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Name:
Correction of Severe FFD with Navigation
Description:
Correction of Severe FFD with Navigation
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https://cadmoremediastorage.blob.core.windows.net/897d63da-a113-4ed1-99ed-89dd316a68ed/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H11M22S
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https://stream.cadmore.media/player/897d63da-a113-4ed1-99ed-89dd316a68ed
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/897d63da-a113-4ed1-99ed-89dd316a68ed/Correction of severe FFD with navigation.mp4?sv=2019-02-02&sr=c&sig=jUZX2NbVCbyra408UE1bbTTsIwOAOWkcHpSTHHzoHxw%3D&st=2024-12-03T18%3A14%3A45Z&se=2024-12-03T20%3A19%3A45Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. Correction of bi-planar deformities is challenging. The commonest deformity that we have is a severe fixed flexion deformity, uncorrectable, the uncorrectable varus. Varus and valgus are coronal plane deformities and can be corrected. What is challenging is to correct bi-planar deformities. That is deformities which are both in coronal and sagittal plane. And fixed flexion
ANOOP JHURANI: deformity with varus can be challenging because if you don't correct the severe fixed flexion deformity as in this case, which is 30 degrees, patient can have severe core weakness if you leave some residual fixed flexion deformity. So this patient, 65-year-old male, has got a fixed flexion deformity of 30 plus degrees and a varus of 15 degrees. Another thing is that it's difficult to quantify the fixed flexion deformity or recover item that is a sagittal plane deformity by naked eye.
ANOOP JHURANI: This video is to share with you the practice and principles of correcting a severe fixed flexion deformity with varus with computer navigation. It gives us objective and accurate data and hence we can correct the deformities very accurately. So it is being performed without tourniquet and that's what we do these days. It reduces the incidence of DVT and decreases pain. The field is a little bloody, but it can be more than clean so that everything is visible. Two femoral pins inside the wound quite distally so that you don't need any extension.
ANOOP JHURANI: You can see the deformity is 35.5 flexion deformity, 15 degree varus so that's a severe bi-planar deformity. And if you analyze the graph, the deformity corrects inflection and most deformities in our patients correct inflection. What that means is you don't need too much soft tissue released anteriorly. What you need is posteriorly.
ANOOP JHURANI: So you can see 35 degree flexion deformity, 15 degree varus, correcting spontaneously by itself in flexion primarily it's in extension that the deformity needs to be corrected. The plan is to cut three or four millimeters more or distal femur because it's a very severe, tight, uncorrectable, fixed flexion deformity. One has to be careful that you don't cut beyond the lateral collateral
ANOOP JHURANI: and you can see we are still seeing with our finger and the plan is to cut three to four millimeters more of distal femur. Don't that elevates the joint line. But in such severe cases, one needs to do that because the extension gap is never bigger than your minimum poly thickness. That is, in this case, 9 millimeters. So extension gap will never take more than 9,
ANOOP JHURANI: that's one part. And you can see we are verifying, you can also keep the femoral component at 3 to 5 degree flexion perpendicular to the sagittal plane and that also tightens up your flexion gap. Another important point is that your extension gap needs to match the flexion gap. Practically, your extension gap is fixed, which is 9 millimeter of poly.
ANOOP JHURANI: So you need to upsize on your femur and decrease the slope on your tibia so that your flexion gap is not more than 9 millimeter of poly thickness. Setting up your rotation is parallel to the entire epicondyle axis and perpendicular to the white side line. You can see we have the small instrument which tells us about the right rotation perpendicular to the white side line parallel to the interior epicondyle axis.
ANOOP JHURANI: And from a six and seven that sizes between six and seven, we have chosen a seven. So in a fixed flexion deformity we should upsize the femur so that our flexion gap is also nine. The extension gap will never be more than nine and the flexion gap needs to be made a nine by upsizing on the femur and decreasing your slope on the tibia so that there is no mismatch or gaps.
ANOOP JHURANI: We are checking the rotation with navigation and then doing the box card. You can see a size seven there. It was between a six and seven and we have chosen a seven lateral using the component helps in patella. The importance of upsizing needs to be emphasized because it's important to get your flexion gap snug
ANOOP JHURANI: otherwise there'll be a mismatch which you cannot balance. In the patellar also, because we've got three or four millimeter more of distal femur, we can superior rise the patella a little two or 3 millimeters because our joint line is elevated, so if we superior rise the patella we are able to sit nicely the patella on the femur. A few tricks about patella, we should see patellar thickness in all four quadrants as described by the Mayo Clinic Group and raffles patella that is
ANOOP JHURANI: and you can see that we are seeing all four quadrants of the patella and we should get the same thickness. You see, we are superior rising the patella a couple of millimeters so that it compensates for the joint line elevation that we have done in this case. Ideally, we should not dissect more of distal femur, but what sits. Even with fixed flexion deformities, we have to do it. Then the tibia will decrease the slope of the tibia to basic three or four, not more than that,
ANOOP JHURANI: otherwise, you will again have an increase in the flexion gap. So the idea is to balance a nine millimeter of extension gap, which is, which is the maximum that a severe fixed flexion deformity is going to take to make it to nine flexion gap. So we can see our slope is three plus one and half so our four degrees of slope varus valgus zero. And it was showing a cut of twelve and we have cut about nine millimeters. That is the minimum thickness of the poly.
ANOOP JHURANI: So you can see the defect on the tibias, navigation mimics it very nicely. We have recreated a minimal slope and then we'll remove all the posterior medial bone so that the fixed flexion deformity is corrected. Not too much release anteriorly because as you saw on the navigation graph, the anteriorly deformity was correcting itself and that's the advantage of navigation is to get objective data of both the cuts, that is static, alignment and of course, the dynamic alignment.
ANOOP JHURANI: Otherwise it's all guesswork. So there you can see clearance of the posterior osteophtyes and then doing the trial. The poly will never be more than nine in extension and we should work on the flexion gap to make it nine by upsizing the femur and decreasing the slope of the tibial poly. So there you see, that's the minimum line,
ANOOP JHURANI: and you will see that we've corrected the deformity completely and we can be sure on navigation, otherwise sometimes manually you're not sure, but you're corrected. So we've corrected two to five degrees. We'll do some more release and corrected to four degrees, which is very acceptable in such a severe extension deformity and varus is within three degrees.
ANOOP JHURANI: So that's important correcting a fifteen degree fixed varus to under three and you can see the graft is nicely correcting. We are getting a range of movement of 120 plus, even clinically you can see the deformity is completely corrected from a thirty five to practically neutral mean. And that's the whole idea of sharing this video is to share the principles of correcting fixed flexion deformity, severe 30 degree plus and we have removed all the posterior medial bone with the saw as you can see there on the tibia to correct the posterior medial corner which corrects the fixed flexion deformity with varus.
ANOOP JHURANI: So to really remove with the saw all the posterior medial bone so that posterior medial corner is corrected. There is a bone defect of less than ten millimeters that we are augmenting with screws. If it's more than ten millimeters, then you have to use a stem. Cocktail, anesthesia, local analgesia. It's very important getting into the posterior medial corner, the capsule, the periosteum, etc., so that your pain control is nice.
ANOOP JHURANI: You don't need too much of systemic analgesia. It's a thin needle all across and then finally, the segmentation of components like pressurization along the posterior anterior side and the chamfers with hand, ensuring that the cement in the digitis goes at least two millimeter inside the bone and hard pressurization will come on the tibia as well so that it's nicely agitated and this is an anatomical tibia
ANOOP JHURANI: and so it does not overhang posterior laterally. This video is not to promote any particular implant or navigation, but share with you the principles of navigated correction, objective correction based on objective data by navigation for severe fixed flexion deformity 30 degree plus associated with varus. There is some anterior slope there, which is which or decreased slope,
ANOOP JHURANI: it's not anterior slope, but it's decreased slope as you can see there on the right side, the left side is nice and central, but this is sometimes necessary to snug in your flexion space. The slope in the body compensates for that. Now you can see this patient. This is a post-op video. He's got a straight leg raised on the third day, he's walking with a walker.
ANOOP JHURANI: Most patients would walk with a stick. Some patients who are wheelchair ridden, like this one, could not walk too much, does need initial support for 7 to 10 days. What is important is to see that the deformity is completely corrected. If you leave these patients with 10 degrees, it's very difficult to correct 10 degree flexion deformity with brace or exercises.
ANOOP JHURANI: We have to correct it on the table and ensure that there is no neurovascular deficit after the correction of this deformity. So thank you friends. This video was to share the practice, philosophy and principles of correcting.
Segment:0 .
ANOOP JHURANI: Hello, friends. Correction of bi-planar deformities is challenging. The commonest deformity that we have is a severe fixed flexion deformity, uncorrectable, the uncorrectable varus. Varus and valgus are coronal plane deformities and can be corrected. What is challenging is to correct bi-planar deformities. That is deformities which are both in coronal and sagittal plane. And fixed flexion
ANOOP JHURANI: deformity with varus can be challenging because if you don't correct the severe fixed flexion deformity as in this case, which is 30 degrees, patient can have severe core weakness if you leave some residual fixed flexion deformity. So this patient, 65-year-old male, has got a fixed flexion deformity of 30 plus degrees and a varus of 15 degrees. Another thing is that it's difficult to quantify the fixed flexion deformity or recover item that is a sagittal plane deformity by naked eye.
ANOOP JHURANI: This video is to share with you the practice and principles of correcting a severe fixed flexion deformity with varus with computer navigation. It gives us objective and accurate data and hence we can correct the deformities very accurately. So it is being performed without tourniquet and that's what we do these days. It reduces the incidence of DVT and decreases pain. The field is a little bloody, but it can be more than clean so that everything is visible. Two femoral pins inside the wound quite distally so that you don't need any extension.
ANOOP JHURANI: You can see the deformity is 35.5 flexion deformity, 15 degree varus so that's a severe bi-planar deformity. And if you analyze the graph, the deformity corrects inflection and most deformities in our patients correct inflection. What that means is you don't need too much soft tissue released anteriorly. What you need is posteriorly.
ANOOP JHURANI: So you can see 35 degree flexion deformity, 15 degree varus, correcting spontaneously by itself in flexion primarily it's in extension that the deformity needs to be corrected. The plan is to cut three or four millimeters more or distal femur because it's a very severe, tight, uncorrectable, fixed flexion deformity. One has to be careful that you don't cut beyond the lateral collateral
ANOOP JHURANI: and you can see we are still seeing with our finger and the plan is to cut three to four millimeters more of distal femur. Don't that elevates the joint line. But in such severe cases, one needs to do that because the extension gap is never bigger than your minimum poly thickness. That is, in this case, 9 millimeters. So extension gap will never take more than 9,
ANOOP JHURANI: that's one part. And you can see we are verifying, you can also keep the femoral component at 3 to 5 degree flexion perpendicular to the sagittal plane and that also tightens up your flexion gap. Another important point is that your extension gap needs to match the flexion gap. Practically, your extension gap is fixed, which is 9 millimeter of poly.
ANOOP JHURANI: So you need to upsize on your femur and decrease the slope on your tibia so that your flexion gap is not more than 9 millimeter of poly thickness. Setting up your rotation is parallel to the entire epicondyle axis and perpendicular to the white side line. You can see we have the small instrument which tells us about the right rotation perpendicular to the white side line parallel to the interior epicondyle axis.
ANOOP JHURANI: And from a six and seven that sizes between six and seven, we have chosen a seven. So in a fixed flexion deformity we should upsize the femur so that our flexion gap is also nine. The extension gap will never be more than nine and the flexion gap needs to be made a nine by upsizing on the femur and decreasing your slope on the tibia so that there is no mismatch or gaps.
ANOOP JHURANI: We are checking the rotation with navigation and then doing the box card. You can see a size seven there. It was between a six and seven and we have chosen a seven lateral using the component helps in patella. The importance of upsizing needs to be emphasized because it's important to get your flexion gap snug
ANOOP JHURANI: otherwise there'll be a mismatch which you cannot balance. In the patellar also, because we've got three or four millimeter more of distal femur, we can superior rise the patella a little two or 3 millimeters because our joint line is elevated, so if we superior rise the patella we are able to sit nicely the patella on the femur. A few tricks about patella, we should see patellar thickness in all four quadrants as described by the Mayo Clinic Group and raffles patella that is
ANOOP JHURANI: and you can see that we are seeing all four quadrants of the patella and we should get the same thickness. You see, we are superior rising the patella a couple of millimeters so that it compensates for the joint line elevation that we have done in this case. Ideally, we should not dissect more of distal femur, but what sits. Even with fixed flexion deformities, we have to do it. Then the tibia will decrease the slope of the tibia to basic three or four, not more than that,
ANOOP JHURANI: otherwise, you will again have an increase in the flexion gap. So the idea is to balance a nine millimeter of extension gap, which is, which is the maximum that a severe fixed flexion deformity is going to take to make it to nine flexion gap. So we can see our slope is three plus one and half so our four degrees of slope varus valgus zero. And it was showing a cut of twelve and we have cut about nine millimeters. That is the minimum thickness of the poly.
ANOOP JHURANI: So you can see the defect on the tibias, navigation mimics it very nicely. We have recreated a minimal slope and then we'll remove all the posterior medial bone so that the fixed flexion deformity is corrected. Not too much release anteriorly because as you saw on the navigation graph, the anteriorly deformity was correcting itself and that's the advantage of navigation is to get objective data of both the cuts, that is static, alignment and of course, the dynamic alignment.
ANOOP JHURANI: Otherwise it's all guesswork. So there you can see clearance of the posterior osteophtyes and then doing the trial. The poly will never be more than nine in extension and we should work on the flexion gap to make it nine by upsizing the femur and decreasing the slope of the tibial poly. So there you see, that's the minimum line,
ANOOP JHURANI: and you will see that we've corrected the deformity completely and we can be sure on navigation, otherwise sometimes manually you're not sure, but you're corrected. So we've corrected two to five degrees. We'll do some more release and corrected to four degrees, which is very acceptable in such a severe extension deformity and varus is within three degrees.
ANOOP JHURANI: So that's important correcting a fifteen degree fixed varus to under three and you can see the graft is nicely correcting. We are getting a range of movement of 120 plus, even clinically you can see the deformity is completely corrected from a thirty five to practically neutral mean. And that's the whole idea of sharing this video is to share the principles of correcting fixed flexion deformity, severe 30 degree plus and we have removed all the posterior medial bone with the saw as you can see there on the tibia to correct the posterior medial corner which corrects the fixed flexion deformity with varus.
ANOOP JHURANI: So to really remove with the saw all the posterior medial bone so that posterior medial corner is corrected. There is a bone defect of less than ten millimeters that we are augmenting with screws. If it's more than ten millimeters, then you have to use a stem. Cocktail, anesthesia, local analgesia. It's very important getting into the posterior medial corner, the capsule, the periosteum, etc., so that your pain control is nice.
ANOOP JHURANI: You don't need too much of systemic analgesia. It's a thin needle all across and then finally, the segmentation of components like pressurization along the posterior anterior side and the chamfers with hand, ensuring that the cement in the digitis goes at least two millimeter inside the bone and hard pressurization will come on the tibia as well so that it's nicely agitated and this is an anatomical tibia
ANOOP JHURANI: and so it does not overhang posterior laterally. This video is not to promote any particular implant or navigation, but share with you the principles of navigated correction, objective correction based on objective data by navigation for severe fixed flexion deformity 30 degree plus associated with varus. There is some anterior slope there, which is which or decreased slope,
ANOOP JHURANI: it's not anterior slope, but it's decreased slope as you can see there on the right side, the left side is nice and central, but this is sometimes necessary to snug in your flexion space. The slope in the body compensates for that. Now you can see this patient. This is a post-op video. He's got a straight leg raised on the third day, he's walking with a walker.
ANOOP JHURANI: Most patients would walk with a stick. Some patients who are wheelchair ridden, like this one, could not walk too much, does need initial support for 7 to 10 days. What is important is to see that the deformity is completely corrected. If you leave these patients with 10 degrees, it's very difficult to correct 10 degree flexion deformity with brace or exercises.
ANOOP JHURANI: We have to correct it on the table and ensure that there is no neurovascular deficit after the correction of this deformity. So thank you friends. This video was to share the practice, philosophy and principles of correcting.
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