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Name:
Which Socket to Use and Why - An Evidence Based Scientific Approach
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Which Socket to Use and Why - An Evidence Based Scientific Approach
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T00H18M52S
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https://cadmoreoriginalmedia.blob.core.windows.net/c6bc4a28-d728-485a-84f2-b9b1d75204d3/Which Socket to use and why - an evidence based scientific a.mp4?sv=2019-02-02&sr=c&sig=UAXGmmvtDYyO8l8CXQRbMzhKII%2FJNCxiHmNMMtSHHp4%3D&st=2024-11-23T09%3A45%3A37Z&se=2024-11-23T11%3A50%3A37Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. A few days back, we discussed various types of femoral implants to be used in various situations in hip arthroplasty. Today, let's discuss various acetabular components to be used in hip arthroplasty. The aim of this video is not to promote any one kind of acetabular implant, but to promote science, philosophy and the practice of acetabular reconstruction in hip arthroplasty.
ANOOP JHURANI: So let's start with some basics first and where to choose, where to place our cup. That's, that's the most important thing. And the first key step is to cut the inferior capsule and identify the transverse acetabular ligament, because dahl is the critical landmark for placement of your cup. And the commonest error that surgeons often make is to place their cup in too much retroversion and hence face instability.
ANOOP JHURANI: To prevent instability, they make the leg longer by putting additional neck lengths and that is the commonest mistake and since most surgeons are posterior approach, they tend to place their cup in retroversion. A small trick is to come on the anterior sides so we are operating from the posterior side, but when we're placing our acetabular component, if we come on the anterior side, we see the transverse acetabular ligament very clearly and the acetabulum is inclined 15/20 degrees in anti-version.
ANOOP JHURANI: So it makes sense to come anterior on the anterior side and then place the cup. So the cup, this is too retroverted, this is too much anti-version, you're seeing too much of anterior wall. If you see too much of posterior wall, that's too much retroversion. This is too horizontal, and this is too vertical. And the commonest error is to place the cup in too much vertical and retroverted positions.
ANOOP JHURANI: So let's do this again because this is important. This is horizontal, this is too vertical. If you see too much of posterior wall, your retroverted. If you see too much of anterior wall, you're anti-verted. So you have to place the cup in about 20 degrees anti-version that's parallel to dahl, and you should see a little bit of the posterior superior cup exposed. So that's the right placement of the cup,
ANOOP JHURANI: when you see little anterior wall and the cup posterior superior, that means you are in about 20/25 degrees of anti-version and the right inclination. Another error is to place the screw holes too posterior and then you end up putting two small screws near the greater sciatic notch. That's not a great idea. So put your screw holes between 11 and 1 o'clock and then you're able to put your screws into
ANOOP JHURANI: the thick iliac bone, that's where you need to put two 30 or 40 millimeter screws into the thick iliac bone. In most primary cases, you don't need to put any screws because your press fit of an uncemented cup is so good. But in case you need to put the screws, put them in the right quadrant in the thick iliac bone so that you get good purchase.
ANOOP JHURANI: Now, all uncemented cups are not the same, so we should look at the history of uncemented cups and find out how they're performing in registry data. So some of the cups that are doing well are the Trident cup from Stryker, the Pinnacle cup from Depuy and some other uncemented cups. And they're all porous coated, mostly are etch coated, so they grow in six to eight weeks if your press fit is good and solid and you can rock the pelvis gently after press fitting your cup, the patient can be mobilized the next day.
ANOOP JHURANI: Now, let's come to the liners. And the liner that's performing best in Australian registry is highly cross-linked poly. So be careful, when they open up the liner, ensure that it's a highly cross-linked poly because that's performing the best. What about the heads? There are three possible heads; the metal head, the ceramic head and the oxinium head.
ANOOP JHURANI: Metal head up to 32 is good, if you're using 36, try and use ceramic heads because there is some evidence that with larger head size there may be trinnulosis with metal heads. So metal heads are good from 32. 36, if you're using, use ceramic heads. Oxinium is also doing well in registry data, so oxinium and highly cross-linked poly is also a reasonable choice.
ANOOP JHURANI: There is some push by companies to use ceramic on ceramic, but you got to be careful because when you use a ceramic on ceramic, the combined anti-version has to be absolutely perfect because if you are mal inclined you'll have edge loading, ceramic wear and fracture or squeaking. So in primary pathology it's good to use ceramic on ceramic, but your inclination has to be dead right.
ANOOP JHURANI: If you're not sure, it's a complex pathology, ceramic on highly cross-linked poly is a reasonable choice. Now let's come to some common pathologic situations in our country. So this is the commonest, simple case and we need to be 40 degrees inclined right next to the teardrop and with or without antiverse screw fixation. Now, the first pathology that we have is a protrusion with a fused hip.
ANOOP JHURANI: And these are neglected rheumatoid cases, and this is a grade 3 protrusion, you can see it's got really in and there is no range of movement, so it's a fused hip. The greater trochanter is very next to the ilium, so this hip is not going to dislocate, it needs an in-situ osteotomy. The right way to do in-situ osteotomy is to identify this interval between the greater trochanter and the ilium, and there is only a few millimeters of the neck.
ANOOP JHURANI: So identify the lesser troch, identify the greater trochanter, may drill holes into the neck, use a c-arm if you need to, use a sharp 20 millimeter osteotome in to break the neck. Don't go into the anterior wall, so keep your osteotome inclined, little posterior so that you're not going into the anterior wall and then pry open the neck, so the femur goes anteriorly and you do initiate the reaming then to come to the real base.
ANOOP JHURANI: Again, come to the real base because you will tend to go a little higher up because that's where you will see the socket, that's where the head is and you will see the socket here.
ANOOP JHURANI: You need to remove all this fibrous tissue, identify the transverse acetabular ligament, identify the fat pad, look into the c-arm in these complex situations, and then put a highly porous cup. Gription revision cup is a great cup to put in these cases because it has got peripheral screw options into the cup, so Gription revision cup, you will have peripheral screw options,
ANOOP JHURANI: and that's a great option because inside from the cup you may not be able to put enough screws for a press fixation, use bone graft at the base and use a larger cup and recreate the offset and the right neck length. See the posterior wall delineated and then identify the neck and then do an in-situ osteotomy, as you can see. The in-situ osteotomy and once we have done an in-situ osteotomy, we can identify below to prepare our socket for what is called is in situ reaming since the head cannot be dislocated in a fused hip,
ANOOP JHURANI: we do the osteotomy, the in-situ osteotomy, then take another wedge of bone out like this, as you can see, and then we are clear that we can take the femur shaft anteriorly and identify all the walls and the margins of the acetabular socket. This another wedge of bone that comes out from the neck, and then we take the femur anteriorly with our socket, as you can see, with a very small reamer.
ANOOP JHURANI: So we can start with the 40 reamer, gradually go inside, step by step. The next pathology that is common is the dysplasia, and in dysplasia the socket is small because the head has never been there, so you'll have a 38/40 socket retroverted mostly. So in these cases, we have to place the socket very near to the teardrop in dysplasia type I and 4. In dysplasia, type 2 and 3, you can go slightly up 1, 1 and 1/2 centimeters, not more than that into the best bone stock
ANOOP JHURANI: but try and come as down as you can near the teardrop, find out the best bone stock and keep smaller cups available because you may need a 42 or 44 cup. And so you ask the company guys to give you smaller cups in dysplasia sockets. We start with the small reamer, first vertical to ream off the medial osteophyte and reach the true floor of the acetabulum.
ANOOP JHURANI: Progressively larger reamer. Further reaming to convert a flat ellipsoid middle acetabulum into a hemispherical socket.
ANOOP JHURANI: We do a trial reduction of the cup. Next pathology that is common in our country is necessity of a total hip replacement, post a neglected acetabular fracture, and the commonest pathology that you have is a posterior fracture dislocation. So in those cases, you will have a deficient posterior wall, try and build the posterior wall with the head graft posterior superiorly, make a hemisphere and use a highly porous cup.
ANOOP JHURANI: Caution needs to be exercised in transverse fractures like these because this is a transverse fracture and what you have is practically a pelvic discontinuity. So first you need to plate that transverse fracture and then use a highly porous Gription revision cup again in this case, and you can see that there are peripherally screw options. It's a good idea for acetabular fractures, to create a 3D model, and now these models are easily made in our country.
ANOOP JHURANI: And what these models do is to give us a very fair idea how the acetabular defect is, where the original plate is, and whether any screws will come our way and how will we need to reconstruct our acetabulum. So this is very critical in acetabular reconstruction, is to figure out if there is a pelvic discontinuity in a transverse fracture, plate it first and then use a highly porous Gription revision cup with additional peripheral screw options
ANOOP JHURANI: so that our reconstruction is very stable. The next situation is common is revision of cemented cups. Now, cemented cups have shown to last long in registry data, but in younger patients they fail early because of high activity level. There is one advantage when you are revising a cemented cup is that you will find good, sclerotic bone behind and you can reconstruct with, you can see a Gription revision cup which gives us peripherally screw options and we need to come to the teardrop, use a larger cup and reconstruct our acetabulum.
ANOOP JHURANI: But for all primary pathologies and complex primary pathologies, we should use uncemented sockets as the evidence stands today in 2017.
ANOOP JHURANI: The last is the use augment and in this revision situation, a peprowski type 3D effect, the socket has migrated, the cemented socket has migrated up and lateral. So in this case, we need to bring our socket down here, and in the residual defect we can use an augment. So augments are great assets and they are available with most revision system, both with Gription and trabecular metal and we'll discuss the difference of Gription and trabecular metal in a while,
ANOOP JHURANI: but we should use augments, mostly posterior superior defect and use peripheral cup screws so that we get excellent robust press fit fixation.
ANOOP JHURANI: Between the Gription revision cup and the trabecular metal system. There are two different systems. They are thought to be the same, but they're two different things. And Gription revision cup has peripheral screw options. It is highly porous, so it really can grow fast, but trabecular metal on the whole is a completely different metal and it grows faster,
ANOOP JHURANI: you can drill through the trabecular metal and if you need, you can fix the trabecular metal cup in any position in the acetabular socket and then cement in a cup in the right version. So for very complex cases where the bone is soft, you have bigger defects, we should use trabecular metal cups, and for primary complex pathology we should use Gription revision cup, which has got peripheral screw options.
ANOOP JHURANI: So the advantage of Gription revision cup is peripheral screw options. The advantage of trabecular metal cup is that you can drill screw holes into it and cement a liner into the right version wherever you think is stable enough. Now there is also push for dual mobility cups. Dual mobility cups is a restraint in the acetabulum and we should use it very wisely. In older patients who have chances of instability, in patients who we need to increase the head size for more stability and restraint, we can use a dual mobility, but not for all primary cases because there is some concern of trinilosis there, an intra-prosthetic dislocation of the dual mobility cup.
ANOOP JHURANI: So we need to be cautious while using dual mobility cup. And the last, but not the least, is the use of a constraint liner. Now, in cases where we have instability, say, for example, a patient with Parkinsonism or dementia or neurological disease, if we want to use uncemented cup primary setting, we should not use a constrained liner because the forces will be so high that the cup will get pulled out.
ANOOP JHURANI: So in these elderly patients we can use a cemented constraint liner. But if we are facing instability due to detachment of the trochanter and the cup has ingrown by then, that is if you have a case of an uncemented cup which was done one year back. The cup is ingrown and the patient has recurrent dislocations, then you can use a constraint liner in an uncemented cup.
ANOOP JHURANI: But for elderly neurological disease patients fresh case, you should use a cemented constraint cup. So that's the difference between uncemented constraint liner and a cemented constraint cup. So friends, just to summarize all of this is that for all primary cases, we should use press fit uncemented cups, preferably with the screw options. There is some push for ceramic monoblock cups, but we should be very cautious because it does not has any adjuvant screw options.
ANOOP JHURANI: So for all our primary cases we should use uncemented hemispherical cups, use right screws into the thick iliac bone, avoid the greater sciatic form, and be absolutely parallel to tall and not retrofitted or combined and the version should be 40/45 degrees. Use a ceramic on highly cross-linked poly for most of our cases. For pathological situations, acetabular fractures we should plate if there is pelvic discontinuity use Gription revision cup with adjuvant peripherally screw options for complex pathology and trabecular metal cups for complex revisions where we can augment our fixation with additional screws and augments.
ANOOP JHURANI: So this is just a summary of how we should reconstruct our complex acetabulum without any intention of promoting any kind of implant, but to guide the right scientific philosophy behind acetabular reconstruction. Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. A few days back, we discussed various types of femoral implants to be used in various situations in hip arthroplasty. Today, let's discuss various acetabular components to be used in hip arthroplasty. The aim of this video is not to promote any one kind of acetabular implant, but to promote science, philosophy and the practice of acetabular reconstruction in hip arthroplasty.
ANOOP JHURANI: So let's start with some basics first and where to choose, where to place our cup. That's, that's the most important thing. And the first key step is to cut the inferior capsule and identify the transverse acetabular ligament, because dahl is the critical landmark for placement of your cup. And the commonest error that surgeons often make is to place their cup in too much retroversion and hence face instability.
ANOOP JHURANI: To prevent instability, they make the leg longer by putting additional neck lengths and that is the commonest mistake and since most surgeons are posterior approach, they tend to place their cup in retroversion. A small trick is to come on the anterior sides so we are operating from the posterior side, but when we're placing our acetabular component, if we come on the anterior side, we see the transverse acetabular ligament very clearly and the acetabulum is inclined 15/20 degrees in anti-version.
ANOOP JHURANI: So it makes sense to come anterior on the anterior side and then place the cup. So the cup, this is too retroverted, this is too much anti-version, you're seeing too much of anterior wall. If you see too much of posterior wall, that's too much retroversion. This is too horizontal, and this is too vertical. And the commonest error is to place the cup in too much vertical and retroverted positions.
ANOOP JHURANI: So let's do this again because this is important. This is horizontal, this is too vertical. If you see too much of posterior wall, your retroverted. If you see too much of anterior wall, you're anti-verted. So you have to place the cup in about 20 degrees anti-version that's parallel to dahl, and you should see a little bit of the posterior superior cup exposed. So that's the right placement of the cup,
ANOOP JHURANI: when you see little anterior wall and the cup posterior superior, that means you are in about 20/25 degrees of anti-version and the right inclination. Another error is to place the screw holes too posterior and then you end up putting two small screws near the greater sciatic notch. That's not a great idea. So put your screw holes between 11 and 1 o'clock and then you're able to put your screws into
ANOOP JHURANI: the thick iliac bone, that's where you need to put two 30 or 40 millimeter screws into the thick iliac bone. In most primary cases, you don't need to put any screws because your press fit of an uncemented cup is so good. But in case you need to put the screws, put them in the right quadrant in the thick iliac bone so that you get good purchase.
ANOOP JHURANI: Now, all uncemented cups are not the same, so we should look at the history of uncemented cups and find out how they're performing in registry data. So some of the cups that are doing well are the Trident cup from Stryker, the Pinnacle cup from Depuy and some other uncemented cups. And they're all porous coated, mostly are etch coated, so they grow in six to eight weeks if your press fit is good and solid and you can rock the pelvis gently after press fitting your cup, the patient can be mobilized the next day.
ANOOP JHURANI: Now, let's come to the liners. And the liner that's performing best in Australian registry is highly cross-linked poly. So be careful, when they open up the liner, ensure that it's a highly cross-linked poly because that's performing the best. What about the heads? There are three possible heads; the metal head, the ceramic head and the oxinium head.
ANOOP JHURANI: Metal head up to 32 is good, if you're using 36, try and use ceramic heads because there is some evidence that with larger head size there may be trinnulosis with metal heads. So metal heads are good from 32. 36, if you're using, use ceramic heads. Oxinium is also doing well in registry data, so oxinium and highly cross-linked poly is also a reasonable choice.
ANOOP JHURANI: There is some push by companies to use ceramic on ceramic, but you got to be careful because when you use a ceramic on ceramic, the combined anti-version has to be absolutely perfect because if you are mal inclined you'll have edge loading, ceramic wear and fracture or squeaking. So in primary pathology it's good to use ceramic on ceramic, but your inclination has to be dead right.
ANOOP JHURANI: If you're not sure, it's a complex pathology, ceramic on highly cross-linked poly is a reasonable choice. Now let's come to some common pathologic situations in our country. So this is the commonest, simple case and we need to be 40 degrees inclined right next to the teardrop and with or without antiverse screw fixation. Now, the first pathology that we have is a protrusion with a fused hip.
ANOOP JHURANI: And these are neglected rheumatoid cases, and this is a grade 3 protrusion, you can see it's got really in and there is no range of movement, so it's a fused hip. The greater trochanter is very next to the ilium, so this hip is not going to dislocate, it needs an in-situ osteotomy. The right way to do in-situ osteotomy is to identify this interval between the greater trochanter and the ilium, and there is only a few millimeters of the neck.
ANOOP JHURANI: So identify the lesser troch, identify the greater trochanter, may drill holes into the neck, use a c-arm if you need to, use a sharp 20 millimeter osteotome in to break the neck. Don't go into the anterior wall, so keep your osteotome inclined, little posterior so that you're not going into the anterior wall and then pry open the neck, so the femur goes anteriorly and you do initiate the reaming then to come to the real base.
ANOOP JHURANI: Again, come to the real base because you will tend to go a little higher up because that's where you will see the socket, that's where the head is and you will see the socket here.
ANOOP JHURANI: You need to remove all this fibrous tissue, identify the transverse acetabular ligament, identify the fat pad, look into the c-arm in these complex situations, and then put a highly porous cup. Gription revision cup is a great cup to put in these cases because it has got peripheral screw options into the cup, so Gription revision cup, you will have peripheral screw options,
ANOOP JHURANI: and that's a great option because inside from the cup you may not be able to put enough screws for a press fixation, use bone graft at the base and use a larger cup and recreate the offset and the right neck length. See the posterior wall delineated and then identify the neck and then do an in-situ osteotomy, as you can see. The in-situ osteotomy and once we have done an in-situ osteotomy, we can identify below to prepare our socket for what is called is in situ reaming since the head cannot be dislocated in a fused hip,
ANOOP JHURANI: we do the osteotomy, the in-situ osteotomy, then take another wedge of bone out like this, as you can see, and then we are clear that we can take the femur shaft anteriorly and identify all the walls and the margins of the acetabular socket. This another wedge of bone that comes out from the neck, and then we take the femur anteriorly with our socket, as you can see, with a very small reamer.
ANOOP JHURANI: So we can start with the 40 reamer, gradually go inside, step by step. The next pathology that is common is the dysplasia, and in dysplasia the socket is small because the head has never been there, so you'll have a 38/40 socket retroverted mostly. So in these cases, we have to place the socket very near to the teardrop in dysplasia type I and 4. In dysplasia, type 2 and 3, you can go slightly up 1, 1 and 1/2 centimeters, not more than that into the best bone stock
ANOOP JHURANI: but try and come as down as you can near the teardrop, find out the best bone stock and keep smaller cups available because you may need a 42 or 44 cup. And so you ask the company guys to give you smaller cups in dysplasia sockets. We start with the small reamer, first vertical to ream off the medial osteophyte and reach the true floor of the acetabulum.
ANOOP JHURANI: Progressively larger reamer. Further reaming to convert a flat ellipsoid middle acetabulum into a hemispherical socket.
ANOOP JHURANI: We do a trial reduction of the cup. Next pathology that is common in our country is necessity of a total hip replacement, post a neglected acetabular fracture, and the commonest pathology that you have is a posterior fracture dislocation. So in those cases, you will have a deficient posterior wall, try and build the posterior wall with the head graft posterior superiorly, make a hemisphere and use a highly porous cup.
ANOOP JHURANI: Caution needs to be exercised in transverse fractures like these because this is a transverse fracture and what you have is practically a pelvic discontinuity. So first you need to plate that transverse fracture and then use a highly porous Gription revision cup again in this case, and you can see that there are peripherally screw options. It's a good idea for acetabular fractures, to create a 3D model, and now these models are easily made in our country.
ANOOP JHURANI: And what these models do is to give us a very fair idea how the acetabular defect is, where the original plate is, and whether any screws will come our way and how will we need to reconstruct our acetabulum. So this is very critical in acetabular reconstruction, is to figure out if there is a pelvic discontinuity in a transverse fracture, plate it first and then use a highly porous Gription revision cup with additional peripheral screw options
ANOOP JHURANI: so that our reconstruction is very stable. The next situation is common is revision of cemented cups. Now, cemented cups have shown to last long in registry data, but in younger patients they fail early because of high activity level. There is one advantage when you are revising a cemented cup is that you will find good, sclerotic bone behind and you can reconstruct with, you can see a Gription revision cup which gives us peripherally screw options and we need to come to the teardrop, use a larger cup and reconstruct our acetabulum.
ANOOP JHURANI: But for all primary pathologies and complex primary pathologies, we should use uncemented sockets as the evidence stands today in 2017.
ANOOP JHURANI: The last is the use augment and in this revision situation, a peprowski type 3D effect, the socket has migrated, the cemented socket has migrated up and lateral. So in this case, we need to bring our socket down here, and in the residual defect we can use an augment. So augments are great assets and they are available with most revision system, both with Gription and trabecular metal and we'll discuss the difference of Gription and trabecular metal in a while,
ANOOP JHURANI: but we should use augments, mostly posterior superior defect and use peripheral cup screws so that we get excellent robust press fit fixation.
ANOOP JHURANI: Between the Gription revision cup and the trabecular metal system. There are two different systems. They are thought to be the same, but they're two different things. And Gription revision cup has peripheral screw options. It is highly porous, so it really can grow fast, but trabecular metal on the whole is a completely different metal and it grows faster,
ANOOP JHURANI: you can drill through the trabecular metal and if you need, you can fix the trabecular metal cup in any position in the acetabular socket and then cement in a cup in the right version. So for very complex cases where the bone is soft, you have bigger defects, we should use trabecular metal cups, and for primary complex pathology we should use Gription revision cup, which has got peripheral screw options.
ANOOP JHURANI: So the advantage of Gription revision cup is peripheral screw options. The advantage of trabecular metal cup is that you can drill screw holes into it and cement a liner into the right version wherever you think is stable enough. Now there is also push for dual mobility cups. Dual mobility cups is a restraint in the acetabulum and we should use it very wisely. In older patients who have chances of instability, in patients who we need to increase the head size for more stability and restraint, we can use a dual mobility, but not for all primary cases because there is some concern of trinilosis there, an intra-prosthetic dislocation of the dual mobility cup.
ANOOP JHURANI: So we need to be cautious while using dual mobility cup. And the last, but not the least, is the use of a constraint liner. Now, in cases where we have instability, say, for example, a patient with Parkinsonism or dementia or neurological disease, if we want to use uncemented cup primary setting, we should not use a constrained liner because the forces will be so high that the cup will get pulled out.
ANOOP JHURANI: So in these elderly patients we can use a cemented constraint liner. But if we are facing instability due to detachment of the trochanter and the cup has ingrown by then, that is if you have a case of an uncemented cup which was done one year back. The cup is ingrown and the patient has recurrent dislocations, then you can use a constraint liner in an uncemented cup.
ANOOP JHURANI: But for elderly neurological disease patients fresh case, you should use a cemented constraint cup. So that's the difference between uncemented constraint liner and a cemented constraint cup. So friends, just to summarize all of this is that for all primary cases, we should use press fit uncemented cups, preferably with the screw options. There is some push for ceramic monoblock cups, but we should be very cautious because it does not has any adjuvant screw options.
ANOOP JHURANI: So for all our primary cases we should use uncemented hemispherical cups, use right screws into the thick iliac bone, avoid the greater sciatic form, and be absolutely parallel to tall and not retrofitted or combined and the version should be 40/45 degrees. Use a ceramic on highly cross-linked poly for most of our cases. For pathological situations, acetabular fractures we should plate if there is pelvic discontinuity use Gription revision cup with adjuvant peripherally screw options for complex pathology and trabecular metal cups for complex revisions where we can augment our fixation with additional screws and augments.
ANOOP JHURANI: So this is just a summary of how we should reconstruct our complex acetabulum without any intention of promoting any kind of implant, but to guide the right scientific philosophy behind acetabular reconstruction. Thank you very much.
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Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode