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Which Knee to Choose and Why - An Evidence Based Approach by Dr. Anoop Jhurani
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Which Knee to Choose and Why - An Evidence Based Approach by Dr. Anoop Jhurani
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Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. It's often difficult to choose the right implant for your patient. With multiple implants in the market and multiple companies promoting their implants, it's challenging for the surgeon to figure out what is the right implant for the patient. It's very important for us as scientific people to choose the right implant based on long term evidence, registry data and published evidence.
ANOOP JHURANI: So this is a video in which we will demonstrate various type of knees with absolutely no intention to promote any particular type of knee. We'll highlight the strengths and weaknesses of every knee design with respect to our patients needs, sizes, shapes and patellar issues. So we base our study on published data, long term registry data and other published evidence, along with our own experience of having used all these types of needs in patients over the last 10 years.
ANOOP JHURANI: So let's start with the Depuy knee, which is the PFC sigma and has been used in our market for the last 25 years. Excellent performance, but with a few issues. So if you look at the design of PFC, we're talking of the posterior stabilized design. The box is very high and the box ratio is too long and the reason is that you can put a stem in the femur,
ANOOP JHURANI: there is a provision of putting a stem in the femur and that is why the box is longer or taller as compared to other knee designs, and this leads to higher incidence of patellar clunk and painful cavities, as is published in many papers. Also, there is a limitation of having only five sizes, and you can downsize your tibia to only one. That is, if you have a three femur, you can only put a 2 and 1/2 tibia.
ANOOP JHURANI: And in Indians, the, especially ladies, the tibia rarely comes down very drastically, and if you want to do a 1.5 on a three femur, you cannot do that in spite of the fact that your tibia may overhang posterior laterally, and that's a little compromise. The reference system is posterior. So essentially what that means is that this will move, this arm will move and it will size your femur, but you will put your pins here based on the posterior condyles and you will reference this
ANOOP JHURANI: as for posterior condyles. Now, if you downsize based on these two reference pins, you are tending to notch. The original AP cutting jigs were very big, but now we have better instruments. So suppose you have a posterior reference of this size 3 and you think you're notching, you can go up minus 2 or you think you're proud and you will over the stop down anterior compartment, you will come down and you will cut less of the posterior condyles.
ANOOP JHURANI: So it's very important to understand your instruments and what they are doing. So this AP cutting jig with plus 2 minus 2 going up and down is pretty useful because that will help you titrate your flexion gap without notching anteriorly or becoming proud anteriorly, so that's the key. So the advantages, I believe, of the Depuy system are that you can put a rod in the femur, though the cases for those are very less you can put a rod in the primary tibia,
ANOOP JHURANI: that's an advantage, definitely. The advantage is that on the AP cutting block, you can go two up and two down depending how you want to titrate your flexion gap and how you are anteriorly. The disadvantage is the higher incidence of patellar clunk crepitus and painful crepitus because of the taller box. But overall, good long term data in the registries.
ANOOP JHURANI: Now let's come to the second knee, which is the Zimmer's LPs NextGen design. Again, a very good design and it has got very good long term data and Australian registry. In fact, it's one of the best performing knees at 15 year follow up in the Australian registry. Now let's come to this design. Very excellent, small box, very good patellar tracking and Zimmer in fact is one knee in which the patellar problems are very less.
ANOOP JHURANI: There was a study published in Clinical Orthopaedics and Related Research where they compared the patellar symptoms of all the designs, and Zimmer had the least patellar problems because of an excellent tracking mechanism and a very good Q angle. Now this is anterior referencing. Now what that means is that you will size here and you will rotate three or five degrees whatever you want, but you will put your pins here and this moves with the anterior mechanism.
ANOOP JHURANI: So you, if you downsize, you will not notch, but you will cut more of posterior condyles. So what that means is that you will put your holes here. And once you put your block there in these two holes, you can turn it slightly medial lateral, that's one thing. Second thing is that the size of the AP cutting block is same as the size of the component, so that's an additional thing,
ANOOP JHURANI: and you can really lateralize, you can put a finger and see your anterior reference. And if you want to come down or up, that's not possible in this. So you really need to make your holes again. there is no way to come up and down once you are committed. Another disadvantage is that you make your primary holes at the time of AP cutting block, and once you take your trial and you want to downsize, you cannot do that because you're already committed with the holes
ANOOP JHURANI: so that's a slight disadvantage, but not that much. If you want to downsize, an anterior referencing system, you will not do anything anteriorly, so your block will remain the same place as far as your anterior reference is concerned, but you will cut more posteriorly. The tibial sizes are also pretty good and you can go two up and two down so that's an advantage over Depuy in which you can only go one up and one down.
ANOOP JHURANI: Overall, a very good design both for CR and PS, and the advantage is a very low incidence of patellar clunk and painful patellar crepitus. Now let's go to the Biomet design. Biomet's design is the Vanguard and the advantages over Depuy and Zimmer, which have five or six sizes, here we have 10 sizes. And sizes are as per the millimeters in AP so it makes it very simple, 55, 57.5, 60 and up to 80.
ANOOP JHURANI: So this system is, again, a posterior referencing. Another advantage is that you can dial your rotation from 0 to 1 to 2 to 3. It's not fixed, 3 or 5 degrees. And you can really put a particular instrument here and you can see that you are parallel to the entire epicondyle axis and the size difference is only 2 millimeters, 2 and 1/2 millimeters, so that's really an advantage.
ANOOP JHURANI: You have 10 femoral sizes and in case you want to downsize here, we have to remember that it will notch. So there is a small slot here and with this, a screwdriver, if you are in between sizes. So suppose you are in between 65 and 67.5, you can take this little up, come on 65 and then put your pins and you will be absolutely fine. And because the difference is only 2, 2 millimeters between components, the incidence of notching or any that kind of problem on the anterior surface is minimal.
ANOOP JHURANI: Nevertheless, you have this beautiful small instrument in case you have your pin slots here and you want to go up, you think you're notching, you can go up or you want to come down, you think you're proud, you can also come down so that you're flush with the anterior surface and posteriorly you can titrate your flexion gap. So again, hypothetically, suppose you are between 65 and 67.5 and you put your pins as for 67.5 and you want to then come to 65, you use this instrument, come down 2 millimeters so that you are flush with the anterior surface and you are not cutting too much posteriorly.
ANOOP JHURANI: And posterior medial,
ANOOP JHURANI: we should cut about 9 or 10 millimeters. What is the size of the thickness of the distal femoral condyle, We should cut that much posterior medial that balances our flexion and extension gap and we cut the tibia then. The tibia then balances both the gaps equally. So it's important to reference your posterior medial condyle, which should be about anywhere between 9/10mm
ANOOP JHURANI: which is the same as the thickness of your distal femur cut. Another advantage of Biomet is that you have this thin patella, which is only 6.2 millimeters. So when you have a thin, very thin 6.2 millimeter patella, we can infra patella, which is so you can see here that the thickness is only 6 millimeters. So in thin patellas where the overall thickness is 20 millimeters, you resect 6/7 millimeters and replace without over dissecting or with the risk
ANOOP JHURANI: of over stuffing. So the great advantage for Indian female patients with thin patellar, you can resurface patellar even in patellar thickness, less than 20 millimeters, that's the advantage of Biomet. Let's come to the lesion knee, which is the Smith Nephew knee. Great design. And the biggest advantage I feel is that the referencing jig here is both anterior and posterior reference.
ANOOP JHURANI: So what you can do here is that whichever way you want to reference, you can reference. So this is for anterior reference and this is for posterior reference. So in case you are absolutely accurate in size, suppose you are coming at 5, you can put your posterior reference and you'll be fine. But if you are between let's say 6 and 7, you can reference, so you have between 6 and 7, you can reference anteriorly, then you can put a 6 block, see how much you are cutting posteriorly.
ANOOP JHURANI: If you are cutting more, you can upsize to 7 and since you are referenced anteriorly you will be same on the anterior surface, so you will not notch or you not be proud. So if you are exact on the same side, you can reference posterior because you're not going to notch, but if you are in between sizes, you can reference anteriorly, put both the blocks and see how much
ANOOP JHURANI: are you cutting posteriorly because with the anterior reference you will be same on the anterior surface, absolutely flush with the anterior surface of the femur, but posteriorly you will see how much you're cutting and you can choose the size, which cuts 9 or 10 millimeters. Another advantage is that if you want to go 2 up or 2 down, you can use a similar instrument that we had in Biomet to go 2 up and 2 down and your anterior referencing, now you want to go 2 up, you can go 2 up, you want to come 2 down, you want to, you can come 2 down, see how you are on the anterior surface, which should absolutely be flush and you should not be notching or you should not be proud,
ANOOP JHURANI: that's the important thing. Depuy has an advantage because it's anatomical and the AP dimension of the lateral tibial condyle is smaller than the medial. So this is an anatomical tibia and that's an advantage because you are not overhanging posteriol laterally even when you externally rotate. So that's a great advantage. The preparation is also very simple and you're not losing too much bone on the table
ANOOP JHURANI: preparation. Now let's go to another design, that's the Maxx and the design of Maxx was published based on a published paper by where they are at all in orthopedics, depending on the size of our own Indian patients. So sizes starts from 50 to the smallest size that is the size A and it goes from A, B, C, D, E, F so you have more sizes, a smaller box.
ANOOP JHURANI: The reference is again anterior, so you reference anteriorly and you can do either three or 5 degree external rotation and if you are in between sizes, so you're referencing anteriorly, so if you choose two sizes, in between sizes, you can see how much you're cutting posteriorly because anteriorly again you'll be the same. So you're putting your pins here, so you are between E and F. You can put E, you can see how much you're cutting posteriorly,
ANOOP JHURANI: if you're cutting too much, you can go to F. Anteriorly you will be the same because there's anterior reference. It's a good design. Again, a very, very deep patellar groove. Patellar tracking is good and even without patellar resurfacing, especially in patients with thin patella, even without patella resurfacing, the results have been good. It's been in use for quite some many years,
ANOOP JHURANI: and we are seeing some early published evidence with this design as well in any Journal of Orthopedics. Also in one more Journal of Arthroplasty, there was a recent paper on 5 to 8 year results of this design. Now, let's come to one more knee, which is the Aesculap knee, Columbus knee and this design is again, you have narrow in each size, just like the Smith Nephew, where you have narrow.
ANOOP JHURANI: So in Smith Nephew and Aesculap, you have narrow in both the designs, so if you want to downsize, just because of MM overhang, you don't need to do that. You can take a narrow size. in Indian patients, the femoral width of the femur is smaller and sometimes we think we are overhanging and for that to prevent overhang, we downsize. But when we downsize we cut more of posterior femur condyle.
ANOOP JHURANI: So here we don't need to downsize, we only need to take a narrow and will not do any MM overhang. The reference is again anterior as you can see, these two holes move with the anterior reference. So this is an anterior reference jig. And again, if you want to upsize or downsize, you will not cut more anteriorly or sharp on the anterior surface and you will titrate your flexion gap.
ANOOP JHURANI: The AP cutting block again has a plus 2 minus 2 slot. So if you are proud, you can come down, if you are notching, you can come up, so this is a great advantage. Some of these recent designs, especially Smith Nephew and Aesculap, you can come up and down on the AP cutting block. The tibia has also many sizes. It's got two in each tibia size, so you can reference your tibia according to the AP and the ml width of the femur.
ANOOP JHURANI: Now, so this is the advantage, one more design that is a Stryker NRG, that's a single radius design, a very good long term results. The only problem is that in Indian patients, because it's a single radius design, the width of each femur is very big. So sometimes in Indian ladies you see overhang with the Stryker NRG design, but it's advantage because it's single radius, it does not have mid flexion instability and that's also proven in a few papers. Very good stability overall, but because it's wider in ml width, sometimes it can cause an overhang.
ANOOP JHURANI: So friends, just to summarize this once again, let's go to each knee quickly and this is a summary. So PFC good long term results, higher box, more patellar crepitas, posterior reference disadvantages only you can downsize one on femur and tibia. Zimmer: good design, very good patellar femural tracking, minimal patellar symptoms, anterior referencing. You comment on the lag holes initially at the time of putting your AP jig, that's a slight disadvantage, but otherwise very good long term results, only six sizes,
ANOOP JHURANI: but when you're downsizing between E and F, you have to be careful because you'll be cutting quite a bit of posterior medial condyle or posteriol condyles. Biomet: 10 sizes. Advantage in terms of sizes, posterior reference, any degree of external rotation, not just 3 and 5, you can reference from 0 to 10, depending on your inter epicondyle axis, a ability to go 2 up and 2 down, depending on whether you want to reference, you want to come 2 up or 2 down.
ANOOP JHURANI: But we flush with the anterior surface and you can titrate your flexion gap. Smith Nephew: great design. Your ability to come down to narrow helps you prevent downsizing. In Indian patients, sometimes we have an MM overhang and we downsize to prevent MM overhang, thus cutting more posterior medial condyles. That's advantageous with Smith Nephew that you can take a narrow size anatomical tibia.
ANOOP JHURANI: Good design. The AP cutting jig is a great one because you can use both anterior and posterior reference. Then Maxx, again sizes according to our own patients. Good early, long term results, jiggers anterior reference again you want notch or become overproud on the anterior surface depending on your correct sizing.
ANOOP JHURANI: And finally, Aesculap, more sizes again, a narrower design, anterior reference and you can go plus up or minus 2 on the AP jig as well so you're sure that you're flush with the anterior surface and you can titrate your flexion gap. So friends, I hope this small video will be useful to you in choosing the right knee for your patient. Let me reiterate, this is not to promote any one design, but this is to give you the right facts, the scientific evidence of how each knee has been performing over a period of last 15 to 20 years, and also based on my experience of the use of each of these knee.
ANOOP JHURANI: Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. It's often difficult to choose the right implant for your patient. With multiple implants in the market and multiple companies promoting their implants, it's challenging for the surgeon to figure out what is the right implant for the patient. It's very important for us as scientific people to choose the right implant based on long term evidence, registry data and published evidence.
ANOOP JHURANI: So this is a video in which we will demonstrate various type of knees with absolutely no intention to promote any particular type of knee. We'll highlight the strengths and weaknesses of every knee design with respect to our patients needs, sizes, shapes and patellar issues. So we base our study on published data, long term registry data and other published evidence, along with our own experience of having used all these types of needs in patients over the last 10 years.
ANOOP JHURANI: So let's start with the Depuy knee, which is the PFC sigma and has been used in our market for the last 25 years. Excellent performance, but with a few issues. So if you look at the design of PFC, we're talking of the posterior stabilized design. The box is very high and the box ratio is too long and the reason is that you can put a stem in the femur,
ANOOP JHURANI: there is a provision of putting a stem in the femur and that is why the box is longer or taller as compared to other knee designs, and this leads to higher incidence of patellar clunk and painful cavities, as is published in many papers. Also, there is a limitation of having only five sizes, and you can downsize your tibia to only one. That is, if you have a three femur, you can only put a 2 and 1/2 tibia.
ANOOP JHURANI: And in Indians, the, especially ladies, the tibia rarely comes down very drastically, and if you want to do a 1.5 on a three femur, you cannot do that in spite of the fact that your tibia may overhang posterior laterally, and that's a little compromise. The reference system is posterior. So essentially what that means is that this will move, this arm will move and it will size your femur, but you will put your pins here based on the posterior condyles and you will reference this
ANOOP JHURANI: as for posterior condyles. Now, if you downsize based on these two reference pins, you are tending to notch. The original AP cutting jigs were very big, but now we have better instruments. So suppose you have a posterior reference of this size 3 and you think you're notching, you can go up minus 2 or you think you're proud and you will over the stop down anterior compartment, you will come down and you will cut less of the posterior condyles.
ANOOP JHURANI: So it's very important to understand your instruments and what they are doing. So this AP cutting jig with plus 2 minus 2 going up and down is pretty useful because that will help you titrate your flexion gap without notching anteriorly or becoming proud anteriorly, so that's the key. So the advantages, I believe, of the Depuy system are that you can put a rod in the femur, though the cases for those are very less you can put a rod in the primary tibia,
ANOOP JHURANI: that's an advantage, definitely. The advantage is that on the AP cutting block, you can go two up and two down depending how you want to titrate your flexion gap and how you are anteriorly. The disadvantage is the higher incidence of patellar clunk crepitus and painful crepitus because of the taller box. But overall, good long term data in the registries.
ANOOP JHURANI: Now let's come to the second knee, which is the Zimmer's LPs NextGen design. Again, a very good design and it has got very good long term data and Australian registry. In fact, it's one of the best performing knees at 15 year follow up in the Australian registry. Now let's come to this design. Very excellent, small box, very good patellar tracking and Zimmer in fact is one knee in which the patellar problems are very less.
ANOOP JHURANI: There was a study published in Clinical Orthopaedics and Related Research where they compared the patellar symptoms of all the designs, and Zimmer had the least patellar problems because of an excellent tracking mechanism and a very good Q angle. Now this is anterior referencing. Now what that means is that you will size here and you will rotate three or five degrees whatever you want, but you will put your pins here and this moves with the anterior mechanism.
ANOOP JHURANI: So you, if you downsize, you will not notch, but you will cut more of posterior condyles. So what that means is that you will put your holes here. And once you put your block there in these two holes, you can turn it slightly medial lateral, that's one thing. Second thing is that the size of the AP cutting block is same as the size of the component, so that's an additional thing,
ANOOP JHURANI: and you can really lateralize, you can put a finger and see your anterior reference. And if you want to come down or up, that's not possible in this. So you really need to make your holes again. there is no way to come up and down once you are committed. Another disadvantage is that you make your primary holes at the time of AP cutting block, and once you take your trial and you want to downsize, you cannot do that because you're already committed with the holes
ANOOP JHURANI: so that's a slight disadvantage, but not that much. If you want to downsize, an anterior referencing system, you will not do anything anteriorly, so your block will remain the same place as far as your anterior reference is concerned, but you will cut more posteriorly. The tibial sizes are also pretty good and you can go two up and two down so that's an advantage over Depuy in which you can only go one up and one down.
ANOOP JHURANI: Overall, a very good design both for CR and PS, and the advantage is a very low incidence of patellar clunk and painful patellar crepitus. Now let's go to the Biomet design. Biomet's design is the Vanguard and the advantages over Depuy and Zimmer, which have five or six sizes, here we have 10 sizes. And sizes are as per the millimeters in AP so it makes it very simple, 55, 57.5, 60 and up to 80.
ANOOP JHURANI: So this system is, again, a posterior referencing. Another advantage is that you can dial your rotation from 0 to 1 to 2 to 3. It's not fixed, 3 or 5 degrees. And you can really put a particular instrument here and you can see that you are parallel to the entire epicondyle axis and the size difference is only 2 millimeters, 2 and 1/2 millimeters, so that's really an advantage.
ANOOP JHURANI: You have 10 femoral sizes and in case you want to downsize here, we have to remember that it will notch. So there is a small slot here and with this, a screwdriver, if you are in between sizes. So suppose you are in between 65 and 67.5, you can take this little up, come on 65 and then put your pins and you will be absolutely fine. And because the difference is only 2, 2 millimeters between components, the incidence of notching or any that kind of problem on the anterior surface is minimal.
ANOOP JHURANI: Nevertheless, you have this beautiful small instrument in case you have your pin slots here and you want to go up, you think you're notching, you can go up or you want to come down, you think you're proud, you can also come down so that you're flush with the anterior surface and posteriorly you can titrate your flexion gap. So again, hypothetically, suppose you are between 65 and 67.5 and you put your pins as for 67.5 and you want to then come to 65, you use this instrument, come down 2 millimeters so that you are flush with the anterior surface and you are not cutting too much posteriorly.
ANOOP JHURANI: And posterior medial,
ANOOP JHURANI: we should cut about 9 or 10 millimeters. What is the size of the thickness of the distal femoral condyle, We should cut that much posterior medial that balances our flexion and extension gap and we cut the tibia then. The tibia then balances both the gaps equally. So it's important to reference your posterior medial condyle, which should be about anywhere between 9/10mm
ANOOP JHURANI: which is the same as the thickness of your distal femur cut. Another advantage of Biomet is that you have this thin patella, which is only 6.2 millimeters. So when you have a thin, very thin 6.2 millimeter patella, we can infra patella, which is so you can see here that the thickness is only 6 millimeters. So in thin patellas where the overall thickness is 20 millimeters, you resect 6/7 millimeters and replace without over dissecting or with the risk
ANOOP JHURANI: of over stuffing. So the great advantage for Indian female patients with thin patellar, you can resurface patellar even in patellar thickness, less than 20 millimeters, that's the advantage of Biomet. Let's come to the lesion knee, which is the Smith Nephew knee. Great design. And the biggest advantage I feel is that the referencing jig here is both anterior and posterior reference.
ANOOP JHURANI: So what you can do here is that whichever way you want to reference, you can reference. So this is for anterior reference and this is for posterior reference. So in case you are absolutely accurate in size, suppose you are coming at 5, you can put your posterior reference and you'll be fine. But if you are between let's say 6 and 7, you can reference, so you have between 6 and 7, you can reference anteriorly, then you can put a 6 block, see how much you are cutting posteriorly.
ANOOP JHURANI: If you are cutting more, you can upsize to 7 and since you are referenced anteriorly you will be same on the anterior surface, so you will not notch or you not be proud. So if you are exact on the same side, you can reference posterior because you're not going to notch, but if you are in between sizes, you can reference anteriorly, put both the blocks and see how much
ANOOP JHURANI: are you cutting posteriorly because with the anterior reference you will be same on the anterior surface, absolutely flush with the anterior surface of the femur, but posteriorly you will see how much you're cutting and you can choose the size, which cuts 9 or 10 millimeters. Another advantage is that if you want to go 2 up or 2 down, you can use a similar instrument that we had in Biomet to go 2 up and 2 down and your anterior referencing, now you want to go 2 up, you can go 2 up, you want to come 2 down, you want to, you can come 2 down, see how you are on the anterior surface, which should absolutely be flush and you should not be notching or you should not be proud,
ANOOP JHURANI: that's the important thing. Depuy has an advantage because it's anatomical and the AP dimension of the lateral tibial condyle is smaller than the medial. So this is an anatomical tibia and that's an advantage because you are not overhanging posteriol laterally even when you externally rotate. So that's a great advantage. The preparation is also very simple and you're not losing too much bone on the table
ANOOP JHURANI: preparation. Now let's go to another design, that's the Maxx and the design of Maxx was published based on a published paper by where they are at all in orthopedics, depending on the size of our own Indian patients. So sizes starts from 50 to the smallest size that is the size A and it goes from A, B, C, D, E, F so you have more sizes, a smaller box.
ANOOP JHURANI: The reference is again anterior, so you reference anteriorly and you can do either three or 5 degree external rotation and if you are in between sizes, so you're referencing anteriorly, so if you choose two sizes, in between sizes, you can see how much you're cutting posteriorly because anteriorly again you'll be the same. So you're putting your pins here, so you are between E and F. You can put E, you can see how much you're cutting posteriorly,
ANOOP JHURANI: if you're cutting too much, you can go to F. Anteriorly you will be the same because there's anterior reference. It's a good design. Again, a very, very deep patellar groove. Patellar tracking is good and even without patellar resurfacing, especially in patients with thin patella, even without patella resurfacing, the results have been good. It's been in use for quite some many years,
ANOOP JHURANI: and we are seeing some early published evidence with this design as well in any Journal of Orthopedics. Also in one more Journal of Arthroplasty, there was a recent paper on 5 to 8 year results of this design. Now, let's come to one more knee, which is the Aesculap knee, Columbus knee and this design is again, you have narrow in each size, just like the Smith Nephew, where you have narrow.
ANOOP JHURANI: So in Smith Nephew and Aesculap, you have narrow in both the designs, so if you want to downsize, just because of MM overhang, you don't need to do that. You can take a narrow size. in Indian patients, the femoral width of the femur is smaller and sometimes we think we are overhanging and for that to prevent overhang, we downsize. But when we downsize we cut more of posterior femur condyle.
ANOOP JHURANI: So here we don't need to downsize, we only need to take a narrow and will not do any MM overhang. The reference is again anterior as you can see, these two holes move with the anterior reference. So this is an anterior reference jig. And again, if you want to upsize or downsize, you will not cut more anteriorly or sharp on the anterior surface and you will titrate your flexion gap.
ANOOP JHURANI: The AP cutting block again has a plus 2 minus 2 slot. So if you are proud, you can come down, if you are notching, you can come up, so this is a great advantage. Some of these recent designs, especially Smith Nephew and Aesculap, you can come up and down on the AP cutting block. The tibia has also many sizes. It's got two in each tibia size, so you can reference your tibia according to the AP and the ml width of the femur.
ANOOP JHURANI: Now, so this is the advantage, one more design that is a Stryker NRG, that's a single radius design, a very good long term results. The only problem is that in Indian patients, because it's a single radius design, the width of each femur is very big. So sometimes in Indian ladies you see overhang with the Stryker NRG design, but it's advantage because it's single radius, it does not have mid flexion instability and that's also proven in a few papers. Very good stability overall, but because it's wider in ml width, sometimes it can cause an overhang.
ANOOP JHURANI: So friends, just to summarize this once again, let's go to each knee quickly and this is a summary. So PFC good long term results, higher box, more patellar crepitas, posterior reference disadvantages only you can downsize one on femur and tibia. Zimmer: good design, very good patellar femural tracking, minimal patellar symptoms, anterior referencing. You comment on the lag holes initially at the time of putting your AP jig, that's a slight disadvantage, but otherwise very good long term results, only six sizes,
ANOOP JHURANI: but when you're downsizing between E and F, you have to be careful because you'll be cutting quite a bit of posterior medial condyle or posteriol condyles. Biomet: 10 sizes. Advantage in terms of sizes, posterior reference, any degree of external rotation, not just 3 and 5, you can reference from 0 to 10, depending on your inter epicondyle axis, a ability to go 2 up and 2 down, depending on whether you want to reference, you want to come 2 up or 2 down.
ANOOP JHURANI: But we flush with the anterior surface and you can titrate your flexion gap. Smith Nephew: great design. Your ability to come down to narrow helps you prevent downsizing. In Indian patients, sometimes we have an MM overhang and we downsize to prevent MM overhang, thus cutting more posterior medial condyles. That's advantageous with Smith Nephew that you can take a narrow size anatomical tibia.
ANOOP JHURANI: Good design. The AP cutting jig is a great one because you can use both anterior and posterior reference. Then Maxx, again sizes according to our own patients. Good early, long term results, jiggers anterior reference again you want notch or become overproud on the anterior surface depending on your correct sizing.
ANOOP JHURANI: And finally, Aesculap, more sizes again, a narrower design, anterior reference and you can go plus up or minus 2 on the AP jig as well so you're sure that you're flush with the anterior surface and you can titrate your flexion gap. So friends, I hope this small video will be useful to you in choosing the right knee for your patient. Let me reiterate, this is not to promote any one design, but this is to give you the right facts, the scientific evidence of how each knee has been performing over a period of last 15 to 20 years, and also based on my experience of the use of each of these knee.
ANOOP JHURANI: Thank you very much.
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