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Name:
Total Knee Replacement in Femur Extraarticular Deformities by Dr. Anoop Jhurani
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Total Knee Replacement in Femur Extraarticular Deformities by Dr. Anoop Jhurani
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Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: So this video is to discuss the practice and principles of total knee replacement in femur extra articular deformities. So the first few minutes are on theory and principles and then there is a surgical video on a live case with femur extra articular deformities. So the principle is if you have femur extra articular deformity, the proximal femur deformities have this effect on knee replacement and the distal femur deformities have the most effect on knee replacement.
ANOOP JHURANI: So the farthest you are from the knee the least is the effect on the investment and the closest we are to the knee, the maximum is the effect of the knee replacement. Now the most common type of proximal femur deformities in which you may need a TKI is the compliance in situ post intertrochanteric fracture or post hip replacement. So you can do this manually. Better to do with navigation because you get the center of the femoral head correct.
ANOOP JHURANI: And usually the deformity is not more than 10/15 degrees and you can correct it intra articular. So the easiest to manage are proximal femur deformities, post a test, post a short nail in the femur, intertrochanteric fracture on both the hip replacement where you need to get the center of rotation right and you can do it better with navigation. Now the more challenging ones are the shaft femur one where the fractured femur happened a few years ago.
ANOOP JHURANI: The patient has a nail in situ or maybe the implant was removed and you have a deformity in middle of shaft. Now the deformity will usually both be in coronel in saggital plane. You may or may not be able to pass a intramedullary rod for a distal cut femur. If you are not able to pass a rod because of severe deformity, you have to use a navigation, this is one of the ideal indications to use navigation.
ANOOP JHURANI: Again, if you have a nail in situ, you need not remove the nail and do a knee replacement with navigation or robotics. Maximum of 20 degrees of extra articular deformity can be corrected intra articular. What that means is that if your deformity is more than 20 degrees, you will cut through the collateral ligament, the lateral collateral.
ANOOP JHURANI: Hence you cannot correct more than 20 degrees off, you more or less extra articular deformity at the knee level anything less than 20 degrees. You can correct the intra-articular because you will not be violating the lateral collateral ligament. That's the important thing. And if you're going with that dimension, you don't need to remove the nail. The last one of the distal femur, extra-articular deformity.
ANOOP JHURANI: They are very challenging. We show two cases in the video that follows in one day the distal femur deformity but no implant, and in another one there is an implant. Now if you have an implant, you don't need to remove it if you doing it navigation and you can take the distal femur cut perpendicular to the mechanical axis with robotics or navigation. If there is no implant and there are previous incisions which show the principles of how to go about choosing the right incision and exposing the knee, because a lot of these knees with distal femur fractures are stiff.
ANOOP JHURANI: So you need to have your maneuvers ready to handle a stiff knee. So there are two important things. One is not to remove the implant using navigation. If you are not, then you have to remove the whole implant and secondly is to take care of the incisions. So let's first summarize the theoretical part and then we go on to the surgical video of the case of distal femur extra articular deformity.
ANOOP JHURANI: So I'll go through principle. The farthest you are from the knee, the least is the effect on knee replacement. So most common situation is an implant in the proximal femur, usually the deformity is less than 10 degrees and is degraded for knee arthritis at the knee. For shaft femur fractures, we are using navigation which you should,
ANOOP JHURANI: there is no need to remove the implant and you can correct up to 20 degrees of femur deformity at the knee level. The most challenging are the distal femur fractures which may be malunited. There may be an implant in situ, ideal indications to use an navigation, not remove the implant and take the cut perpendicular to the mechanical axis. The important thing with the soft tissue management, which we will show in the video that follows.
ANOOP JHURANI: So this is our patient with distal femur, extra articular deformity, and he's got lower 10 degree varus. You can see that he's got two incisions, one on the lateral side, one midline, and we'll discuss that in more detail. But he's not able to walk because of arthritis progression and because of the extra articular distal femur deformity, which is in about 10 to 15 degrees of varus, as you can see.
ANOOP JHURANI: So deformity is both at the fracture site, which is malulnited and also because of knee arthritis, which has progressed because of the varus deformity at the distal femur. So this much of deformity, which is less than 20 degrees, can be corrected intra articular with TK, of course, this needs a navigated TK because you can't pass an intermedulliary rod into this kind of deformity
ANOOP JHURANI: and you can see that the distal femur is also in some degrees of flexion, that is patella varchar and serial patellofemoral arthritis. So patient has poor range of movement, which is from 0 to about 25/30 degrees. There is no medial lateral instability, but this is a stiff knee, 0 to 30 degree range of movement. Those are the two incisions there which you can see, one is midline and one is lateral, which was for the incision, for bone grafting, then about 19 years back.
ANOOP JHURANI: So for 19 years, this patient patient did not have range of movement more than 30. He was somehow managing, but now it's painful. So we'll go through the midline incision and leave a two to three finger breadth between two incisions. The ideal distance between two incisions is four finger, but that's usually not possible. The minimum has to be two fingers, at least, otherwise that may lead to intramedullary flap necrosis.
ANOOP JHURANI: So two finger breadth between the lateral and the midline chosen incision and in these stiff knees, it's important to do vastus lateralis snip. So we do a rectus snip, so we go right up there and cut into the vastus at the top of the tendons. So go to the most proximal part of the tendon and cut into the fibers of vastus lateralis so as to give us lateral release.
ANOOP JHURANI: Now these cases are very stiff and it's important to first do all the lateral releases first. So first is rectus snip number one. Number two is to debride the patella. So here you saw a very thick scarred patella, then to do a lateral release. So we do the lateral release at the outset, don't wait till the end, so do it at the outset so that the whole extensor reticulum is mobile and free and then it is gives us access to the knee.
ANOOP JHURANI: So if it's not free scar, not mobile, then there are chances of avulsion from the tibial tubercle so that's a disastrous complication. So to prevent tibial tubercle avulsion of the quadriceps tendon, we should do all the lateral releases first. Then at the end we should come to the medial release. So first is rectus snip, a lateral release debulking of the patella, removal of all intraoperatively scar tissue.
ANOOP JHURANI: Then we remove the fibrous tissue from the tibiofemoral joint. So there is a lot of fibrous scar tissue, gradually start removing it. And as we do that, the knee starts flexing. So then we start keeping padded rolls under it. We start the whole operation with the knee at 20/ 30 degree flexed, and as the knee starts flexing more and more, we keep rolls of sheet under it so that the knee is gradually flexed up to 100 degrees
ANOOP JHURANI: and here you see it started bending, it's come up about 70, 80 and you can see that the distal femur is distorted. The condyle is hyperplastic, the medial condyle. There is a lot of hypertrophy on the lateral side. The last soft tissue release is on the medial side and then we gradually sublux the tibia out. If we start from the medial side, we'll over release the whole knee and cause instability.
ANOOP JHURANI: So first we do a rectus snip, then we do a lateral release, then we do infra patellar scar excision, we debug the patella, that's the work on the lateral side. That gives us flexion towards 60/70 degrees. Then we remove all the scar tissue from the tibiofemoral joint, and then finally we do a medial release. Medial release that is at the end because otherwise it will cause over release and instability.
ANOOP JHURANI: So that's, now you can see the knee started flexing about 120 degrees and now we can perform the operation. It's only after you've achieved complete range of movement with soft tissue releases starting from lateral coming to the medial at the end that the knee starts moving up to 120. Now we put our navigation pins and start resisting the femur, which is as you can see. It is really part of the pattern.
ANOOP JHURANI: Artemis involves the hyperplasia of the medial femoral condyle and a lot of hyperplasia on the lateral side so there is really a distorted anatomy. And regarding the kinematics, you can see the knees in about neutral knee with 12 degrees varus, so we need to correct the varus, the extra articular deformity will need to be corrected intra articular. Because there is patellar varchar
ANOOP JHURANI: we can resect 2 millimeter less of distal femur, as you can see there on the navigation screen. So we are bypassing the deformity, which you can see by using navigation. And that's the best tool for this successful performance of knee replacement in these cases. Then of course, it's the sizing ensuring that the rotation is right. Now, rotation by conventional methods will give us erroneous rotation because there is a lot of distortion of the posterior condyle anotomy.
ANOOP JHURANI: So we should follow the wide sideline and our conventional wisdom, which is basically a grand piano sign, cutting more on the lateral side and less on the medial side. And we're really cutting on the distorted lateral side because there is a big bump of bone, hypertrophic bone on the lateral side and we have to really cut that so that the pattella femoral space is not over.
ANOOP JHURANI: Stop and then you can see where that rotation is already. You can see that the grand piano sign is maintained and so both is maintained and then we do our box cuts, then we see the spaces again before cutting the tibia in space. Look equal body flexion extension space. So we need to cut about eight, nine millimeter of tibia to get the basic nine millimeter of poly in and you can see that the joint is completely arthritic.
ANOOP JHURANI: And then we do our tibial cut and maintain a natural slope, which is three to four degrees in a PS knee, and then take a tibial cut, which again we validate with navigation and it ensures that in a young man will get our coronal and sagittal alignment correct, which is imperative for the long term success of knee arthroplasty in a young patient. To correct the medial deformity or varus deformity, we release the medial soft tissue structures and excess osteoporotic bone on the medial side to correct the deformity, as you can see here
ANOOP JHURANI: so everything outside the size of the tibia is removed and there's the final trial, you can see in the knees, nicely aligned. We'll check it under navigation and you can see that the movement achieved in these cases is not more than 90 to 100 degrees because of scarring. And at the end, we do pie crusting of quadriceps to get at least 80 or 90 degree of movement, get coronal alignment correct, get sagittal alignment correct, get the soft tissue balance right and get patellar tracking right.
ANOOP JHURANI: If we do all that, the patient will be painless, happy, even if he has got 90 degree range of movement. So you can see here that the patient has a 80 to 90 degree range of movement. Finally, the patellar perforation, the tibial perforation and the putting of the poly and the final reduction, which should be easy and smooth. It should not be very tight because the patient has already difficulty inflection.
ANOOP JHURANI: And that's the X-ray that you can see that both the components are well aligned as per mechanical axis and we have bypassed the extra articular deformity with navigation. The knee is very nicely aligned in coronal and sagittal plane. Now this operation, we cannot perform with navigation without navigation by conventional methods because there is no way you can pass inter-medulliary rod and do this operation. Full length exit raised to further evaluate our coronal and sagittal alignment and
ANOOP JHURANI: here we can see that the knee is nicely aligned both in the coronal and sagittal planes. So good operation then with the help of navigation, bypassing the distal femur extra-articular deformity. Let's come to the next case, which is extra articular femur deformity with implant in situ. So another case here, you can see that there is old DCS done 20 years back and there is a DCS implant and the release painful.
ANOOP JHURANI: Now we can't remove the DCS because it would be a big operation, which you'll have to do either two stage, or even if you do one stage, it will be a big operation two incisions, one on the lateral side and one midline. So with navigation, we can just completely avoid the plate and still do the operation without going inter-medulliary. And with navigation, we can just bypass the whole distal femur deformity and the implant and it's still performed a good knee replacement.
ANOOP JHURANI: So here you can see that the DCS is about 20 millimeters from the joint line and we'll use a CR knee here because the PS box otherwise is going to hit the lag screw. And here we can see that the plate and the fracture are very old. There is no need to just go and remove the whole thing and create a lot of the stress riser, which will essentially mean that we need to put a bigger stem.
ANOOP JHURANI: But if you don't remove the plate and do the operation with navigation, it's very simple. Do a CR knee, especially with a distal inline. Here you're going to see a big incision on the lateral side, very old incision, patient has got about 15 degrees of flexion deformity clinically, a varus of 5 to 8 degrees and there you see the old lateral incision and fixed flexion deformity.
ANOOP JHURANI: So this operation again can be performed with navigation. You can see 11, 12 degrees of flexion, and deformity, some varus. And there is a pre-op kinematic analysis of the patient, and that's the distal femur cut. We take some more distal femur off because we are doing a CR knee and the patient has got a fixed flexion deformity. Then we'll do our TKR cut, maintain about a 6/7 degree slow because we are doing a CR knee,
ANOOP JHURANI: so we have to give it a 7 degree slope. And that is the final kinematic correction, and you will see that we have used a CR knee so there is no need to take a box because there is the lag screw, which is just two centimeters away from the joint line. So this is a CR deep dish knee and you can see nice patellar tracking, no lift off of the tray, which means that the PCL is nicely balanced and you can see the medial lag is screwed which is coming off the medial condyle and we can't remove it because in a DCS to remove the screw we have to remove the plate.
ANOOP JHURANI: Unlike a locking plate where you can remove some of the distal screws and do a PS knee in a DCS, to remove the screw, you have to remove the whole plate, so we don't need to do that. Instead use a CR knee as in this particular case, and it'll still do a good operation with the help of navigation. The nicely balanced knee going through the full range of movement, we have achieved full correction, achieved good balance,
ANOOP JHURANI: you can see the medial screw of the old DCS, which we're not trying to remove, and there is a post op X-ray for critical analysis. You can see coronal and sagittal alignment of the implant nicely maintained and we have done nothing to the distal femur implant because we've used navigation, we maintained the joint line and used the CR knee to complete this operation. So more examples of PFM which are common
ANOOP JHURANI: these days. In C2, again, you can use navigation, you can see the post op X-ray. On the other side, we maintained coronal alignment without removing the nail, without using any intramedullary guidance and using navigation. Same bilateral total hips. Again, use navigation to achieve correct alignment. This is the valgus deformity, the edge.
ANOOP JHURANI: You can use an intramedullary rod and get a good alignment, with navigation. you can get very handsome alignment. So friends, for any femur extra articular deformity, whether it's proximal, middle or distal, if we use navigation, we can achieve great coronal alignment, sagittal alignment without removing the implants and without bothering about the deformity. Thank you very much.
ANOOP JHURANI:
Segment:0 .
ANOOP JHURANI: So this video is to discuss the practice and principles of total knee replacement in femur extra articular deformities. So the first few minutes are on theory and principles and then there is a surgical video on a live case with femur extra articular deformities. So the principle is if you have femur extra articular deformity, the proximal femur deformities have this effect on knee replacement and the distal femur deformities have the most effect on knee replacement.
ANOOP JHURANI: So the farthest you are from the knee the least is the effect on the investment and the closest we are to the knee, the maximum is the effect of the knee replacement. Now the most common type of proximal femur deformities in which you may need a TKI is the compliance in situ post intertrochanteric fracture or post hip replacement. So you can do this manually. Better to do with navigation because you get the center of the femoral head correct.
ANOOP JHURANI: And usually the deformity is not more than 10/15 degrees and you can correct it intra articular. So the easiest to manage are proximal femur deformities, post a test, post a short nail in the femur, intertrochanteric fracture on both the hip replacement where you need to get the center of rotation right and you can do it better with navigation. Now the more challenging ones are the shaft femur one where the fractured femur happened a few years ago.
ANOOP JHURANI: The patient has a nail in situ or maybe the implant was removed and you have a deformity in middle of shaft. Now the deformity will usually both be in coronel in saggital plane. You may or may not be able to pass a intramedullary rod for a distal cut femur. If you are not able to pass a rod because of severe deformity, you have to use a navigation, this is one of the ideal indications to use navigation.
ANOOP JHURANI: Again, if you have a nail in situ, you need not remove the nail and do a knee replacement with navigation or robotics. Maximum of 20 degrees of extra articular deformity can be corrected intra articular. What that means is that if your deformity is more than 20 degrees, you will cut through the collateral ligament, the lateral collateral.
ANOOP JHURANI: Hence you cannot correct more than 20 degrees off, you more or less extra articular deformity at the knee level anything less than 20 degrees. You can correct the intra-articular because you will not be violating the lateral collateral ligament. That's the important thing. And if you're going with that dimension, you don't need to remove the nail. The last one of the distal femur, extra-articular deformity.
ANOOP JHURANI: They are very challenging. We show two cases in the video that follows in one day the distal femur deformity but no implant, and in another one there is an implant. Now if you have an implant, you don't need to remove it if you doing it navigation and you can take the distal femur cut perpendicular to the mechanical axis with robotics or navigation. If there is no implant and there are previous incisions which show the principles of how to go about choosing the right incision and exposing the knee, because a lot of these knees with distal femur fractures are stiff.
ANOOP JHURANI: So you need to have your maneuvers ready to handle a stiff knee. So there are two important things. One is not to remove the implant using navigation. If you are not, then you have to remove the whole implant and secondly is to take care of the incisions. So let's first summarize the theoretical part and then we go on to the surgical video of the case of distal femur extra articular deformity.
ANOOP JHURANI: So I'll go through principle. The farthest you are from the knee, the least is the effect on knee replacement. So most common situation is an implant in the proximal femur, usually the deformity is less than 10 degrees and is degraded for knee arthritis at the knee. For shaft femur fractures, we are using navigation which you should,
ANOOP JHURANI: there is no need to remove the implant and you can correct up to 20 degrees of femur deformity at the knee level. The most challenging are the distal femur fractures which may be malunited. There may be an implant in situ, ideal indications to use an navigation, not remove the implant and take the cut perpendicular to the mechanical axis. The important thing with the soft tissue management, which we will show in the video that follows.
ANOOP JHURANI: So this is our patient with distal femur, extra articular deformity, and he's got lower 10 degree varus. You can see that he's got two incisions, one on the lateral side, one midline, and we'll discuss that in more detail. But he's not able to walk because of arthritis progression and because of the extra articular distal femur deformity, which is in about 10 to 15 degrees of varus, as you can see.
ANOOP JHURANI: So deformity is both at the fracture site, which is malulnited and also because of knee arthritis, which has progressed because of the varus deformity at the distal femur. So this much of deformity, which is less than 20 degrees, can be corrected intra articular with TK, of course, this needs a navigated TK because you can't pass an intermedulliary rod into this kind of deformity
ANOOP JHURANI: and you can see that the distal femur is also in some degrees of flexion, that is patella varchar and serial patellofemoral arthritis. So patient has poor range of movement, which is from 0 to about 25/30 degrees. There is no medial lateral instability, but this is a stiff knee, 0 to 30 degree range of movement. Those are the two incisions there which you can see, one is midline and one is lateral, which was for the incision, for bone grafting, then about 19 years back.
ANOOP JHURANI: So for 19 years, this patient patient did not have range of movement more than 30. He was somehow managing, but now it's painful. So we'll go through the midline incision and leave a two to three finger breadth between two incisions. The ideal distance between two incisions is four finger, but that's usually not possible. The minimum has to be two fingers, at least, otherwise that may lead to intramedullary flap necrosis.
ANOOP JHURANI: So two finger breadth between the lateral and the midline chosen incision and in these stiff knees, it's important to do vastus lateralis snip. So we do a rectus snip, so we go right up there and cut into the vastus at the top of the tendons. So go to the most proximal part of the tendon and cut into the fibers of vastus lateralis so as to give us lateral release.
ANOOP JHURANI: Now these cases are very stiff and it's important to first do all the lateral releases first. So first is rectus snip number one. Number two is to debride the patella. So here you saw a very thick scarred patella, then to do a lateral release. So we do the lateral release at the outset, don't wait till the end, so do it at the outset so that the whole extensor reticulum is mobile and free and then it is gives us access to the knee.
ANOOP JHURANI: So if it's not free scar, not mobile, then there are chances of avulsion from the tibial tubercle so that's a disastrous complication. So to prevent tibial tubercle avulsion of the quadriceps tendon, we should do all the lateral releases first. Then at the end we should come to the medial release. So first is rectus snip, a lateral release debulking of the patella, removal of all intraoperatively scar tissue.
ANOOP JHURANI: Then we remove the fibrous tissue from the tibiofemoral joint. So there is a lot of fibrous scar tissue, gradually start removing it. And as we do that, the knee starts flexing. So then we start keeping padded rolls under it. We start the whole operation with the knee at 20/ 30 degree flexed, and as the knee starts flexing more and more, we keep rolls of sheet under it so that the knee is gradually flexed up to 100 degrees
ANOOP JHURANI: and here you see it started bending, it's come up about 70, 80 and you can see that the distal femur is distorted. The condyle is hyperplastic, the medial condyle. There is a lot of hypertrophy on the lateral side. The last soft tissue release is on the medial side and then we gradually sublux the tibia out. If we start from the medial side, we'll over release the whole knee and cause instability.
ANOOP JHURANI: So first we do a rectus snip, then we do a lateral release, then we do infra patellar scar excision, we debug the patella, that's the work on the lateral side. That gives us flexion towards 60/70 degrees. Then we remove all the scar tissue from the tibiofemoral joint, and then finally we do a medial release. Medial release that is at the end because otherwise it will cause over release and instability.
ANOOP JHURANI: So that's, now you can see the knee started flexing about 120 degrees and now we can perform the operation. It's only after you've achieved complete range of movement with soft tissue releases starting from lateral coming to the medial at the end that the knee starts moving up to 120. Now we put our navigation pins and start resisting the femur, which is as you can see. It is really part of the pattern.
ANOOP JHURANI: Artemis involves the hyperplasia of the medial femoral condyle and a lot of hyperplasia on the lateral side so there is really a distorted anatomy. And regarding the kinematics, you can see the knees in about neutral knee with 12 degrees varus, so we need to correct the varus, the extra articular deformity will need to be corrected intra articular. Because there is patellar varchar
ANOOP JHURANI: we can resect 2 millimeter less of distal femur, as you can see there on the navigation screen. So we are bypassing the deformity, which you can see by using navigation. And that's the best tool for this successful performance of knee replacement in these cases. Then of course, it's the sizing ensuring that the rotation is right. Now, rotation by conventional methods will give us erroneous rotation because there is a lot of distortion of the posterior condyle anotomy.
ANOOP JHURANI: So we should follow the wide sideline and our conventional wisdom, which is basically a grand piano sign, cutting more on the lateral side and less on the medial side. And we're really cutting on the distorted lateral side because there is a big bump of bone, hypertrophic bone on the lateral side and we have to really cut that so that the pattella femoral space is not over.
ANOOP JHURANI: Stop and then you can see where that rotation is already. You can see that the grand piano sign is maintained and so both is maintained and then we do our box cuts, then we see the spaces again before cutting the tibia in space. Look equal body flexion extension space. So we need to cut about eight, nine millimeter of tibia to get the basic nine millimeter of poly in and you can see that the joint is completely arthritic.
ANOOP JHURANI: And then we do our tibial cut and maintain a natural slope, which is three to four degrees in a PS knee, and then take a tibial cut, which again we validate with navigation and it ensures that in a young man will get our coronal and sagittal alignment correct, which is imperative for the long term success of knee arthroplasty in a young patient. To correct the medial deformity or varus deformity, we release the medial soft tissue structures and excess osteoporotic bone on the medial side to correct the deformity, as you can see here
ANOOP JHURANI: so everything outside the size of the tibia is removed and there's the final trial, you can see in the knees, nicely aligned. We'll check it under navigation and you can see that the movement achieved in these cases is not more than 90 to 100 degrees because of scarring. And at the end, we do pie crusting of quadriceps to get at least 80 or 90 degree of movement, get coronal alignment correct, get sagittal alignment correct, get the soft tissue balance right and get patellar tracking right.
ANOOP JHURANI: If we do all that, the patient will be painless, happy, even if he has got 90 degree range of movement. So you can see here that the patient has a 80 to 90 degree range of movement. Finally, the patellar perforation, the tibial perforation and the putting of the poly and the final reduction, which should be easy and smooth. It should not be very tight because the patient has already difficulty inflection.
ANOOP JHURANI: And that's the X-ray that you can see that both the components are well aligned as per mechanical axis and we have bypassed the extra articular deformity with navigation. The knee is very nicely aligned in coronal and sagittal plane. Now this operation, we cannot perform with navigation without navigation by conventional methods because there is no way you can pass inter-medulliary rod and do this operation. Full length exit raised to further evaluate our coronal and sagittal alignment and
ANOOP JHURANI: here we can see that the knee is nicely aligned both in the coronal and sagittal planes. So good operation then with the help of navigation, bypassing the distal femur extra-articular deformity. Let's come to the next case, which is extra articular femur deformity with implant in situ. So another case here, you can see that there is old DCS done 20 years back and there is a DCS implant and the release painful.
ANOOP JHURANI: Now we can't remove the DCS because it would be a big operation, which you'll have to do either two stage, or even if you do one stage, it will be a big operation two incisions, one on the lateral side and one midline. So with navigation, we can just completely avoid the plate and still do the operation without going inter-medulliary. And with navigation, we can just bypass the whole distal femur deformity and the implant and it's still performed a good knee replacement.
ANOOP JHURANI: So here you can see that the DCS is about 20 millimeters from the joint line and we'll use a CR knee here because the PS box otherwise is going to hit the lag screw. And here we can see that the plate and the fracture are very old. There is no need to just go and remove the whole thing and create a lot of the stress riser, which will essentially mean that we need to put a bigger stem.
ANOOP JHURANI: But if you don't remove the plate and do the operation with navigation, it's very simple. Do a CR knee, especially with a distal inline. Here you're going to see a big incision on the lateral side, very old incision, patient has got about 15 degrees of flexion deformity clinically, a varus of 5 to 8 degrees and there you see the old lateral incision and fixed flexion deformity.
ANOOP JHURANI: So this operation again can be performed with navigation. You can see 11, 12 degrees of flexion, and deformity, some varus. And there is a pre-op kinematic analysis of the patient, and that's the distal femur cut. We take some more distal femur off because we are doing a CR knee and the patient has got a fixed flexion deformity. Then we'll do our TKR cut, maintain about a 6/7 degree slow because we are doing a CR knee,
ANOOP JHURANI: so we have to give it a 7 degree slope. And that is the final kinematic correction, and you will see that we have used a CR knee so there is no need to take a box because there is the lag screw, which is just two centimeters away from the joint line. So this is a CR deep dish knee and you can see nice patellar tracking, no lift off of the tray, which means that the PCL is nicely balanced and you can see the medial lag is screwed which is coming off the medial condyle and we can't remove it because in a DCS to remove the screw we have to remove the plate.
ANOOP JHURANI: Unlike a locking plate where you can remove some of the distal screws and do a PS knee in a DCS, to remove the screw, you have to remove the whole plate, so we don't need to do that. Instead use a CR knee as in this particular case, and it'll still do a good operation with the help of navigation. The nicely balanced knee going through the full range of movement, we have achieved full correction, achieved good balance,
ANOOP JHURANI: you can see the medial screw of the old DCS, which we're not trying to remove, and there is a post op X-ray for critical analysis. You can see coronal and sagittal alignment of the implant nicely maintained and we have done nothing to the distal femur implant because we've used navigation, we maintained the joint line and used the CR knee to complete this operation. So more examples of PFM which are common
ANOOP JHURANI: these days. In C2, again, you can use navigation, you can see the post op X-ray. On the other side, we maintained coronal alignment without removing the nail, without using any intramedullary guidance and using navigation. Same bilateral total hips. Again, use navigation to achieve correct alignment. This is the valgus deformity, the edge.
ANOOP JHURANI: You can use an intramedullary rod and get a good alignment, with navigation. you can get very handsome alignment. So friends, for any femur extra articular deformity, whether it's proximal, middle or distal, if we use navigation, we can achieve great coronal alignment, sagittal alignment without removing the implants and without bothering about the deformity. Thank you very much.
ANOOP JHURANI:
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