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Name:
MAKO Robotic Total Hip Replacement
Description:
MAKO Robotic Total Hip Replacement
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T00H19M11S
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https://cadmoreoriginalmedia.blob.core.windows.net/8b834fea-7850-41f2-8abe-16a48be54c25/452741 Mayman MAKO 2022 Channel Partner.mp4?sv=2019-02-02&sr=c&sig=nKulH%2FWtWYEFMCeIBe4KpjRqlRSl4MoUj%2F4PZixqE%2F4%3D&st=2024-11-23T12%3A11%3A06Z&se=2024-11-23T14%3A16%3A06Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DAVID MAYMAN: Hi. I'm Dave Mayman here at the Hospital for Special Surgery and we're going to be showing you a robotic assisted primary total hip arthroplasty today. So I'm going to start just running through the X-rays quickly. We're going to spend a couple of minutes going through the plan on the computer and then we'll get into the case.
DAVID MAYMAN: So the patient today is here for a right hip replacement. He has osteoarthritis of both hips. He's actually had his left hip done recently, and now we're doing his right hip. So we template on the preoperative X rays. On the preoperative X-rays, his template is a 52 millimeter acetabular component, size 4 accolade stem.
DAVID MAYMAN: The other thing that we do on all of our patients is we get sitting and standing lateral spine X-rays and we look at sacral slope on the sitting and standing spine X-rays so we can see whether they've got stiffness of their spine or whether they've got flexible spines. He's got quite an arthritic spine. His sacral slope standing is 32 degrees and his sacral slope sitting is 29 degrees
DAVID MAYMAN: so he only has three degrees of difference between the two. That's quite stiff. As we go over to our plan on the computer, we can see sitting and standing impingement modeling and what we're going to do because of his stiff spine. So here we've got our CT scan and I'll run through how we plan on the CT scan. You can see from the image here he's actually got a hip replacement already on the other side.
DAVID MAYMAN: We did that a few months ago. We're back to do the right hip today. So first we're going to look at our acetabular component and we can look at our three dimensional plan of the acetabulum. So if we go to these transverse views, we're now planning from front to back on the acetabulum and we can see what size acetabular component fits in there.
DAVID MAYMAN: So Blake, our MPS, our MAKO product specialist, has a 52 millimeter acetabular component, which is the same size as we had planned on our X-ray, and we can see where our center of rotation is. We can see acetabular cysts and we can see position of our acetabular component. My starting acetabular component position is usually around 42/22. We may adjust that as we look through our impingement modeling.
DAVID MAYMAN: The next thing I'm looking for in our acetabular component is to make sure there's no anterior overhang of that acetabular component, I don't want to get iliopsoas impingement. We can rotate the 3D model around and you can see right up front, we're going to be OK in terms of the iliopsoas. If we take anteversion off of our Kupffer impingement modeling, we may have to worry about that.
DAVID MAYMAN: This is a projected X-ray of what our post-operative image will look like. Then we go to the femur and if we look at the femur, same thing, three dimensional planning. We can see size of the acetabular, of the femoral component. Really what I'm looking at here is how the medial calcar matches up, making sure that we've got good fit along that medial calcar.
DAVID MAYMAN: And then when we go to the level of the planned neck cut, we can actually see our version here. So to make sure that we're pointing right at that medial calcar with the version and we can see our projected femoral version is 16 degrees of anteversion. So I'm pretty happy with our femoral template and we can see that we're going to be lengthening the leg by 3 millimeters with this plan.
DAVID MAYMAN: So now we go to our impingement modeling, which is really the fun part of this, is we take those numbers that I showed you over there, the sitting and standing sacral slope, and we enter those into our system. So the computer now knows if we're looking at extension external rotation, it's with the pelvis in the standing position and when we look at flexion internal rotation, it's with the pelvis in the sitting position.
DAVID MAYMAN: So here we're going to look at sitting first. So we flex the hip to 90 degrees and then we internally rotate the femur. So you can see that we're internally rotating and you're going to start to see some red up here on the AIIS. So what we're seeing is the trochanter impinging on the AIIS before you ever have any impingement of the implant on the implant.
DAVID MAYMAN: So, Blake, if you just remove the femur again so we can see the acetabular component, there's a little bit of impingement on that osteophyte right there, impingement on the AIIS, but we are not hitting the acetabular component. So if we go to standing now, I typically go to 10 degrees of extension and then we start externally rotating and we can see as we get to 30 degrees, we start to get some impingement of the neck on the acetabular component.
DAVID MAYMAN: So now we can play with our acetabular component a little bit and see if we can get rid of that impingement. If we start decreasing the anteversion, you can see that impingement disappear. So if we go to 19 degrees of anteversion, that impingement at 30 degrees of external rotation has disappeared. So I like that 19 degree anteversion better for this patient.
DAVID MAYMAN: We're going to go back to sitting here and make sure that we haven't caused any impingement in the front, and you can see we still have our impingement on the AIIS and the osteophyte, but no impingement on the acetabular component. The last thing that we're going to do here as part of our plan is make sure now that we've checked our acetabular, we've moved our acetabular component, that we haven't caused any anterior overhang
DAVID MAYMAN: and you can see we're close. We're right at the edge of bone there, but we don't have any anterior overhang so I'm happy with that acetabular component position. 42 degrees of inclination, 19 degrees of antiversion. When we get into the case, we're going to have a very accurate tool, very precise tool to help make sure that we actually achieve our plan.
DAVID MAYMAN: Over the years, we've done hip replacements and we've been very successful doing hip replacements with manual instruments, but there are still times that we have problems. We can't be this precise with manual instruments. We can't really look at this impingement modeling. Then we kind of progressed from manual instruments to computerized instruments. Those computerized instruments were more accurate, but they didn't add this impingement modeling in.
DAVID MAYMAN: Now we've got a system where we've got a CT scan so we can do three dimensional planning, so we're very accurate in terms of our implant size planning to the point where we're actually going to open our acetabular component as we start the case. We don't have to wait until we ream because we know what size acetabular component we're putting in that improves OR efficiency. And then we can actually attain that accuracy in terms of hitting our targets and hitting our plan.
DAVID MAYMAN: So this today, I think, is state of the art. It's how I do all of my hip replacements and I think it makes me a better hip surgeon. [AUDIO CRACKLES] So I also like looking through the soft tissues. I feel that I'm down on the iliac crest, start slow and then into the crest, of course. So reamers. There are two different ways. There are two different reamers that you can use for this.
DAVID MAYMAN: One that has to sit right on the iliac crest, but it makes it a little easier to get your pelvic checkpoint and one where you just put three pins in here, put this way and it slides on just like any extra fixator. The closer you are to bone, the more rigid it is. So we're going to take that up, bring that back a little bit. It's good. And you want to make sure these are tight when you put them on. If anything moves here after we start, you lose your registration.
DAVID MAYMAN: So you need to make sure that these arrays are on here. Let's put this back on. Right we're in a teaser. OK, so now we're going to the initial leg length and offset measurements using the navigation system. Can you take that point there for me, please? And then we've got an EKG lead on the knee so we're going to take a point down here. Good. So now we've registered our leg length and all.
DAVID MAYMAN: So you want to see not just the hip, but you want to see me and the position we're in here. All right, so I'm taking our acetabular check point, and if you guys see on the screen as well, hopefully we've got picture and picture here what we're doing. So I've just registered my acetabular check point. Now I'm going to take one point from the iliac crest, so I go through that little poke hole that I made and I go down onto the crest.
DAVID MAYMAN: And can you register that point for me, please? OK and now I take 15 points from inside the acetabulum. I typically do two semicircles, so a seven and an eight. So one, two, three, four, five, six, seven and then I come back to one, two, two. And then I usually lose count somewhere in here so I have to look up at the screen and figure out what I'm doing.
DAVID MAYMAN: OK. So these points are actually critical points for registration. So this gives it the Sim orientation. So that's my posterior horn there. And then I come down here and I get an anterior horn point and then I take 15 extra articular points. So these extra articular points, you actually want them to be reasonably far away from the acetabulum
DAVID MAYMAN: and you want them to be spread out. So there are three possibilities of what's going to happen here. After I get my last point, it's either going to tell me that I've auto passed, which means it's happy with my registration. We'll see after I take this last point, or it's going to tell me that I have to just confirm some points or it's going to tell me that I have to take a few extra points to get my registration.
DAVID MAYMAN: OK, so it said, hey, I'm pretty happy with your registration, but I just want some confirmation. It's not asking me to take any other points. And when you look on there, the green points it's really happy with, the yellow points are within about half a millimeter, if there are any red points, those points are greater than a millimeter off of what it expects. So this actually looks like a pretty good registration.
DAVID MAYMAN: This one I'd be a little disappointed that it didn't give me that auto pass, but it is what it is. So I'm going, I'm taking my probe and I'm just confirming each of these. I'm just holding my probe tip right over each of those points and you've got to be within a millimeter. And then you just hold your probe there within a millimeter and it says, yep, you've got all those points.
DAVID MAYMAN: You just need to be over those patches. OK. So now it says, all right, we're happy with your registration. The computer knows where the acetabulum is, where the pelvis is in space, we're OK to go ahead. So now we're going to ream. I'm just going to move this stuff up a little bit. So before we ream, Blake is just moving the robot in.
DAVID MAYMAN: I have to check point. It asks you to check point a bunch of times, so I have to check point and confirm that my reamer is actually accurate. OK and that was its confirmation that the reamer was accurate. Now we're adding power here. Good. So I'm going to go into the acetabulum, and now I'm in the acetabulum and as soon as I pull the trigger, it's going to let me start reaming
DAVID MAYMAN: and you're going to see green disappear as we ream bone away. And if you haven't noticed, I'm standing on a standing stool, so I get a little higher because I'm actually pushing pretty hard on this femur. Let's keep going. Good OK, so the reaming is done.
DAVID MAYMAN: You can see all of the bone that comes out on that one reamer. Can you unlock it again for a second Blake. I'm going to put it back here so Ryan can get the acetabular component in. I'm just going to suction here and clean out any debris, and some people will actually do two reams. They'll ream with a smaller reamer first for some of the larger sizes or for some harder bone and then do the second ream.
DAVID MAYMAN: I think when you start doing these hips, that's a reasonable thing to do. Once you're comfortable with them, it's perfectly fine to do it as a single ream. You just have to push pretty hard on that reamer sometimes. So if I'm just going to try to get a picture in there of that acetabular ream before we move on so that people can see. You did a great job. OK? That's OK for you?
DAVID MAYMAN: And you can get the light right in there, and if you can move the suction, please? Yeah. Right here. One more second. OK got it. Great. OK, so that's a nice ream, nice cancellous bone all the way around. OK, unlock the arm. So you can see Drake's working here, holding both retractors front and back, because he,
DAVID MAYMAN: he has to. You can't have an assistant in on the other side. We've gotten pretty good at positioning to do this. So I put the acetabulum in here. I look at the numbers on the screen. Remember, we planned 42/19. I tried to get it close and then I tell my MP's to lock in the haptics and that pulls, pulls it into position. OK, then I need to get a sponge just so we don't spray everybody and cover this because I know where we're going.
DAVID MAYMAN: So I'm going to start hitting this in, and right now we're five millimeters proud still, so I need to keep hitting it. Three millimeters, one millimeter, and it's not uncommon for these, it's not uncommon to see your final number at one millimeter. That's OK. We're going to check in here and make sure that when we look, it's down, but one millimeter or zero are the numbers that I'm looking for.
DAVID MAYMAN: So now I'm going to suction in the acetabulum and look and make sure that my cup's down. And I'm happy that my cup's down there so that's good. So let's get another picture in there with the acetabulum in, and if we can just go on the computer screen to what we planned our acetabulum to look like. So I like doing this double check where in three dimensions I look at what my actual cup looks like in the pelvis
DAVID MAYMAN: and if you can just rotate that around. So like, I'm looking at it from the back. That's right. Perfect right there. So really what I'm looking at, can you just take your mouse arrow and point over the posterior superior acetabulum. Yeah, right there. So there,
DAVID MAYMAN: I want to see that and I want to look in here and I want to see that look the same. That really tells me that I'm happy with my position of the cup. So the next thing we're going to do to confirm here is with the probe, I'm going to take five points along the rim. So I actually use one of the locking rings in here. Just an easy way to do it. One, two, three, four, five.
DAVID MAYMAN: OK? And usually that's within a degree or two, so I'm pretty happy with that. All right. So liner, please. So now we're going to put the liner in, take that. And we know it's going to get this lined up here. Good ball impactor. Just suction down the acetabular and we don't want to spray anybody or spray the cameras for sure.
DAVID MAYMAN: Good. So we know from our preoperative plan that there's a little bit of impingement of a superior anterior osteophyte with flexion internal rotation. So I'm going to take an osteotome here and I'm going to take off that superior anterior osteophyte, but I also know that I don't have impingement anywhere else. So this is one of the places where I think this really improves the efficiency of my operation is I know which osteophytes are important to remove and I know which osteophytes are not going to be impinging so that I don't have to remove them.
DAVID MAYMAN: All right. So we've taken off that anterior superior osteophyte. Next. Good. All right, so let's see where we are. Remember, we have done nothing to measure leg length yet. All I did was my neck cut was about a centimeter below the inferior head neck junction. So this is really our first measurement of leg length. So we're going to do this and then we're going to fine tune whatever we need to do.
DAVID MAYMAN: So a forty millimeter head, which we can put in with a fifty two cup in this system, and I'm using a forty head because this patient has a stiff spine. Remember, this patient's spine only moves three degrees from sitting to standing. OK, so Ryan's reduced the hip. You know, first I kind of have a feel. What do the soft tissues feel like? I would say that feels a little bit tight, but not bad.
DAVID MAYMAN: We go back into the position where we started and we take leg length and offset measurements again. so that point there, please, and then that point there. OK so let's just can we just snap that? So right now, if you look at the bottom right of the screen, we have lengthened the leg by five millimeters compared to where we started and we've increased our offset by two millimeters. Our plan was to lengthen the leg two or three millimeters.
DAVID MAYMAN: So we're going to try to get this broach down another two or three millimeters and then we'll be at three. All right, if we just want to do a stability test, we take, which I do less of these days because I know the impingement modeling, but extension, external rotation, I'm not impinging there and we have no anterior instability, thirty degrees flexion, thirty degrees of in-deduction, that's still in there.
DAVID MAYMAN: So nice and stable there. And then, Ryan, if you flex the hip up here, deep flexion, nice and stable there, OK, dislocate. You can open up four 127 stem. By hand. Insertion handle. I'm going to suction here, try not to spray anybody and here I just a little bit more out into the trochanter as you're hitting it. Good. Good.
DAVID MAYMAN: Good. OK. Can we see a -2.5 head trial, please? OK, so we're going to trial again. I'm holding the femoral head in place while Ryan reduces it. Good. Put the leg back in place. And we're going to take those legs length and offset measurements again.
DAVID MAYMAN: And we're going to choose now what our neck length is. There, please. And there, please. OK, so that's a minus 2.5 neck and that makes us 2 millimeters longer, but it's decreased our offset a little bit. So I'm actually going to go to a zero. The zero will make us, will lengthen us by three and it'll make our offset a little closer.
DAVID MAYMAN: OK. Jaws. Frank C. You the forty head. OK ball impactor and mallet. OK. We get the retractors out. So Ryan's going to bring the leg back up on the table here. I'm actually going to look directly into the acetabulum. At this point in the operation,
DAVID MAYMAN: I want to make sure that I can see in the acetabulum there's no debris. Just irrigate in there. Good. OK, Ryan, you can go ahead and reduce that. I'm helping him reduce it, I'm just pushing the head in. And we're going to get some final measurements here. There, please.
DAVID MAYMAN: And there. OK, so we've lengthened the leg by three and we've increased offset by one, which is really what we planned to do. [VIDEO ENDS]
Segment:0 .
DAVID MAYMAN: Hi. I'm Dave Mayman here at the Hospital for Special Surgery and we're going to be showing you a robotic assisted primary total hip arthroplasty today. So I'm going to start just running through the X-rays quickly. We're going to spend a couple of minutes going through the plan on the computer and then we'll get into the case.
DAVID MAYMAN: So the patient today is here for a right hip replacement. He has osteoarthritis of both hips. He's actually had his left hip done recently, and now we're doing his right hip. So we template on the preoperative X rays. On the preoperative X-rays, his template is a 52 millimeter acetabular component, size 4 accolade stem.
DAVID MAYMAN: The other thing that we do on all of our patients is we get sitting and standing lateral spine X-rays and we look at sacral slope on the sitting and standing spine X-rays so we can see whether they've got stiffness of their spine or whether they've got flexible spines. He's got quite an arthritic spine. His sacral slope standing is 32 degrees and his sacral slope sitting is 29 degrees
DAVID MAYMAN: so he only has three degrees of difference between the two. That's quite stiff. As we go over to our plan on the computer, we can see sitting and standing impingement modeling and what we're going to do because of his stiff spine. So here we've got our CT scan and I'll run through how we plan on the CT scan. You can see from the image here he's actually got a hip replacement already on the other side.
DAVID MAYMAN: We did that a few months ago. We're back to do the right hip today. So first we're going to look at our acetabular component and we can look at our three dimensional plan of the acetabulum. So if we go to these transverse views, we're now planning from front to back on the acetabulum and we can see what size acetabular component fits in there.
DAVID MAYMAN: So Blake, our MPS, our MAKO product specialist, has a 52 millimeter acetabular component, which is the same size as we had planned on our X-ray, and we can see where our center of rotation is. We can see acetabular cysts and we can see position of our acetabular component. My starting acetabular component position is usually around 42/22. We may adjust that as we look through our impingement modeling.
DAVID MAYMAN: The next thing I'm looking for in our acetabular component is to make sure there's no anterior overhang of that acetabular component, I don't want to get iliopsoas impingement. We can rotate the 3D model around and you can see right up front, we're going to be OK in terms of the iliopsoas. If we take anteversion off of our Kupffer impingement modeling, we may have to worry about that.
DAVID MAYMAN: This is a projected X-ray of what our post-operative image will look like. Then we go to the femur and if we look at the femur, same thing, three dimensional planning. We can see size of the acetabular, of the femoral component. Really what I'm looking at here is how the medial calcar matches up, making sure that we've got good fit along that medial calcar.
DAVID MAYMAN: And then when we go to the level of the planned neck cut, we can actually see our version here. So to make sure that we're pointing right at that medial calcar with the version and we can see our projected femoral version is 16 degrees of anteversion. So I'm pretty happy with our femoral template and we can see that we're going to be lengthening the leg by 3 millimeters with this plan.
DAVID MAYMAN: So now we go to our impingement modeling, which is really the fun part of this, is we take those numbers that I showed you over there, the sitting and standing sacral slope, and we enter those into our system. So the computer now knows if we're looking at extension external rotation, it's with the pelvis in the standing position and when we look at flexion internal rotation, it's with the pelvis in the sitting position.
DAVID MAYMAN: So here we're going to look at sitting first. So we flex the hip to 90 degrees and then we internally rotate the femur. So you can see that we're internally rotating and you're going to start to see some red up here on the AIIS. So what we're seeing is the trochanter impinging on the AIIS before you ever have any impingement of the implant on the implant.
DAVID MAYMAN: So, Blake, if you just remove the femur again so we can see the acetabular component, there's a little bit of impingement on that osteophyte right there, impingement on the AIIS, but we are not hitting the acetabular component. So if we go to standing now, I typically go to 10 degrees of extension and then we start externally rotating and we can see as we get to 30 degrees, we start to get some impingement of the neck on the acetabular component.
DAVID MAYMAN: So now we can play with our acetabular component a little bit and see if we can get rid of that impingement. If we start decreasing the anteversion, you can see that impingement disappear. So if we go to 19 degrees of anteversion, that impingement at 30 degrees of external rotation has disappeared. So I like that 19 degree anteversion better for this patient.
DAVID MAYMAN: We're going to go back to sitting here and make sure that we haven't caused any impingement in the front, and you can see we still have our impingement on the AIIS and the osteophyte, but no impingement on the acetabular component. The last thing that we're going to do here as part of our plan is make sure now that we've checked our acetabular, we've moved our acetabular component, that we haven't caused any anterior overhang
DAVID MAYMAN: and you can see we're close. We're right at the edge of bone there, but we don't have any anterior overhang so I'm happy with that acetabular component position. 42 degrees of inclination, 19 degrees of antiversion. When we get into the case, we're going to have a very accurate tool, very precise tool to help make sure that we actually achieve our plan.
DAVID MAYMAN: Over the years, we've done hip replacements and we've been very successful doing hip replacements with manual instruments, but there are still times that we have problems. We can't be this precise with manual instruments. We can't really look at this impingement modeling. Then we kind of progressed from manual instruments to computerized instruments. Those computerized instruments were more accurate, but they didn't add this impingement modeling in.
DAVID MAYMAN: Now we've got a system where we've got a CT scan so we can do three dimensional planning, so we're very accurate in terms of our implant size planning to the point where we're actually going to open our acetabular component as we start the case. We don't have to wait until we ream because we know what size acetabular component we're putting in that improves OR efficiency. And then we can actually attain that accuracy in terms of hitting our targets and hitting our plan.
DAVID MAYMAN: So this today, I think, is state of the art. It's how I do all of my hip replacements and I think it makes me a better hip surgeon. [AUDIO CRACKLES] So I also like looking through the soft tissues. I feel that I'm down on the iliac crest, start slow and then into the crest, of course. So reamers. There are two different ways. There are two different reamers that you can use for this.
DAVID MAYMAN: One that has to sit right on the iliac crest, but it makes it a little easier to get your pelvic checkpoint and one where you just put three pins in here, put this way and it slides on just like any extra fixator. The closer you are to bone, the more rigid it is. So we're going to take that up, bring that back a little bit. It's good. And you want to make sure these are tight when you put them on. If anything moves here after we start, you lose your registration.
DAVID MAYMAN: So you need to make sure that these arrays are on here. Let's put this back on. Right we're in a teaser. OK, so now we're going to the initial leg length and offset measurements using the navigation system. Can you take that point there for me, please? And then we've got an EKG lead on the knee so we're going to take a point down here. Good. So now we've registered our leg length and all.
DAVID MAYMAN: So you want to see not just the hip, but you want to see me and the position we're in here. All right, so I'm taking our acetabular check point, and if you guys see on the screen as well, hopefully we've got picture and picture here what we're doing. So I've just registered my acetabular check point. Now I'm going to take one point from the iliac crest, so I go through that little poke hole that I made and I go down onto the crest.
DAVID MAYMAN: And can you register that point for me, please? OK and now I take 15 points from inside the acetabulum. I typically do two semicircles, so a seven and an eight. So one, two, three, four, five, six, seven and then I come back to one, two, two. And then I usually lose count somewhere in here so I have to look up at the screen and figure out what I'm doing.
DAVID MAYMAN: OK. So these points are actually critical points for registration. So this gives it the Sim orientation. So that's my posterior horn there. And then I come down here and I get an anterior horn point and then I take 15 extra articular points. So these extra articular points, you actually want them to be reasonably far away from the acetabulum
DAVID MAYMAN: and you want them to be spread out. So there are three possibilities of what's going to happen here. After I get my last point, it's either going to tell me that I've auto passed, which means it's happy with my registration. We'll see after I take this last point, or it's going to tell me that I have to just confirm some points or it's going to tell me that I have to take a few extra points to get my registration.
DAVID MAYMAN: OK, so it said, hey, I'm pretty happy with your registration, but I just want some confirmation. It's not asking me to take any other points. And when you look on there, the green points it's really happy with, the yellow points are within about half a millimeter, if there are any red points, those points are greater than a millimeter off of what it expects. So this actually looks like a pretty good registration.
DAVID MAYMAN: This one I'd be a little disappointed that it didn't give me that auto pass, but it is what it is. So I'm going, I'm taking my probe and I'm just confirming each of these. I'm just holding my probe tip right over each of those points and you've got to be within a millimeter. And then you just hold your probe there within a millimeter and it says, yep, you've got all those points.
DAVID MAYMAN: You just need to be over those patches. OK. So now it says, all right, we're happy with your registration. The computer knows where the acetabulum is, where the pelvis is in space, we're OK to go ahead. So now we're going to ream. I'm just going to move this stuff up a little bit. So before we ream, Blake is just moving the robot in.
DAVID MAYMAN: I have to check point. It asks you to check point a bunch of times, so I have to check point and confirm that my reamer is actually accurate. OK and that was its confirmation that the reamer was accurate. Now we're adding power here. Good. So I'm going to go into the acetabulum, and now I'm in the acetabulum and as soon as I pull the trigger, it's going to let me start reaming
DAVID MAYMAN: and you're going to see green disappear as we ream bone away. And if you haven't noticed, I'm standing on a standing stool, so I get a little higher because I'm actually pushing pretty hard on this femur. Let's keep going. Good OK, so the reaming is done.
DAVID MAYMAN: You can see all of the bone that comes out on that one reamer. Can you unlock it again for a second Blake. I'm going to put it back here so Ryan can get the acetabular component in. I'm just going to suction here and clean out any debris, and some people will actually do two reams. They'll ream with a smaller reamer first for some of the larger sizes or for some harder bone and then do the second ream.
DAVID MAYMAN: I think when you start doing these hips, that's a reasonable thing to do. Once you're comfortable with them, it's perfectly fine to do it as a single ream. You just have to push pretty hard on that reamer sometimes. So if I'm just going to try to get a picture in there of that acetabular ream before we move on so that people can see. You did a great job. OK? That's OK for you?
DAVID MAYMAN: And you can get the light right in there, and if you can move the suction, please? Yeah. Right here. One more second. OK got it. Great. OK, so that's a nice ream, nice cancellous bone all the way around. OK, unlock the arm. So you can see Drake's working here, holding both retractors front and back, because he,
DAVID MAYMAN: he has to. You can't have an assistant in on the other side. We've gotten pretty good at positioning to do this. So I put the acetabulum in here. I look at the numbers on the screen. Remember, we planned 42/19. I tried to get it close and then I tell my MP's to lock in the haptics and that pulls, pulls it into position. OK, then I need to get a sponge just so we don't spray everybody and cover this because I know where we're going.
DAVID MAYMAN: So I'm going to start hitting this in, and right now we're five millimeters proud still, so I need to keep hitting it. Three millimeters, one millimeter, and it's not uncommon for these, it's not uncommon to see your final number at one millimeter. That's OK. We're going to check in here and make sure that when we look, it's down, but one millimeter or zero are the numbers that I'm looking for.
DAVID MAYMAN: So now I'm going to suction in the acetabulum and look and make sure that my cup's down. And I'm happy that my cup's down there so that's good. So let's get another picture in there with the acetabulum in, and if we can just go on the computer screen to what we planned our acetabulum to look like. So I like doing this double check where in three dimensions I look at what my actual cup looks like in the pelvis
DAVID MAYMAN: and if you can just rotate that around. So like, I'm looking at it from the back. That's right. Perfect right there. So really what I'm looking at, can you just take your mouse arrow and point over the posterior superior acetabulum. Yeah, right there. So there,
DAVID MAYMAN: I want to see that and I want to look in here and I want to see that look the same. That really tells me that I'm happy with my position of the cup. So the next thing we're going to do to confirm here is with the probe, I'm going to take five points along the rim. So I actually use one of the locking rings in here. Just an easy way to do it. One, two, three, four, five.
DAVID MAYMAN: OK? And usually that's within a degree or two, so I'm pretty happy with that. All right. So liner, please. So now we're going to put the liner in, take that. And we know it's going to get this lined up here. Good ball impactor. Just suction down the acetabular and we don't want to spray anybody or spray the cameras for sure.
DAVID MAYMAN: Good. So we know from our preoperative plan that there's a little bit of impingement of a superior anterior osteophyte with flexion internal rotation. So I'm going to take an osteotome here and I'm going to take off that superior anterior osteophyte, but I also know that I don't have impingement anywhere else. So this is one of the places where I think this really improves the efficiency of my operation is I know which osteophytes are important to remove and I know which osteophytes are not going to be impinging so that I don't have to remove them.
DAVID MAYMAN: All right. So we've taken off that anterior superior osteophyte. Next. Good. All right, so let's see where we are. Remember, we have done nothing to measure leg length yet. All I did was my neck cut was about a centimeter below the inferior head neck junction. So this is really our first measurement of leg length. So we're going to do this and then we're going to fine tune whatever we need to do.
DAVID MAYMAN: So a forty millimeter head, which we can put in with a fifty two cup in this system, and I'm using a forty head because this patient has a stiff spine. Remember, this patient's spine only moves three degrees from sitting to standing. OK, so Ryan's reduced the hip. You know, first I kind of have a feel. What do the soft tissues feel like? I would say that feels a little bit tight, but not bad.
DAVID MAYMAN: We go back into the position where we started and we take leg length and offset measurements again. so that point there, please, and then that point there. OK so let's just can we just snap that? So right now, if you look at the bottom right of the screen, we have lengthened the leg by five millimeters compared to where we started and we've increased our offset by two millimeters. Our plan was to lengthen the leg two or three millimeters.
DAVID MAYMAN: So we're going to try to get this broach down another two or three millimeters and then we'll be at three. All right, if we just want to do a stability test, we take, which I do less of these days because I know the impingement modeling, but extension, external rotation, I'm not impinging there and we have no anterior instability, thirty degrees flexion, thirty degrees of in-deduction, that's still in there.
DAVID MAYMAN: So nice and stable there. And then, Ryan, if you flex the hip up here, deep flexion, nice and stable there, OK, dislocate. You can open up four 127 stem. By hand. Insertion handle. I'm going to suction here, try not to spray anybody and here I just a little bit more out into the trochanter as you're hitting it. Good. Good.
DAVID MAYMAN: Good. OK. Can we see a -2.5 head trial, please? OK, so we're going to trial again. I'm holding the femoral head in place while Ryan reduces it. Good. Put the leg back in place. And we're going to take those legs length and offset measurements again.
DAVID MAYMAN: And we're going to choose now what our neck length is. There, please. And there, please. OK, so that's a minus 2.5 neck and that makes us 2 millimeters longer, but it's decreased our offset a little bit. So I'm actually going to go to a zero. The zero will make us, will lengthen us by three and it'll make our offset a little closer.
DAVID MAYMAN: OK. Jaws. Frank C. You the forty head. OK ball impactor and mallet. OK. We get the retractors out. So Ryan's going to bring the leg back up on the table here. I'm actually going to look directly into the acetabulum. At this point in the operation,
DAVID MAYMAN: I want to make sure that I can see in the acetabulum there's no debris. Just irrigate in there. Good. OK, Ryan, you can go ahead and reduce that. I'm helping him reduce it, I'm just pushing the head in. And we're going to get some final measurements here. There, please.
DAVID MAYMAN: And there. OK, so we've lengthened the leg by three and we've increased offset by one, which is really what we planned to do. [VIDEO ENDS]
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