, extensive scarring, we'll show you the soft tissues.
ANOOP JHURANI: And very important to observe here is a patella baja, a very severe patella baja with scarring of the infrapatellar tendon and the scarring there. This you can see is the extra-articular deformity, it's in varus deformity, the sagittal plane is all right, coronal there is a varus of about 10 degrees at the fracture femur site. But our plan is to correct the extra-articular deformity, intra-articular, and not complicate it more by doing an extra-articular osteotomy because very high up you can't fix it with the stem of the femur, it's so high up.
ANOOP JHURANI: So we'll let the extra-articular deformity be there, it's an old fracture. We'll correct the deformity intra-articular because as I said, if we do extra-articular osteotomy here, then it's too high up for the stem to fix the fractures, so we'll be probably complicating it more. So this is the challenging situation here, currently the ESR CRP are normal and the patient has taken appropriate antibiotics for a good amount of time.
ANOOP JHURANI: And now the patient is silent, there is no clinical sign of infection as you can see that there is extensive scarring anteriorly. This been operated three times. The lateral scar is of the previous fractured femur. So there is extensile lateral scarring. So we have to take into account that the range of motion is only 0 to 30 under anaesthesia, so it's only 0 to 30,
ANOOP JHURANI: there is no collateral instability so we are not expecting a hinge here. {INAUDIBLE} backup. So we're expecting a normal revision TKA with a highly constrained poly, but not a hinge. As far as the exposure is concerned, it's very important to go for meticulous exposure there because there is extensive soft tissue scarring. We go on the most lateral part of the incision.
ANOOP JHURANI: The incision is midline, but there are three incisions. So we go in the most lateral part and then as a procedure of choice, in this particular case, we are doing a tibial tubercle osteotomy because of scarring, stiffness and, most importantly, patella baja. So we'll be able to proximalize our osteotomy and take care of patella baja, at least to some extent. So there is extensive patella baha, very stiff knee, very tight knee, only movement 0 to 30 with a spacer in situ.
ANOOP JHURANI: So the best is to prevent any aversion, go for a tibial tubercle osteotomy right at the outset, even before a rectus snip. Because if you do a rectus snip and then do a {INAUDIBLE}. We have actually compromised the quadriceps expansion at two regions, both proximally and distally. So if we are thinking that this is a very stiff knee, it's not going to flex for us to complete the reconstructive procedure.
ANOOP JHURANI: We should do a tibial tubercle osteotomy right at the outset. The principles are the osteotomy is 3 to 4 centimeters, about half a centimeter wide. We make a few drill holes and then with a sharp osteotome raise the {INAUDIBLE} of the tibial tubercle osteotomy We don't need to make it very long as described by Whiteside, but this is enough of three to four centimeters, but we have to be very careful, it should not be thinning out because if it's thin, it will crack.
ANOOP JHURANI: So it has to be about half a centimeter. It should take the thick part of the tibial tubercle. And once you do that, it's very easy to reflect the quadriceps expansion laterally. We are doing a lateral release also here at the outset because of the extensile lateral scarring. Otherwise the patella just won't go lateral. Once we do that, then we start exposing medially. So the lateral work comes first.
ANOOP JHURANI: In this case a tibial tubercle osteotomy, a lateral release, will help us gain knee flexion, then some medial release. We have to ensure we don't cause any instability, we don't harm the medial collateral ligament. Hence all the work for the knee flexion should be done laterally. Once your lateral quadriceps expansion starts giving away, it's supple enough, the knee flexes.
ANOOP JHURANI: So we have not done the rectus snip here, because the knee was very stiff. We have done a tibial tubercle osteotomy. Now the spacer comes out. You can see the femoral part. It's a prefabricated spacer. We take it out easily. Not much of a challenge there. Do extensive debris, remove every bit of suspicious synovial tissue and send samples also. We send three samples at least, the ideal is to send five samples from various aspects of the joint, especially the medullary cavity, and look for cells per high power field and the cell count.
ANOOP JHURANI: Those are the two things that we need to see. The cells per high power field have to be less than 10, and the cell count has to be less than 2000. Then we remove the tibial and the femur spacer. There is an intramedullary cement block in the tibia and we have to remove that very carefully because that is stuck. We are expecting some trouble there because it is incarcerated in the tibia.
ANOOP JHURANI: So we are removing the osteotomy. We have put a drill in the cement block inside the tibia and we are removing it. It will take some time. We have to be gentle. We have to be expeditious. We don't have to cause any damage to the bone because there is already a tibial tubercle osteotomy and there it comes out beautifully.
ANOOP JHURANI: The whole thing, the block of cement into the tibia. Once all that is removed, we do extensive debridement, we do extensive pulse lavage with betadine and antibiotic solution and remove every bit of suspicious tissue, thorough curettage of bone throughout so that there is no reinfection. We can't afford a reinfection in a revision TKA. So all that tissue comes out and then we take the tibia out and remove all the fibrous tissue.
ANOOP JHURANI: We have to be careful. There is a tibial tubercle osteotomy there. So we don't have to damage the anterior cortex of tibia. Then we assess the gap. This is the extension gap. You can see it's a tight extension gap, and the flexion gap is bigger. So flexion gap is bigger, extension gap is tight. So we have to upsize the femur component.
ANOOP JHURANI: Then we drill the femur tibia and take a minimal tibial cut. It's in varus, so obviously it will cut laterally, it won't cut anything medially. You can see that. So we are cutting lateral because the tibia has failed in varus. So we are taking the tibial cut with the help of an intramedullary rod.
ANOOP JHURANI: Then we'll check that the tibial cut is perfect and then we start reaming for the tibia for the tibial stem. So reamers are progressively and when it catches the cortex of the tibia, that's our stem size. We externally rotate the tibial component appropriately so that we aid in patella tracking. And we use offset stem here so that we can lateralize our tibial component. This system of Smith & Nephew allows for offsetting the tibial stem at the metaphyseal area.
ANOOP JHURANI: So we are not trying to promote any particular implant, but this system has the advantage of offsetting 360 degrees the stem. So then we are preparing for the tibia and ensuring appropriate external rotation. Then we go to the femur. Since the femur is an extra-articular deformity, we have to enter laterally. If we enter conventionally, we'll be in gross varus.
ANOOP JHURANI: So we have to enter quite lateral actually through the lateral condyle. As you are seeing here, we are entering laterally so that our cut does not cut anything medially. Only then we'll be able to compensate for the extra-articular varus that we have at the middle third of femur. So you can see that our entry hole into the femur is quite lateral.
ANOOP JHURANI: It's from the lateral condyle and we are using a short cemented stem because we can't use a long cemented stem, long uncemented stem because of the extra-articular deformity. So we are using a short, we are planning for a short cemented stem and preparing accordingly, from the lateral condyle. We check under the C-arm to ensure that we are correctly placed.
ANOOP JHURANI: Then the distal femur cut has to be very minimal in appropriate values. Only medial part will cut and I beg your pardon, only lateral part will cut. Nothing will cut medially. Then we size the femur. We are upsizing by one. It's a size 5 femur. So that we tighten up our flexion gap.
ANOOP JHURANI: We also see medial laterally. It should not overhang and we'll be using offset femur rods so that we place our femur component appropriately, laterally and posteriorly. So that we snug up our flexion space. We should not {INAUDIBLE} anteriorly, that's very important. Fixing the {INAUDIBLE}, as you can see here, taking a rough anterior cut in appropriate external rotation.
ANOOP JHURANI: So the {INAUDIBLE} has to be parallel to the {INAUDIBLE} axis and the tibial cut, that's important. So we are parallel to the tibial cut, as you can see here, and the external rotation looks good. So the {INAUDIBLE} boot or the grand piano sign is there, showing that we are adequately externally rotated. Then we prepare for the offset stem because we are offsetting, so that we can {INAUDIBLE} rise and lateralise our femur component.
ANOOP JHURANI: Once that is done, we do the final box cut for the revision femur. On the femur side we have a 16 rod. On the tibial side, we have a 14 rod offset so that we place our components appropriately laterally. Then we take a minimum poly because it's very tight in extension. You can see that the tibial tubercle osteotomy is there and that is the range of motion, about 0 to 80-90 that is expected in this patient.
ANOOP JHURANI: We are getting good extension, not hyperextension. We will have to avoid a or hyperextension. We have to avoid flexion laxity. So those are all very important things in the revision TKA, drilling some holes for cement preparation. The femoral stem has to be cemented in this case because it's a short canal, it's extra-articular deformity. We can't bypass the canal, so it's a short 16 cemented stem.
ANOOP JHURANI: And then for the {INAUDIBLE}, before we put our tibial implants in, we are drilling holes from lateral to medial and passing this external wire which our cardiac friends use for closing the sternum after bypass. This comes on a needle and we pass the wires before we put the components anterior to the stem. Anterior to the stem, not posterior, because otherwise you cannot tighten it.
ANOOP JHURANI: Once the cement sets in, you cannot pull the wire. So it is anterior on the anterior cortex before we put out the stem. So you can see that we have passed two wires, external wires on the anterior cortex, and then we'll just keep it on the anterior cortex so that we can tighten it after the cement is set. That's very important to {INAUDIBLE} and pass the wires {INAUDIBLE}. So that's the way to close the tibial tubercle osteotomy, thorough pulse lavage and then we are ready for implantation.
ANOOP JHURANI: You can see that the tibia and the femur components are offset so that we have laterals them and position them appropriately. On the femur side we are using a short cemented stem, so we are cementing into the canal. So actually two or three packs of cement, two on the femur, one on the tibia and enough {INAUDIBLE}, 16 inch diameter, five femur goes in nicely. It's lateralized to {INAUDIBLE} patellar tracking 14 stem and a three tibia goes in lateralized and 11 poly.
ANOOP JHURANI: So this gives us very good stability in flexion, gives us nice stability in extension. We release some more laterally so that it helps. In patellar tracking we have debugged the patella on the inferior pole, so that it does not impinge on. the poly, patient is counselled that the range of motion will only be 0 to 80 or 0 to 90. Now this is important. We are proximalizing the tibial tubercle osteotomy, so that the patella does not impinge on the poly and takes care of the patella baja. Normally when we close the tibial tubercle osteotomy the nodes of the wire have to be in the lateral soft tissue, but here there is extensive lateral scarring.
ANOOP JHURANI: So we are tying the nodes on the medial side. So those are the nodes on the medial side and you can see that the osteotomy is proximalized by about half a centimetre. Those are the final X-rays. There is still patella baja, but this is the best that we can do after a tibial tubercle osteotomy proximalization, it's not hitting the poly much and we expect the range of motion anywhere between 0 to 70 to 0 to 90.
ANOOP JHURANI: Overall alignment is good, the tibia stem is uncemented, the femur stem is cemented for the reasons that we have discussed before. The overall alignment is pretty decent. We also have a full length X-ray to see the overall alignment. The range of motion is started about 0 to 30 initially and full weight bearing patient with a Walker. Gradually the knee movement will be increased once the osteotomy starts uniting.
ANOOP JHURANI: So these patients generally would get anywhere between 0 to 70 to 0 to 90. But tibial tubercle osteotomy has helped us do two things. One was to expose this very stiff knee joint, a multiple time operated, and second, proximalization so that we take care of patella baja. That's the overall alignment, you can see in spite of the extra-articular deformity with the revision TKA, the overall alignment is pretty decent, and we expect good results if the infection does not recur.
ANOOP JHURANI: The Baroque cultures that we took during the operation were sterile for any microorganisms, so we hope for a good result in this patient. Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision decay in an infected knee. So as you can see, this was a 60-year-old gentleman who had a primary total knee about three years back. He got immediately infected and the knee was removed and a spacer put. He grew MRSA and then it still he was infected, so a second spacer was done with extensive debridement.
ANOOP JHURANI: All the three procedures were done elsewhere. So we received the patient, as you can see now. Interestingly, the patient has extra articular deformity, as you can see. So the patient had an extra articular deformity in the revision decay, which makes it very challenging. The patient has got a spacer, three surgeries, extensive scarring, we'll show you the soft tissues.
ANOOP JHURANI: And very important to observe here is a patella baja, a very severe patella baja with scarring of the infrapatellar tendon and the scarring there. This you can see is the extra-articular deformity, it's in varus deformity, the sagittal plane is all right, coronal there is a varus of about 10 degrees at the fracture femur site. But our plan is to correct the extra-articular deformity, intra-articular, and not complicate it more by doing an extra-articular osteotomy because very high up you can't fix it with the stem of the femur, it's so high up.
ANOOP JHURANI: So we'll let the extra-articular deformity be there, it's an old fracture. We'll correct the deformity intra-articular because as I said, if we do extra-articular osteotomy here, then it's too high up for the stem to fix the fractures, so we'll be probably complicating it more. So this is the challenging situation here, currently the ESR CRP are normal and the patient has taken appropriate antibiotics for a good amount of time.
ANOOP JHURANI: And now the patient is silent, there is no clinical sign of infection as you can see that there is extensive scarring anteriorly. This been operated three times. The lateral scar is of the previous fractured femur. So there is extensile lateral scarring. So we have to take into account that the range of motion is only 0 to 30 under anaesthesia, so it's only 0 to 30,
ANOOP JHURANI: there is no collateral instability so we are not expecting a hinge here. {INAUDIBLE} backup. So we're expecting a normal revision TKA with a highly constrained poly, but not a hinge. As far as the exposure is concerned, it's very important to go for meticulous exposure there because there is extensive soft tissue scarring. We go on the most lateral part of the incision.
ANOOP JHURANI: The incision is midline, but there are three incisions. So we go in the most lateral part and then as a procedure of choice, in this particular case, we are doing a tibial tubercle osteotomy because of scarring, stiffness and, most importantly, patella baja. So we'll be able to proximalize our osteotomy and take care of patella baja, at least to some extent. So there is extensive patella baha, very stiff knee, very tight knee, only movement 0 to 30 with a spacer in situ.
ANOOP JHURANI: So the best is to prevent any aversion, go for a tibial tubercle osteotomy right at the outset, even before a rectus snip. Because if you do a rectus snip and then do a {INAUDIBLE}. We have actually compromised the quadriceps expansion at two regions, both proximally and distally. So if we are thinking that this is a very stiff knee, it's not going to flex for us to complete the reconstructive procedure.
ANOOP JHURANI: We should do a tibial tubercle osteotomy right at the outset. The principles are the osteotomy is 3 to 4 centimeters, about half a centimeter wide. We make a few drill holes and then with a sharp osteotome raise the {INAUDIBLE} of the tibial tubercle osteotomy We don't need to make it very long as described by Whiteside, but this is enough of three to four centimeters, but we have to be very careful, it should not be thinning out because if it's thin, it will crack.
ANOOP JHURANI: So it has to be about half a centimeter. It should take the thick part of the tibial tubercle. And once you do that, it's very easy to reflect the quadriceps expansion laterally. We are doing a lateral release also here at the outset because of the extensile lateral scarring. Otherwise the patella just won't go lateral. Once we do that, then we start exposing medially. So the lateral work comes first.
ANOOP JHURANI: In this case a tibial tubercle osteotomy, a lateral release, will help us gain knee flexion, then some medial release. We have to ensure we don't cause any instability, we don't harm the medial collateral ligament. Hence all the work for the knee flexion should be done laterally. Once your lateral quadriceps expansion starts giving away, it's supple enough, the knee flexes.
ANOOP JHURANI: So we have not done the rectus snip here, because the knee was very stiff. We have done a tibial tubercle osteotomy. Now the spacer comes out. You can see the femoral part. It's a prefabricated spacer. We take it out easily. Not much of a challenge there. Do extensive debris, remove every bit of suspicious synovial tissue and send samples also. We send three samples at least, the ideal is to send five samples from various aspects of the joint, especially the medullary cavity, and look for cells per high power field and the cell count.
ANOOP JHURANI: Those are the two things that we need to see. The cells per high power field have to be less than 10, and the cell count has to be less than 2000. Then we remove the tibial and the femur spacer. There is an intramedullary cement block in the tibia and we have to remove that very carefully because that is stuck. We are expecting some trouble there because it is incarcerated in the tibia.
ANOOP JHURANI: So we are removing the osteotomy. We have put a drill in the cement block inside the tibia and we are removing it. It will take some time. We have to be gentle. We have to be expeditious. We don't have to cause any damage to the bone because there is already a tibial tubercle osteotomy and there it comes out beautifully.
ANOOP JHURANI: The whole thing, the block of cement into the tibia. Once all that is removed, we do extensive debridement, we do extensive pulse lavage with betadine and antibiotic solution and remove every bit of suspicious tissue, thorough curettage of bone throughout so that there is no reinfection. We can't afford a reinfection in a revision TKA. So all that tissue comes out and then we take the tibia out and remove all the fibrous tissue.
ANOOP JHURANI: We have to be careful. There is a tibial tubercle osteotomy there. So we don't have to damage the anterior cortex of tibia. Then we assess the gap. This is the extension gap. You can see it's a tight extension gap, and the flexion gap is bigger. So flexion gap is bigger, extension gap is tight. So we have to upsize the femur component.
ANOOP JHURANI: Then we drill the femur tibia and take a minimal tibial cut. It's in varus, so obviously it will cut laterally, it won't cut anything medially. You can see that. So we are cutting lateral because the tibia has failed in varus. So we are taking the tibial cut with the help of an intramedullary rod.
ANOOP JHURANI: Then we'll check that the tibial cut is perfect and then we start reaming for the tibia for the tibial stem. So reamers are progressively and when it catches the cortex of the tibia, that's our stem size. We externally rotate the tibial component appropriately so that we aid in patella tracking. And we use offset stem here so that we can lateralize our tibial component. This system of Smith & Nephew allows for offsetting the tibial stem at the metaphyseal area.
ANOOP JHURANI: So we are not trying to promote any particular implant, but this system has the advantage of offsetting 360 degrees the stem. So then we are preparing for the tibia and ensuring appropriate external rotation. Then we go to the femur. Since the femur is an extra-articular deformity, we have to enter laterally. If we enter conventionally, we'll be in gross varus.
ANOOP JHURANI: So we have to enter quite lateral actually through the lateral condyle. As you are seeing here, we are entering laterally so that our cut does not cut anything medially. Only then we'll be able to compensate for the extra-articular varus that we have at the middle third of femur. So you can see that our entry hole into the femur is quite lateral.
ANOOP JHURANI: It's from the lateral condyle and we are using a short cemented stem because we can't use a long cemented stem, long uncemented stem because of the extra-articular deformity. So we are using a short, we are planning for a short cemented stem and preparing accordingly, from the lateral condyle. We check under the C-arm to ensure that we are correctly placed.
ANOOP JHURANI: Then the distal femur cut has to be very minimal in appropriate values. Only medial part will cut and I beg your pardon, only lateral part will cut. Nothing will cut medially. Then we size the femur. We are upsizing by one. It's a size 5 femur. So that we tighten up our flexion gap.
ANOOP JHURANI: We also see medial laterally. It should not overhang and we'll be using offset femur rods so that we place our femur component appropriately, laterally and posteriorly. So that we snug up our flexion space. We should not {INAUDIBLE} anteriorly, that's very important. Fixing the {INAUDIBLE}, as you can see here, taking a rough anterior cut in appropriate external rotation.
ANOOP JHURANI: So the {INAUDIBLE} has to be parallel to the {INAUDIBLE} axis and the tibial cut, that's important. So we are parallel to the tibial cut, as you can see here, and the external rotation looks good. So the {INAUDIBLE} boot or the grand piano sign is there, showing that we are adequately externally rotated. Then we prepare for the offset stem because we are offsetting, so that we can {INAUDIBLE} rise and lateralise our femur component.
ANOOP JHURANI: Once that is done, we do the final box cut for the revision femur. On the femur side we have a 16 rod. On the tibial side, we have a 14 rod offset so that we place our components appropriately laterally. Then we take a minimum poly because it's very tight in extension. You can see that the tibial tubercle osteotomy is there and that is the range of motion, about 0 to 80-90 that is expected in this patient.
ANOOP JHURANI: We are getting good extension, not hyperextension. We will have to avoid a or hyperextension. We have to avoid flexion laxity. So those are all very important things in the revision TKA, drilling some holes for cement preparation. The femoral stem has to be cemented in this case because it's a short canal, it's extra-articular deformity. We can't bypass the canal, so it's a short 16 cemented stem.
ANOOP JHURANI: And then for the {INAUDIBLE}, before we put our tibial implants in, we are drilling holes from lateral to medial and passing this external wire which our cardiac friends use for closing the sternum after bypass. This comes on a needle and we pass the wires before we put the components anterior to the stem. Anterior to the stem, not posterior, because otherwise you cannot tighten it.
ANOOP JHURANI: Once the cement sets in, you cannot pull the wire. So it is anterior on the anterior cortex before we put out the stem. So you can see that we have passed two wires, external wires on the anterior cortex, and then we'll just keep it on the anterior cortex so that we can tighten it after the cement is set. That's very important to {INAUDIBLE} and pass the wires {INAUDIBLE}. So that's the way to close the tibial tubercle osteotomy, thorough pulse lavage and then we are ready for implantation.
ANOOP JHURANI: You can see that the tibia and the femur components are offset so that we have laterals them and position them appropriately. On the femur side we are using a short cemented stem, so we are cementing into the canal. So actually two or three packs of cement, two on the femur, one on the tibia and enough {INAUDIBLE}, 16 inch diameter, five femur goes in nicely. It's lateralized to {INAUDIBLE} patellar tracking 14 stem and a three tibia goes in lateralized and 11 poly.
ANOOP JHURANI: So this gives us very good stability in flexion, gives us nice stability in extension. We release some more laterally so that it helps. In patellar tracking we have debugged the patella on the inferior pole, so that it does not impinge on. the poly, patient is counselled that the range of motion will only be 0 to 80 or 0 to 90. Now this is important. We are proximalizing the tibial tubercle osteotomy, so that the patella does not impinge on the poly and takes care of the patella baja. Normally when we close the tibial tubercle osteotomy the nodes of the wire have to be in the lateral soft tissue, but here there is extensive lateral scarring.
ANOOP JHURANI: So we are tying the nodes on the medial side. So those are the nodes on the medial side and you can see that the osteotomy is proximalized by about half a centimetre. Those are the final X-rays. There is still patella baja, but this is the best that we can do after a tibial tubercle osteotomy proximalization, it's not hitting the poly much and we expect the range of motion anywhere between 0 to 70 to 0 to 90.
ANOOP JHURANI: Overall alignment is good, the tibia stem is uncemented, the femur stem is cemented for the reasons that we have discussed before. The overall alignment is pretty decent. We also have a full length X-ray to see the overall alignment. The range of motion is started about 0 to 30 initially and full weight bearing patient with a Walker. Gradually the knee movement will be increased once the osteotomy starts uniting.
ANOOP JHURANI: So these patients generally would get anywhere between 0 to 70 to 0 to 90. But tibial tubercle osteotomy has helped us do two things. One was to expose this very stiff knee joint, a multiple time operated, and second, proximalization so that we take care of patella baja. That's the overall alignment, you can see in spite of the extra-articular deformity with the revision TKA, the overall alignment is pretty decent, and we expect good results if the infection does not recur.
ANOOP JHURANI: The Baroque cultures that we took during the operation were sterile for any microorganisms, so we hope for a good result in this patient. Thank you very much.
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You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode