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Revision of Failed UKA to Computer Assisted TKA by Dr. Anoop Jhurani
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Revision of Failed UKA to Computer Assisted TKA by Dr. Anoop Jhurani
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T00H15M58S
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https://cadmoreoriginalmedia.blob.core.windows.net/bb9e1f35-1cf0-4af8-9ef7-dbad10bd6579/Revision of Failed UKA to Computer Assisted TKA by Dr. Anoop.mp4?sv=2019-02-02&sr=c&sig=mxSBHXJE%2FcJZWTa5P3mR5QB5H6IlUyPOFGkMhKTQrXY%3D&st=2024-11-23T10%3A11%3A47Z&se=2024-11-23T12%3A16%3A47Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, friends. Partial knee replacement is a great option for medial compartment arthritis with end-stage bone-on-bone degeneration. And partial knee replacement, historically, has been either mobile bearing, which is the Oxford, or fixed bearing, which, the most popular was Zouk implant, which is now used as a Journey knee, partial knee. So both these knees are pretty popular, but the short-term results with conventional methods can have challenges and early failures. In mobile bearing knee, the main mode of failure is progression of lateral compartment arthritis, because of mechanical axis deviation on the lateral side by a tight poly.
That's the main cause of failure in a Oxford mobile bearing uni. In a fixed bearing uni, the main cause of failure is in varus, and especially on the tibial side. If there is more bone resection, or the tibial pins cause stress fractures and the tibial plateau medially will apply to fractures as in this case, which can also happen with the mobile bearing Oxford uni. If the pins are not appropriately placed or placed repeatedly, which can cause stress risers and stress fractures, as you can see here.
So this is a fixed bearing uni. If the tibial resection is more, and the pins are not placed appropriately, and placed two or three times, then it may lead to stress fractures like in this case, the tibial plateau has collapsed, and the knee is in about 12, 13 degrees of varus. This is a 70-year-old doctor who had this partial knee only one month back. So the failure is very recent, unfortunate, and needs to be revised now.
So this was done elsewhere by conventional methods, and the problem with conventional method for uni especially is that you cannot analyze the kinematics, and that's why robotics have great advantage for uni knee replacements where the bone dissection is less, there is no need to put the tibial pins as there is no tibial jig and the robotic burr actually takes {INAUDIBLE} the tibia. So great advantages of robotic to prevent failures like these early failures, one month failure of a fixed bearing uni on the tibial side, failure in varus, patient can't walk and we are revising him.
There are no signs of infection, this is the range of motion is pretty fair, but the knee's in varus, there is no ligament instability of course, the knee is in varus. The patient has got comorbidity issues. He has had a bypass and two angioplasties. We'll be doing a computer-assisted revision of a uni to a TKA, and as we go through we'll discuss the advantages of navigation in these cases.
So you can see that that's the medial uni, there is no infection. However, we always send samples, two to three samples and to the biochemistry to see the cellular count, and we also send them for culture. So this is the medial uni, you can see it's failed in varus. The femur component is OK, but the tibia has subsided with the medial tibial fracture. So the key here when you're doing navigated is not to remove the implants but put your pins and do the registration on the implants.
The advantage is that that prevents any varus cut. Now, hypothetically, if you remove the implants and use conventional method, then both the femur and the tibia jig may tilt in varus. So when you remove the femur implant and take the tibial cut or the femur cut, the jigs may go into varus and again, it may lead to failure. So navigation is recommended or robotics is recommended for revisions also these days very valuable for a uni revision.
So we'll register on the implants. And then take our femur cut, distal femur cut, with the implant on, and you will see how advantageous that is to prevent over-cutting of bone or deviation into varus. So we are registering currently the anterior side on the femur implant, all the tibial implant, and we'll see that the deformity is 12, 13 degree varus with a neutral knee, and this will require conservative femur and tibial cut, because on the medial side the bone is already cut, so we should not be led by the already cut medial bone.
We have to look carefully on the lateral bone and do conservative cuts to prevent a very thick poly or instability. So those are the key points of any operated knee, just like a revision situation. Here you can see 13 degree varus, 1 degree extension. That means the distal femur cut has to be minus 2 millimeters, and that can be really nicely guided by navigation. So that we are removing just the top of the anterior surface, the top clear part, and fixing our distal femur jig under navigation control, and proper varus-valgus, we can see about three degree flexion.
We are planning a resection of minus 1.5, minus 2 millimeters, varus of 1 degree is okay, and where to ensure that we aren't cutting much from the medial side. The implant is still on, and we are cutting 7 to 8 millimeters of distal femur only, because the knee has got one degree extension, severe varus deformity. When we correct both of that, the knee will further open and extension.
Now, once we have taken a lateral distal femur cut, we see where the saw is passing from. So it will take one or 2 millimeters of distal femur cut even radially. Now we gradually, gently remove the implant. This is important. We have taken the cut first. Now we know that little will cut from the medial side. Now we remove the implant with the attempt to minimize bone loss.
You can see just some bone loss on the posterior side, with very sharp 10 millimeter osteotome. You go all around the sham first posterior condyle, and then remove the implant carefully. Then you go medially just one or 2 millimeters cut from the medial side, 7 to 8 millimeters. Now you can see those two peg hole defects. And that's the cut. Now medial gap looks very opened up, but this is because, not because laxity of the medial collateral ligament, but because of the tibial defect.
So our femur cut is conservative. We have registered our femur cut, marking the interepicondylar axis. Now for rotation, also we are to be very careful, because there is no posterior medial condyle, so we can't take a 3 degree rotation because that will be a lot of external rotation because there is no posterior medial condyle. So we are extremely careful.
We have kept a minus 2 degree rotation to compensate for the lack of posteromedial condyle, but we'll check it with navigation. It will be three degrees to the interepicondylar axis, perpendicular to the wide side line as you will see here. But we have to be aware that there is no posterior medial condyle. So, you can see we have kept it around 4 degrees of external rotation, which is fair for patellar tracking and revision situations.
Now we will take our cut, and we are confirming that it's perpendicular to the wide sideline you can see there, and it's parallel to the interepicondylar axis. You can see the {INAUDIBLE} there coming up nicely. Then we take the cuts very carefully on the medial side, nothing much will cut because the implant was there. So on the medial side, nothing much, then the sham force of course, and then the final preparation. You can see the rotation is good.
The lateral side is bigger than the medial side, which it should be. That indicates that our rotation is fine, so be very careful of rotation. Now you can see the medial gap looks very big, but actually is the tibial component, which is subsided. Our rotation is good, the medial collateral ligament is fine. We are checking it again and again, but we have to be very careful with our cuts.
Now, this is the final chamfer for the box cut for the implant. And then we go to the tibial cut. The tibia will be reconstructed with a wedge and with a stem. That is a standard mode of construction for fair uni. Again, uni is being removed very carefully now, so that there is minimal loss of bone. And there's a big defect, almost of about two centimeters on the medial side, because there is a fracture and there is subsidence.
So the gap is more. We may be using 15 millimeter medial augment there. Now we are doing a conservative tibial cut, and you can see the fracture of the medial tibial plateau, medial most part will fix it, but one screw, but the main reconstruction modality will be with augment and a stem, respiratory stem. So here you can see we are checking our tibial cut, minimal 7 to 8 millimeters of cut from the lateral side.
Medial side, already there is a big defect, so we don't have to be misguided by the medial side. It's very important. Otherwise you could {INAUDIBLE} a lot of bone and will be difficult to reconstruct. So you can see that neutral mechanical axis of the tibia conservative cut 3 and 1/2 degree posterior slope, and there's the defect on the tibia.
So we'll size the tibia now and then reconstruct the tibia with a wedge, will show how to prepare for a wedge and how to use the stem, a press-fitted stem of this particular system, which is slanted and which is good to prevent end-of-stem pain. So we are removing some posterior osteophytes now, clearing of the capsule, and initial trial without the stem, because still we have navigation pins, so we are not preparing for a stem.
We'll do that later. But this is an initial trial to show us the final mechanical alignment, and the ligament balance and the patellar tracking. So patella, you can see striking beautifully, so our rotation is nice, and we can check our medial lateral gap balance both in flexion and extension, and we will see the final alignment.
Alignment is in 3 degree flexion, 5-and-a-half degree varus, so we need some more connection there. But this also is due to dipping of the tibial {INAUDIBLE} the defect. So once we correct that, it's about 3-degree varus, about 3-degree flexion, which is very happy situation. And you can see the flexion gap is nicely balanced in 6 and 6. So flexion gap is nicely balanced with...prepare the patella now, always resurface the patella, so that there are no secondary delayed patellar complications.
Then we come onto the tibia now. Now we remove the pins, and the reason is that now we are to prepare for the stem. One option is to put the pins very distally on the tibia, but we don't like doing that, because that may lead to iatrogenic periprosthetic fracture. So we like to put our pins in the metaphyseal part to prevent any periprosthetic fractures. And when we're preparing for this stem, we check our first alignment ligament balance, and then we prepare for the stem, because after that nothing much changes.
We want to press-fit the stem here, absolutely with cortical touch, because there is a big medial defect, and this system has a provision for offset the stem and the metaphyseal area. But here we don't need it. If we need it, we can use a 2 millimeter, 4 millimeter or 6 millimeter offset stem, to ensure proper component positioning of the tibial side. But here the component is nicely placed with normal bushing, so we are not using offset in this particular case.
Otherwise we revision, we use it very often, and once we do that, we put our cutting jig for the medial wedge. And there you can see that the first slot is 10 millimeter, the second slot is 15 millimeter, and the saw will go at 15 millimeters, so this is a really big defect, and my colleague is pressing the fracture with a small osteotome, we'll fix it later. This is not truly a saw cut, just to level it, especially posteriorly, and just to ensure that we have a level surface for the medial tibial wedge, just rasping to ensure that it sits nicely and beautifully on the surface.
Tibia should be an external rotation. It's a 14 millimeter stem, which is nice and press fit 160 millimeters, and then we have a 15 millimeter of medial wedge. Final preparation and the final trial. You can see with the wedge and with the stem. Nice and stable. Patellar tracking, very stable, fully extended.
We keep the knee in 3 to 5 degrees of flexion, which on weight-bearing becomes neutral. So if you keep the knee in hyperextension, it goes into further hyperextension, leads to instability and failure. So our goal is to correctly align it in the coronal plane within three degrees and 3 to 5 degrees of flexion, so that when the patient bears weight, it becomes nice and neutral.
We don't want any {INAUDIBLE}, at the same time we don't want any recurvatum either, because that may lead to failure. Both recurvatum and {INAUDIBLE} are failure situations. Now we are putting the medial wedge with those two screws, and you can see the stem is slotted here to prevent end-of-stem pain. Final cementing, very important step, to push the cement into the bone defect on the medial side, and then implant the femur, then the tibia.
The stem is hybrid cementing, so we don't put any cement in the canal, but there is some on the metaphyseal part of the stem. There you can see the medial wedge, and this is balanced with a 9 millimeter poly because our cuts are conservative, and we always attempt to put a 9 millimeter minimal poly. And that can be done with assessment, correct assessment of soft tissues, that there you can see the medial wedge and a 9 millimeter poly.
This is always possible with computer navigation or robotics, where you have better assessment of soft tissues. The screw medially is to hold the fracture. Not doing much maybe, but the main fixation is distally with the stem and the medial wedge. The overall mechanical alignment is pretty good, it's neutral, and the knee is also in 3 to 5 degrees of flexion, which when the patient bears weight, becomes neutral. So this joint line is maintained, the medial side is nicely reconstructed, and the patient is up and about the same day.
So these are the principles of reconstructing of revision of uni to a TKA through computer- assisted surgery. Thank you very much.
Segment:0 .
Hello, friends. Partial knee replacement is a great option for medial compartment arthritis with end-stage bone-on-bone degeneration. And partial knee replacement, historically, has been either mobile bearing, which is the Oxford, or fixed bearing, which, the most popular was Zouk implant, which is now used as a Journey knee, partial knee. So both these knees are pretty popular, but the short-term results with conventional methods can have challenges and early failures. In mobile bearing knee, the main mode of failure is progression of lateral compartment arthritis, because of mechanical axis deviation on the lateral side by a tight poly.
That's the main cause of failure in a Oxford mobile bearing uni. In a fixed bearing uni, the main cause of failure is in varus, and especially on the tibial side. If there is more bone resection, or the tibial pins cause stress fractures and the tibial plateau medially will apply to fractures as in this case, which can also happen with the mobile bearing Oxford uni. If the pins are not appropriately placed or placed repeatedly, which can cause stress risers and stress fractures, as you can see here.
So this is a fixed bearing uni. If the tibial resection is more, and the pins are not placed appropriately, and placed two or three times, then it may lead to stress fractures like in this case, the tibial plateau has collapsed, and the knee is in about 12, 13 degrees of varus. This is a 70-year-old doctor who had this partial knee only one month back. So the failure is very recent, unfortunate, and needs to be revised now.
So this was done elsewhere by conventional methods, and the problem with conventional method for uni especially is that you cannot analyze the kinematics, and that's why robotics have great advantage for uni knee replacements where the bone dissection is less, there is no need to put the tibial pins as there is no tibial jig and the robotic burr actually takes {INAUDIBLE} the tibia. So great advantages of robotic to prevent failures like these early failures, one month failure of a fixed bearing uni on the tibial side, failure in varus, patient can't walk and we are revising him.
There are no signs of infection, this is the range of motion is pretty fair, but the knee's in varus, there is no ligament instability of course, the knee is in varus. The patient has got comorbidity issues. He has had a bypass and two angioplasties. We'll be doing a computer-assisted revision of a uni to a TKA, and as we go through we'll discuss the advantages of navigation in these cases.
So you can see that that's the medial uni, there is no infection. However, we always send samples, two to three samples and to the biochemistry to see the cellular count, and we also send them for culture. So this is the medial uni, you can see it's failed in varus. The femur component is OK, but the tibia has subsided with the medial tibial fracture. So the key here when you're doing navigated is not to remove the implants but put your pins and do the registration on the implants.
The advantage is that that prevents any varus cut. Now, hypothetically, if you remove the implants and use conventional method, then both the femur and the tibia jig may tilt in varus. So when you remove the femur implant and take the tibial cut or the femur cut, the jigs may go into varus and again, it may lead to failure. So navigation is recommended or robotics is recommended for revisions also these days very valuable for a uni revision.
So we'll register on the implants. And then take our femur cut, distal femur cut, with the implant on, and you will see how advantageous that is to prevent over-cutting of bone or deviation into varus. So we are registering currently the anterior side on the femur implant, all the tibial implant, and we'll see that the deformity is 12, 13 degree varus with a neutral knee, and this will require conservative femur and tibial cut, because on the medial side the bone is already cut, so we should not be led by the already cut medial bone.
We have to look carefully on the lateral bone and do conservative cuts to prevent a very thick poly or instability. So those are the key points of any operated knee, just like a revision situation. Here you can see 13 degree varus, 1 degree extension. That means the distal femur cut has to be minus 2 millimeters, and that can be really nicely guided by navigation. So that we are removing just the top of the anterior surface, the top clear part, and fixing our distal femur jig under navigation control, and proper varus-valgus, we can see about three degree flexion.
We are planning a resection of minus 1.5, minus 2 millimeters, varus of 1 degree is okay, and where to ensure that we aren't cutting much from the medial side. The implant is still on, and we are cutting 7 to 8 millimeters of distal femur only, because the knee has got one degree extension, severe varus deformity. When we correct both of that, the knee will further open and extension.
Now, once we have taken a lateral distal femur cut, we see where the saw is passing from. So it will take one or 2 millimeters of distal femur cut even radially. Now we gradually, gently remove the implant. This is important. We have taken the cut first. Now we know that little will cut from the medial side. Now we remove the implant with the attempt to minimize bone loss.
You can see just some bone loss on the posterior side, with very sharp 10 millimeter osteotome. You go all around the sham first posterior condyle, and then remove the implant carefully. Then you go medially just one or 2 millimeters cut from the medial side, 7 to 8 millimeters. Now you can see those two peg hole defects. And that's the cut. Now medial gap looks very opened up, but this is because, not because laxity of the medial collateral ligament, but because of the tibial defect.
So our femur cut is conservative. We have registered our femur cut, marking the interepicondylar axis. Now for rotation, also we are to be very careful, because there is no posterior medial condyle, so we can't take a 3 degree rotation because that will be a lot of external rotation because there is no posterior medial condyle. So we are extremely careful.
We have kept a minus 2 degree rotation to compensate for the lack of posteromedial condyle, but we'll check it with navigation. It will be three degrees to the interepicondylar axis, perpendicular to the wide side line as you will see here. But we have to be aware that there is no posterior medial condyle. So, you can see we have kept it around 4 degrees of external rotation, which is fair for patellar tracking and revision situations.
Now we will take our cut, and we are confirming that it's perpendicular to the wide sideline you can see there, and it's parallel to the interepicondylar axis. You can see the {INAUDIBLE} there coming up nicely. Then we take the cuts very carefully on the medial side, nothing much will cut because the implant was there. So on the medial side, nothing much, then the sham force of course, and then the final preparation. You can see the rotation is good.
The lateral side is bigger than the medial side, which it should be. That indicates that our rotation is fine, so be very careful of rotation. Now you can see the medial gap looks very big, but actually is the tibial component, which is subsided. Our rotation is good, the medial collateral ligament is fine. We are checking it again and again, but we have to be very careful with our cuts.
Now, this is the final chamfer for the box cut for the implant. And then we go to the tibial cut. The tibia will be reconstructed with a wedge and with a stem. That is a standard mode of construction for fair uni. Again, uni is being removed very carefully now, so that there is minimal loss of bone. And there's a big defect, almost of about two centimeters on the medial side, because there is a fracture and there is subsidence.
So the gap is more. We may be using 15 millimeter medial augment there. Now we are doing a conservative tibial cut, and you can see the fracture of the medial tibial plateau, medial most part will fix it, but one screw, but the main reconstruction modality will be with augment and a stem, respiratory stem. So here you can see we are checking our tibial cut, minimal 7 to 8 millimeters of cut from the lateral side.
Medial side, already there is a big defect, so we don't have to be misguided by the medial side. It's very important. Otherwise you could {INAUDIBLE} a lot of bone and will be difficult to reconstruct. So you can see that neutral mechanical axis of the tibia conservative cut 3 and 1/2 degree posterior slope, and there's the defect on the tibia.
So we'll size the tibia now and then reconstruct the tibia with a wedge, will show how to prepare for a wedge and how to use the stem, a press-fitted stem of this particular system, which is slanted and which is good to prevent end-of-stem pain. So we are removing some posterior osteophytes now, clearing of the capsule, and initial trial without the stem, because still we have navigation pins, so we are not preparing for a stem.
We'll do that later. But this is an initial trial to show us the final mechanical alignment, and the ligament balance and the patellar tracking. So patella, you can see striking beautifully, so our rotation is nice, and we can check our medial lateral gap balance both in flexion and extension, and we will see the final alignment.
Alignment is in 3 degree flexion, 5-and-a-half degree varus, so we need some more connection there. But this also is due to dipping of the tibial {INAUDIBLE} the defect. So once we correct that, it's about 3-degree varus, about 3-degree flexion, which is very happy situation. And you can see the flexion gap is nicely balanced in 6 and 6. So flexion gap is nicely balanced with...prepare the patella now, always resurface the patella, so that there are no secondary delayed patellar complications.
Then we come onto the tibia now. Now we remove the pins, and the reason is that now we are to prepare for the stem. One option is to put the pins very distally on the tibia, but we don't like doing that, because that may lead to iatrogenic periprosthetic fracture. So we like to put our pins in the metaphyseal part to prevent any periprosthetic fractures. And when we're preparing for this stem, we check our first alignment ligament balance, and then we prepare for the stem, because after that nothing much changes.
We want to press-fit the stem here, absolutely with cortical touch, because there is a big medial defect, and this system has a provision for offset the stem and the metaphyseal area. But here we don't need it. If we need it, we can use a 2 millimeter, 4 millimeter or 6 millimeter offset stem, to ensure proper component positioning of the tibial side. But here the component is nicely placed with normal bushing, so we are not using offset in this particular case.
Otherwise we revision, we use it very often, and once we do that, we put our cutting jig for the medial wedge. And there you can see that the first slot is 10 millimeter, the second slot is 15 millimeter, and the saw will go at 15 millimeters, so this is a really big defect, and my colleague is pressing the fracture with a small osteotome, we'll fix it later. This is not truly a saw cut, just to level it, especially posteriorly, and just to ensure that we have a level surface for the medial tibial wedge, just rasping to ensure that it sits nicely and beautifully on the surface.
Tibia should be an external rotation. It's a 14 millimeter stem, which is nice and press fit 160 millimeters, and then we have a 15 millimeter of medial wedge. Final preparation and the final trial. You can see with the wedge and with the stem. Nice and stable. Patellar tracking, very stable, fully extended.
We keep the knee in 3 to 5 degrees of flexion, which on weight-bearing becomes neutral. So if you keep the knee in hyperextension, it goes into further hyperextension, leads to instability and failure. So our goal is to correctly align it in the coronal plane within three degrees and 3 to 5 degrees of flexion, so that when the patient bears weight, it becomes nice and neutral.
We don't want any {INAUDIBLE}, at the same time we don't want any recurvatum either, because that may lead to failure. Both recurvatum and {INAUDIBLE} are failure situations. Now we are putting the medial wedge with those two screws, and you can see the stem is slotted here to prevent end-of-stem pain. Final cementing, very important step, to push the cement into the bone defect on the medial side, and then implant the femur, then the tibia.
The stem is hybrid cementing, so we don't put any cement in the canal, but there is some on the metaphyseal part of the stem. There you can see the medial wedge, and this is balanced with a 9 millimeter poly because our cuts are conservative, and we always attempt to put a 9 millimeter minimal poly. And that can be done with assessment, correct assessment of soft tissues, that there you can see the medial wedge and a 9 millimeter poly.
This is always possible with computer navigation or robotics, where you have better assessment of soft tissues. The screw medially is to hold the fracture. Not doing much maybe, but the main fixation is distally with the stem and the medial wedge. The overall mechanical alignment is pretty good, it's neutral, and the knee is also in 3 to 5 degrees of flexion, which when the patient bears weight, becomes neutral. So this joint line is maintained, the medial side is nicely reconstructed, and the patient is up and about the same day.
So these are the principles of reconstructing of revision of uni to a TKA through computer- assisted surgery. Thank you very much.
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