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When to Uni, When to CR, When to PS, When to PS Plus, When to Constraint a Knee: A Perspective
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When to Uni, When to CR, When to PS, When to PS Plus, When to Constraint a Knee: A Perspective
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Language: EN.
Segment:0 .
ANOOP JHURANI: It's often confusing how to choose your level of constraint in knee arthroplasty. Market forces force us to think in terms of their perspective. But what is the scientific standpoint? How to choose the right implant for your patient who has got osteoarthrosis of the knee? So this video is about the evidence based perspective on how to choose the right case for a uni.
ANOOP JHURANI: What is the right case for a CR? What is the right case for a PS? PS Plus semi constraint, a hinge and a tumor. So we'll look at 1 x ray example of each case, discuss the ways to diagnose arthritis of that particular compartment and choose the right implant for that particular knee and be very scientific about our judgment. So let's first look at anterior medial arthritis of the knee and that's how arthritis truly starts is from the medial compartment
ANOOP JHURANI: and this is a common case. Now imagine if this patient is 48, 50-year-old lady with medial compartment pain. The lateral compartment looks very good, the patella looks very good. If you do a PS knee in this, this lady at 70 will need a big revision. So we need to think as is just medial compartment way limited to the medial compartment.
ANOOP JHURANI: Do we really need to do a total knee or should we do something else? The right way to think is that we should do a valgus stress X-ray and when we do a valgus stress X-ray, the knee opens up medially. What that means is that the epiphyseal has not undergone a permanent bone fracture and the disease is because of loss of cartilage. When you give a valgus stress, as you can see here, and the knee opens up,
ANOOP JHURANI: that means that if you put the implant replacing the cartilage part, rest of the knee is quite all right. So your cruciates are all right, your patellofemoral joint is all right. All you have is medial compartment of the knee, which is primarily due to cartilage loss. Now, this is a great case for a partial knee replacement. And you can see here that partial knee replacement just replaces the medial compartment.
ANOOP JHURANI: The lateral compartment is beautiful, patella is beautiful, and the knee has been restored nicely to mechanical axis, one or two degree in varus, in a uni, and the cruciate remain intact. One of the ways to see whether the cruciate is intact, the anterior cruciate especially, is to see the lateral concavity of the medial plateau, now, on the lateral X-ray. Now, if the medial tibial plateau retains its concave structure, that what that means is that the ACL is intact and the knee is not subluxaing posteriorly because when the ACL is gone, the medial sub looks posteriorly and the medial epicondyle will flatten out,
ANOOP JHURANI: and that is not the case for a uni. So for a partial knee replacement, ACL has to be intact, the disease has to be confined to the medial compartment, patella has to be good and the deformity has to be correctable on a valgus stress, that's a great case for a uni. Now uni can be of two types, either a fixed bearing or a mobile bearing.
ANOOP JHURANI: Mobile bearing Oxford type of design has been in there for four decades now. Very good long term data, reasonably good data of about 85% survivorship at 10 years in registries as well. Little high learning curve. What you can always learn and do this because in a young patient less than 50 years, it's a good operation to do for isolated medial compartment because then all your four cruciates are intact, you get excellent range of movement and uni has to been shown to have the highest forgotten knee scores.
ANOOP JHURANI: What that means is that the patient really forgets that patient has had an operation on the knee. So it's a good, good thing to learn. More important is to identify the right patient that we just did. Now let's go on; when to do a cruciate retaining knee and when to do a posterior stabilized knee. Now, when the disease is advanced, more than a case of uni, that is, the disease has advanced to the other compartments of the knee,
ANOOP JHURANI: the patella is also involved. It is primarily medial compartment, some subluxation is there, the deformity is not much, it is less than 10/15 degrees, which is primarily correctable, especially in a young patient, then that's a great case for cruciate retaining knee. Now, you can do a posterior acetablular I mean, all the cases you want, but then the thought process is, should we really sacrifice the PCL and should we really do a posterior stabilizing in all our cases, or should we think of cruciate retention?
ANOOP JHURANI: The reason we should think is that the long term survivorship of a cruciate retaining knee is longer than a posterior stabilized knee because there is no box and cam, it's a unconstrained knee. So the maximum unconstrained knee is a uni where all four ligaments are intact. Next is the the cruciate retaining, then the ACL is gone because of arthritic process, but you retain the PCL and that gives a natural stability to the knee and you don't need a box and a cam.
ANOOP JHURANI: Now, when you don't have a box and cam, your knee is unconstrained and will last longer and that is proved in long term registry data. So you can see the right case is for CRA where you don't need the most soft tissue release. You do a measured resection, cut 9 millimeters of tibia and femur and replace with equivalent amount of metal. You don't need much soft tissue release
ANOOP JHURANI: and you can see here that the knee is nicely, mechanically aligned. It's got a nice slope and it's beautifully balanced in extension and flexion. Now let's go into a little bit of detail of cruciate retaining knee. Now, cruciate retaining knee has two polys, one a standard poly, and some companies give you a deep dish poly. Now they say you can take off the PCL and put a deep dish poly.
ANOOP JHURANI: Now, that is not really a cruciate retaining knee. Cruciate retaining knee is only when you retain the PCL to its normal structure and function and put a normal CR poly. When you put a deep dish poly, you have to take off the PCL and then it's more of a anterior stabilized knee. So the difference between a CR and a deep dish poly is that when you put a deep dish, it's got more constrained anterior posteriorly.
ANOOP JHURANI: Your PCL is insufficient when this knee is called anterior stabilized. All right? So that's the difference between CR and anterior stabilized with the deep dish poly. As you can see, there is no box and camps so there'll be no third part where and CR, if properly balanced, will last longer. Some people find it difficult to balance the PCL and they say PCL is tight.
ANOOP JHURANI: It's not the PCL, which is tight because PCL is what God gave or nature gave to that particular knee. It's always nice and pristine and beautiful. What is tight is the flexion gap. So one has to give 7 degree slope and downsize the femur in case you are between sizes, so you have adequate 9/10 millimeter space to put your poly. So if you really give a 7 degree slope
ANOOP JHURANI: and if you cut 10 millimeter of posterior condyles, to give adequate flexion space, you'll always be able to put a 9 millimeter poly and you will never be in a need to release PCL. So cruciate retaining knee is a good knee to do, good knee to learn, especially in young patients who are expected to live longer. Now when to do PS is I'm sure you all know that, a lot of you do PS knees and some do PS in every case.
ANOOP JHURANI: But as I said, it's important to think when to uni, when to CR, and when the deformity is more than 10/15 degrees, especially the fixed deformity, big posterior osteophytes, a lot of patellofemoral disease, and you know, you can't balance the PCL because of the big osteophyte fixed deformity, you need more soft tissue release. Then, then it is better to do a posterior stabilized knee. So you know that posterior stabilized knee has a box and cam.
ANOOP JHURANI: And in this particular case, when the knee is very tight, big deformity, more than 15 degrees, all big osteophytes near the area of PCL, then you can do a posterior stabilized knee like all of us do but, you can differentiate when to do CR and when to do PS; less deformity, correctable deformity CR especially young patient. There is another constraint called the PS Plus, now that's available in some of the implants like this particular one
ANOOP JHURANI: and it gives more constraint than a PS insert. So here you can see this is a normal PS insert and this is a PS Plus insert. Now what that means is it is a little more constrained, it is wider and it is a little thicker, so it gives a more rotational stability. Now, in elderly patients who have been walking on very severe varus deformity, there is lateral collateral laxity and the knee is still a little lax laterally,
ANOOP JHURANI: then you can use a PS Plus insert. But this is for an elderly patient because more the constraint, more the wear. So you should remember that you should not use it in every case, but use it judiciously, only in the cases which have got more lateral laxity or in a valgus knee severe type III where there is laxity in elderly patient, you can use a PS Plus insert.
ANOOP JHURANI: So friends, we have seen when to uni, when to CR, when to PS and when to PS Plus. Now let's go to the rest of the three constraints. When there is furthermore instability and the patient is more deformed, as you can see here, very severe deformity, no joint line, regional osteoporosis, big osteophytes, the gap becomes little mismatched and because of osteoporosis, you need to add stems into it,
ANOOP JHURANI: then you can go up to the next constraint, which is a semi constraint type of a knee. And whenever you use a semi constraint, which is a bigger and a deeper box, you should use the stems. And the reason is that the thicker the constraint or higher the constraint, the forces will be transmitted to the implant bone interface. And that's why you should have a load sharing device, which is the stem on both the sides.
ANOOP JHURANI: And here you can see in the post op X-ray that we have used the stems on both the sides. We've done some medial epicondyle or osteotomy to correct the deformity and the deformity is nicely corrected, but because the lateral laxity is big, the gaps are little bigger and there is regional osteoporosis. We use a higher constraint with stems on both the sides and we should know that stems are load shedding and there is a particular way to put the stamps.
ANOOP JHURANI: You should not put them very tight that they can cause anti stem pain. You should not put them very loose because otherwise they are no good. You should have enough fixation in the diaphysis of both femur and tibia and you can use offset of the stem to lateralize the tray. So you can use an offset tray in case you have to position your component correctly.
ANOOP JHURANI: So if stems not only fix but also influence the position of the component. So if you want to shift your tibia laterally, you have to offset your stem medially and similarly femurly, usually we have to bring down and that's why you have to offset the stem anteriorly. So this is a semi constraint and the semi constraint, the LCCK or TC3, we will discuss in a later on video - What is the difference between TC3 and LCCK?
ANOOP JHURANI: There are two revision systems, but each has got its strengths and pitfalls or drawbacks. We'll discuss that in a later revision video. But right now it suffices to say that we should use higher constraint in case where there is instability, in case the gaps are bigger and we are not able to balance it with a 15 or 17 standard, poly. Especially now when the collateral insufficiency is more, so
ANOOP JHURANI: you are revising or you are doing a case where there is MCL insufficiency, you can use a hinge. So what happens in hinges is that both the components are logged. So there is a hinge in between and the right indications for using a hinge are in a primary case as a neuropathic joint or a joint where the gaps are too big, the flexion gap is too big, and you want to constrain it or hinge it
ANOOP JHURANI: or in a revision case where there is discollateral insufficiency, the commonest primary indication is a neuropathic joint, is a hinge joint. Right? So last constraint is a tumor prosthesis, and we all knee surgeons should know how to do a tumor prostheses. Now, I have this case, which is a total knee done three years back. The lady, 85, fell down and this fracture was almost one-month-old when she presented to us.
ANOOP JHURANI: And you can see there is so much regional osteoporosis, so much comminution here that this fracture will not unite by osteosynthesis, especially an elderly patient, 80 years, 85 with cardiac comorbidities. If the patient is on the bed, probably they will have a lot of medical complications. So in this case, you want to mobilize the patient faster, and this is a great case for a tumor prosthesis, and you can immediately take that part off and put in a tumor prostheses.
ANOOP JHURANI: Now tumor prostheses is another step forward to a hinge. So obviously it is a hinge, obviously it is a hinge, no question about it, but you can add spacers depending on what bone you have to resect. So the basic segment can be 5 to 7 centimeters depending on what system you use, and then you can add a spacers. You can use uncemented stems in case the bone quality is good, or use cemented stems, especially in elderly patients like this case, you can cement both the stems.
ANOOP JHURANI: So tumor prostheses you have to put in the right rotation. External rotation, aspalinear espera is very important because otherwise patellar tracking will be a problem. So whenever you're doing a tumor prosthesis, be very careful of the rotation of the femur and the tibial component. So friends, the objective of this video was to share with you a scientific based perspective on when to choose all of these implants based on the level of constraint.
ANOOP JHURANI: It's the objective is not to promote any implant, but to share the scientific standpoint, and let me now quickly summarize this. So, medial compartment osteoarthritis, no fix deformity, opening up on a valgus stress X-ray, ACL intact is a good case for partial knee replacement. Dry compartmental disease, younger patient, less than 10/15 degree of deformities, especially correctable, is a great case for CR.
ANOOP JHURANI: If the PCL is not intact or is violated, you can do anterior stabilized knee, which is deep dish. PS, we all know, is a standard knee, but you can use a PS Plus insert, especially in elderly where you have more lateral laxity or there is some imbalance of the gaps in extension apart from your doing a maticular soft tissue release. In revision situations or in more unstable situations, more deformed, we can use a semi constraint at TC3, LCCK, but then we should always use the stems and use the stems to modify the component position to our advantage. In a neuropathic knee,
ANOOP JHURANI: in a knee, which is lost its collaterals, you have to hinge a knee. Again, we have to use the stems on both the sides. And in periprosthetic fractures or loss of distal femur bone suprapatellar fractures post TKR community fractures post CTR we can use a tumor prosthesis cemented or uncemented stems depending on the bone quality. So thank you very much and I hope you will find this video useful, especially in when you're doing a decision on how to choose your level of constraint for a knee implant.
ANOOP JHURANI: Thank you very much.
Segment:0 .
ANOOP JHURANI: It's often confusing how to choose your level of constraint in knee arthroplasty. Market forces force us to think in terms of their perspective. But what is the scientific standpoint? How to choose the right implant for your patient who has got osteoarthrosis of the knee? So this video is about the evidence based perspective on how to choose the right case for a uni.
ANOOP JHURANI: What is the right case for a CR? What is the right case for a PS? PS Plus semi constraint, a hinge and a tumor. So we'll look at 1 x ray example of each case, discuss the ways to diagnose arthritis of that particular compartment and choose the right implant for that particular knee and be very scientific about our judgment. So let's first look at anterior medial arthritis of the knee and that's how arthritis truly starts is from the medial compartment
ANOOP JHURANI: and this is a common case. Now imagine if this patient is 48, 50-year-old lady with medial compartment pain. The lateral compartment looks very good, the patella looks very good. If you do a PS knee in this, this lady at 70 will need a big revision. So we need to think as is just medial compartment way limited to the medial compartment.
ANOOP JHURANI: Do we really need to do a total knee or should we do something else? The right way to think is that we should do a valgus stress X-ray and when we do a valgus stress X-ray, the knee opens up medially. What that means is that the epiphyseal has not undergone a permanent bone fracture and the disease is because of loss of cartilage. When you give a valgus stress, as you can see here, and the knee opens up,
ANOOP JHURANI: that means that if you put the implant replacing the cartilage part, rest of the knee is quite all right. So your cruciates are all right, your patellofemoral joint is all right. All you have is medial compartment of the knee, which is primarily due to cartilage loss. Now, this is a great case for a partial knee replacement. And you can see here that partial knee replacement just replaces the medial compartment.
ANOOP JHURANI: The lateral compartment is beautiful, patella is beautiful, and the knee has been restored nicely to mechanical axis, one or two degree in varus, in a uni, and the cruciate remain intact. One of the ways to see whether the cruciate is intact, the anterior cruciate especially, is to see the lateral concavity of the medial plateau, now, on the lateral X-ray. Now, if the medial tibial plateau retains its concave structure, that what that means is that the ACL is intact and the knee is not subluxaing posteriorly because when the ACL is gone, the medial sub looks posteriorly and the medial epicondyle will flatten out,
ANOOP JHURANI: and that is not the case for a uni. So for a partial knee replacement, ACL has to be intact, the disease has to be confined to the medial compartment, patella has to be good and the deformity has to be correctable on a valgus stress, that's a great case for a uni. Now uni can be of two types, either a fixed bearing or a mobile bearing.
ANOOP JHURANI: Mobile bearing Oxford type of design has been in there for four decades now. Very good long term data, reasonably good data of about 85% survivorship at 10 years in registries as well. Little high learning curve. What you can always learn and do this because in a young patient less than 50 years, it's a good operation to do for isolated medial compartment because then all your four cruciates are intact, you get excellent range of movement and uni has to been shown to have the highest forgotten knee scores.
ANOOP JHURANI: What that means is that the patient really forgets that patient has had an operation on the knee. So it's a good, good thing to learn. More important is to identify the right patient that we just did. Now let's go on; when to do a cruciate retaining knee and when to do a posterior stabilized knee. Now, when the disease is advanced, more than a case of uni, that is, the disease has advanced to the other compartments of the knee,
ANOOP JHURANI: the patella is also involved. It is primarily medial compartment, some subluxation is there, the deformity is not much, it is less than 10/15 degrees, which is primarily correctable, especially in a young patient, then that's a great case for cruciate retaining knee. Now, you can do a posterior acetablular I mean, all the cases you want, but then the thought process is, should we really sacrifice the PCL and should we really do a posterior stabilizing in all our cases, or should we think of cruciate retention?
ANOOP JHURANI: The reason we should think is that the long term survivorship of a cruciate retaining knee is longer than a posterior stabilized knee because there is no box and cam, it's a unconstrained knee. So the maximum unconstrained knee is a uni where all four ligaments are intact. Next is the the cruciate retaining, then the ACL is gone because of arthritic process, but you retain the PCL and that gives a natural stability to the knee and you don't need a box and a cam.
ANOOP JHURANI: Now, when you don't have a box and cam, your knee is unconstrained and will last longer and that is proved in long term registry data. So you can see the right case is for CRA where you don't need the most soft tissue release. You do a measured resection, cut 9 millimeters of tibia and femur and replace with equivalent amount of metal. You don't need much soft tissue release
ANOOP JHURANI: and you can see here that the knee is nicely, mechanically aligned. It's got a nice slope and it's beautifully balanced in extension and flexion. Now let's go into a little bit of detail of cruciate retaining knee. Now, cruciate retaining knee has two polys, one a standard poly, and some companies give you a deep dish poly. Now they say you can take off the PCL and put a deep dish poly.
ANOOP JHURANI: Now, that is not really a cruciate retaining knee. Cruciate retaining knee is only when you retain the PCL to its normal structure and function and put a normal CR poly. When you put a deep dish poly, you have to take off the PCL and then it's more of a anterior stabilized knee. So the difference between a CR and a deep dish poly is that when you put a deep dish, it's got more constrained anterior posteriorly.
ANOOP JHURANI: Your PCL is insufficient when this knee is called anterior stabilized. All right? So that's the difference between CR and anterior stabilized with the deep dish poly. As you can see, there is no box and camps so there'll be no third part where and CR, if properly balanced, will last longer. Some people find it difficult to balance the PCL and they say PCL is tight.
ANOOP JHURANI: It's not the PCL, which is tight because PCL is what God gave or nature gave to that particular knee. It's always nice and pristine and beautiful. What is tight is the flexion gap. So one has to give 7 degree slope and downsize the femur in case you are between sizes, so you have adequate 9/10 millimeter space to put your poly. So if you really give a 7 degree slope
ANOOP JHURANI: and if you cut 10 millimeter of posterior condyles, to give adequate flexion space, you'll always be able to put a 9 millimeter poly and you will never be in a need to release PCL. So cruciate retaining knee is a good knee to do, good knee to learn, especially in young patients who are expected to live longer. Now when to do PS is I'm sure you all know that, a lot of you do PS knees and some do PS in every case.
ANOOP JHURANI: But as I said, it's important to think when to uni, when to CR, and when the deformity is more than 10/15 degrees, especially the fixed deformity, big posterior osteophytes, a lot of patellofemoral disease, and you know, you can't balance the PCL because of the big osteophyte fixed deformity, you need more soft tissue release. Then, then it is better to do a posterior stabilized knee. So you know that posterior stabilized knee has a box and cam.
ANOOP JHURANI: And in this particular case, when the knee is very tight, big deformity, more than 15 degrees, all big osteophytes near the area of PCL, then you can do a posterior stabilized knee like all of us do but, you can differentiate when to do CR and when to do PS; less deformity, correctable deformity CR especially young patient. There is another constraint called the PS Plus, now that's available in some of the implants like this particular one
ANOOP JHURANI: and it gives more constraint than a PS insert. So here you can see this is a normal PS insert and this is a PS Plus insert. Now what that means is it is a little more constrained, it is wider and it is a little thicker, so it gives a more rotational stability. Now, in elderly patients who have been walking on very severe varus deformity, there is lateral collateral laxity and the knee is still a little lax laterally,
ANOOP JHURANI: then you can use a PS Plus insert. But this is for an elderly patient because more the constraint, more the wear. So you should remember that you should not use it in every case, but use it judiciously, only in the cases which have got more lateral laxity or in a valgus knee severe type III where there is laxity in elderly patient, you can use a PS Plus insert.
ANOOP JHURANI: So friends, we have seen when to uni, when to CR, when to PS and when to PS Plus. Now let's go to the rest of the three constraints. When there is furthermore instability and the patient is more deformed, as you can see here, very severe deformity, no joint line, regional osteoporosis, big osteophytes, the gap becomes little mismatched and because of osteoporosis, you need to add stems into it,
ANOOP JHURANI: then you can go up to the next constraint, which is a semi constraint type of a knee. And whenever you use a semi constraint, which is a bigger and a deeper box, you should use the stems. And the reason is that the thicker the constraint or higher the constraint, the forces will be transmitted to the implant bone interface. And that's why you should have a load sharing device, which is the stem on both the sides.
ANOOP JHURANI: And here you can see in the post op X-ray that we have used the stems on both the sides. We've done some medial epicondyle or osteotomy to correct the deformity and the deformity is nicely corrected, but because the lateral laxity is big, the gaps are little bigger and there is regional osteoporosis. We use a higher constraint with stems on both the sides and we should know that stems are load shedding and there is a particular way to put the stamps.
ANOOP JHURANI: You should not put them very tight that they can cause anti stem pain. You should not put them very loose because otherwise they are no good. You should have enough fixation in the diaphysis of both femur and tibia and you can use offset of the stem to lateralize the tray. So you can use an offset tray in case you have to position your component correctly.
ANOOP JHURANI: So if stems not only fix but also influence the position of the component. So if you want to shift your tibia laterally, you have to offset your stem medially and similarly femurly, usually we have to bring down and that's why you have to offset the stem anteriorly. So this is a semi constraint and the semi constraint, the LCCK or TC3, we will discuss in a later on video - What is the difference between TC3 and LCCK?
ANOOP JHURANI: There are two revision systems, but each has got its strengths and pitfalls or drawbacks. We'll discuss that in a later revision video. But right now it suffices to say that we should use higher constraint in case where there is instability, in case the gaps are bigger and we are not able to balance it with a 15 or 17 standard, poly. Especially now when the collateral insufficiency is more, so
ANOOP JHURANI: you are revising or you are doing a case where there is MCL insufficiency, you can use a hinge. So what happens in hinges is that both the components are logged. So there is a hinge in between and the right indications for using a hinge are in a primary case as a neuropathic joint or a joint where the gaps are too big, the flexion gap is too big, and you want to constrain it or hinge it
ANOOP JHURANI: or in a revision case where there is discollateral insufficiency, the commonest primary indication is a neuropathic joint, is a hinge joint. Right? So last constraint is a tumor prosthesis, and we all knee surgeons should know how to do a tumor prostheses. Now, I have this case, which is a total knee done three years back. The lady, 85, fell down and this fracture was almost one-month-old when she presented to us.
ANOOP JHURANI: And you can see there is so much regional osteoporosis, so much comminution here that this fracture will not unite by osteosynthesis, especially an elderly patient, 80 years, 85 with cardiac comorbidities. If the patient is on the bed, probably they will have a lot of medical complications. So in this case, you want to mobilize the patient faster, and this is a great case for a tumor prosthesis, and you can immediately take that part off and put in a tumor prostheses.
ANOOP JHURANI: Now tumor prostheses is another step forward to a hinge. So obviously it is a hinge, obviously it is a hinge, no question about it, but you can add spacers depending on what bone you have to resect. So the basic segment can be 5 to 7 centimeters depending on what system you use, and then you can add a spacers. You can use uncemented stems in case the bone quality is good, or use cemented stems, especially in elderly patients like this case, you can cement both the stems.
ANOOP JHURANI: So tumor prostheses you have to put in the right rotation. External rotation, aspalinear espera is very important because otherwise patellar tracking will be a problem. So whenever you're doing a tumor prosthesis, be very careful of the rotation of the femur and the tibial component. So friends, the objective of this video was to share with you a scientific based perspective on when to choose all of these implants based on the level of constraint.
ANOOP JHURANI: It's the objective is not to promote any implant, but to share the scientific standpoint, and let me now quickly summarize this. So, medial compartment osteoarthritis, no fix deformity, opening up on a valgus stress X-ray, ACL intact is a good case for partial knee replacement. Dry compartmental disease, younger patient, less than 10/15 degree of deformities, especially correctable, is a great case for CR.
ANOOP JHURANI: If the PCL is not intact or is violated, you can do anterior stabilized knee, which is deep dish. PS, we all know, is a standard knee, but you can use a PS Plus insert, especially in elderly where you have more lateral laxity or there is some imbalance of the gaps in extension apart from your doing a maticular soft tissue release. In revision situations or in more unstable situations, more deformed, we can use a semi constraint at TC3, LCCK, but then we should always use the stems and use the stems to modify the component position to our advantage. In a neuropathic knee,
ANOOP JHURANI: in a knee, which is lost its collaterals, you have to hinge a knee. Again, we have to use the stems on both the sides. And in periprosthetic fractures or loss of distal femur bone suprapatellar fractures post TKR community fractures post CTR we can use a tumor prosthesis cemented or uncemented stems depending on the bone quality. So thank you very much and I hope you will find this video useful, especially in when you're doing a decision on how to choose your level of constraint for a knee implant.
ANOOP JHURANI: Thank you very much.
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Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
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Embed Size
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You Size - Responsive
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We Size - Responsive
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Picture Overlay Popup
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400 x 225
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512 x 288
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400 x 700
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768 x 1024
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1024 x 512
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1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
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