Chapters Transcript Video Medial JOURNEY II UK Surgical Technique Video Dr. Kevin Fricka, MD, performs a medial JOURNEY II partial knee replacement. Good morning everybody kevin fricka. I'm part of the Anderson orthopedic clinic and we're here at harborside Surgery center. We're gonna do a journey to partial knee replacement or unit condo attorney. Gentleman here today is a 72 year old. You can see medial compartment arthritis, a pristine patella, femoral joint and a P. A. Flexion view shows again, you know significant medial arthritis. He has a little bit of a flexion contracture but that doesn't deter us from doing a partial knee replacement. We'll go ahead and get started. We have his patella and tibia to brickell. Usually the incision goes to length from the superior pole patella to the typical typical. We'll make it a little bit bigger just for the camera. Take that meniscus sort of back to the rim. Really identify the meniscus here and take that all the way back which will help with meniscal removal later. Okay and we're gonna tuck this home in sort of underneath and again in a fixed various deformity. We can be a little more aggressive with our media release but in someone with not much deformity we're probably not going to do as much of a release like to do. Give me a half inch Osti tone is take out the nachos to fight. So here's the but he does have a nacho Stephanie is going to hit this for us just to remove the osteo fight. Go ahead Steph you can hit good. We just give the a. C. L. Little room to breathe there so that we don't have any late attritional ruptures related to sort of impingement. So now the has plenty of room to breathe. Um And we're gonna now begin the partial knee replacement. So I'm gonna use the spoon technique which allows us to set a depth of reception for an eight millimeter polyethylene most of the time. What we do is we set this spoon underneath the con dial. Okay and let it rest in there. There's a couple of thicknesses. So if it's a little loose you can use a two or a three millimeter thickness. And then we're gonna take our tibial guide here. So we're going to set this up and we're gonna match his slope. He has a little bit of a flexion contracture. So you can be a little lower on the slope. But you can see this guide has, you know this is for height, this is gonna be for various Vegas and this will be for slope. So we're gonna just dial maybe a little bit more slope in. Okay? And then bring this up. I usually I set this not all the way down because if we need to re cut we can just put the tibial guide back on. So this is for an eight and we're going to just sort of match these two up. Okay? And sometimes if it's a little bit hard you put it in the other one first and then you allow that to go in like that. Okay so now what we're going to do is set our position here. okay, David's gonna hold this over here. We're gonna take the pin. And the nice thing with this system is the one pin system. So I just set this pin and now I can take the guide out. Okay? And I can check my cut. He's a little bit snug because of his fixed various deformity. So we're going to take an angel wing and just look at the depth of our reception here. Now there are other ways to do this to you can also use the style. So use the stylus. This is going to fit into the guide. It's a two or a four millimeter section. We also have a three or a five millimeter section but sets us for an eight millimeter polyethylene. And I just check the height of it with my angel wing and then once that's in place again, one pin only, you tighten this up and that makes the jig secure. So I do not need to use any more pins in the tibia. And now we're just going to make our tibia cut. So then we can just again we just slide this off. Now here, in terms of the vertical cut. Okay, Roger 1st so there's a couple osteo fights here which we're just gonna take out. I'm gonna take a little bit of the fat pad out for exposure. Now a lot of times just as on the other side where the A. C. L. Was, there's an osteopath fight a lot of times there's an osteopath fight here and if you don't remove it, it'll be hard to get your vertical cut completed assertion of the A. C. L. We're going to make the vertical cut and I just sort of market with the bovie or sip stop please. And then I'm gonna take the cut. Now I use a double sided recipe because I can cut forward as well. But some people prefer a single side of the sip. It just allows us to go in and then move move back and then we can come and also finish our cup. And this is a pretty thin cut. So he has a little more of a post here, medial wear pattern than anterior medial. And so the benefit here is the re cut is very easy. We just put this guy back on, we take this and we undo it and then we just lower it all the way to do the re cut here. So the tibia re cut if we needed to is pretty straightforward. No further pins are needed and we just put that guide back on and make our cut here. Okay, so we want to get the aid in. Give me a plus one given that he's a little bit tight extension. We're going to take one millimeter more distal femur. So we have a plus one versus the standard resection of 6.5. And that will give us a little bit of more space also with his flexion contracture, you know, that'll help as well mallet. So we get that block in there, get it lined up good. And so someone with the flexion tractor, I'm also going to take the bump, we're gonna put it under his heel. We're trying to get rid of most of that flexion contracture and then we're gonna pin this in place. So as we can see, we're lined up with the tibia and the femur and we're gonna make our distal femoral resection. Now, a lot of times you can't completely finish that cut because you're cutting on yourself and the bone will tend to bind a little bit. And so we're gonna take this out now and then finish our cut. Hey, and we use the path of the previous cut. Break that off console. And this is our distal femoral cut again, millimeter thicker just to give us that little extra space. Put our hand in there, we know are still intact. We've got a pretty good space. Here's our eight. So now this is the receptive block. So I've cut the femur and tibia and we want to make sure the eight goes in and you can see here by taking that extra one. The eight goes in very easily. Okay, now we're not correcting this guy's flexion contracture, not gonna be able to correct it much. So, but the eight goes in easily now. And so we know that we're balancing extension at the eight Now inflection, we're gonna take the gray eight. Now we're gonna see if he's balanced with the Gray eight. The goal is an eight on both sides. And now the eight goes in pretty easily again. Okay? You know, it's not hard to put in, put it in nice and easy. So that means the aid is balanced. Okay, so now we're gonna come finish sizing the femur okay, Roger for a second. Just have a little lip on the femur here. Okay. A couple of different ways to do this when it's tight like this. I prefer it with just the T handle. Okay, like this because there's not as much bulk back here, but you can also do it where you put this guide on here and slide that in together. Okay, in this case he's a little snug in the back so I'm not gonna do that. And I want a size eight, eight is what we're gonna start with now. Four through seven are the same cutting guide, Eight through 10 of the same cutting guide and one through three of the same cutting guide. So if the eight is on and I want it bigger, I could just cut the eight and then put the nine on. That's the advantage of the system. But here, what we look at here is we're right where we want to be, so there's the cartilage margin up there, the eight is in good position. Okay and so once that's in good position, all I concentrate on is putting the top pin in. Okay? And we're gonna pin that like that. So now we want to look at make sure that our tibial cut is parallel to our post, your femoral cut. So a lot of times we're going to turn the handle and if you use the other technique, this is going to write the femur all the time because it's based off the tibia. But if you're just using the T handle, sometimes you're just gonna have to turn it into the notch a little bit and then finish pinning it. So we'll take a gold pin And I'm just gonna use one here. I do secure this block with three pins. Um Again the nice thing here is we don't have to commit to our medial lateral femoral position right now what we do here is we could if we said, hey this is money, just drill our lugs. But the advantage of this system is we can use these holes here and we'll have a femur that can shift a few millimeters. So we are not committing to our position, medial lateral to the femur with these cuts. Okay, we are committing to our rotation. So it's important to get out. So we'll start first with the post the ephemeral cut. Good and then we're gonna start with. Now there's no pins in the way for those cuts. Okay, so now we're gonna take the sizer so I just take the hook and on it it has different sizes. We're gonna hook the back of the tibia and read the front, so the front is reading an eight or a nine. Okay we want to make sure that he doesn't have any significant osteo fights along the tibia but you don't necessarily want to take every single one of those because that can narrow your tibia on the medial side. Your dimensions run out medial collateral rather than front to back. So if we look at the eight, the eight looks a little small So we're gonna look at the nine And the nine's pretty good. There is a paper that talks about you know you don't want more than two of overhang. So I like to get it right to the edge but we do like to maximize the size of the tibial component for good cement fixation and good support. Um Before I put this in, I'm just going to talk about it. So there's a couple ways to do this one is you know the old method where we just hit the keel in. Okay this has a sharp keel, we just use this guy to hit it in place. The other is you can use these guys here and just put this in place, there is an osteo tome that can pre make your keel and then drill your love drills as well. So a couple of different ways to do that. I prefer doing it with getting the keel set in place. So we use that and we take a mallet and we hit that down okay? And that also then allows me to get it in place and securely I may need to move it back a little bit so we do that. Now. I prefer it to be sort of right on the front rim as is here, you know some people are gonna like it a little more posterior and again you can just easily move that a little posterior and make sure it's hit and secured. All right, So now this is a This is kind of the bells and whistles of this system which is nice. We have our femur which has our spikes on it and allows us to have 2-3 mm of medial excursion if we want. So we get this lined up with our holes. Is that line that day, yep, we're lined up with our holes and then we hit that in place. Okay? I do give it a final imp action with this. Okay. And at this point if I wanted to I could move the femur so you can either hit it with this to move it mallet and I don't need to move it much but just over right there because we're pretty good and if you look, you know there are lines so it's nice to have the female line line up with the tibial line and that means we're in pretty good position, we're close to the notch. We don't really hug the condo, we hug the notch, we're gonna take an eight polly, okay, I'm gonna take this eight polly and slide that in like that. So now so again we're you know this guy again, he's not fully straight because he has a flexion contractor. We've corrected as varies two formula a little bit but we haven't overcorrected. Most people prefer to an extension and two inflections. Okay. But a lot of people do want their flexion gap just slightly looser so they might prefer three. But again we're doing the various valdas stress, you know, we're checking his range of motion and this guy, he's not going to get fully straight but objectively. We want the amber guide to go in like that. So straightforward, easy straight in two millimeters and then inflection, we can start with the two millimeter guide. Okay. And two millimeter guide is pretty good. So I know I'm happy if if and and again we knew this guy was a little bit tight inflection. His femur sits a little more posterior so the three, you know the three goes in, it's a little snug, we're kind of at 2.5 but we're fine there. So the three is a little snug er but I'm not gonna chase that right now we've got good range of motion. We've got excellent component position and if we want to look here again all these lines on the components, let me get the light back on here so everybody can see this. But again there's a line on the femur, there's a line on the tibia and we're all in good position there. Okay so we're gonna now finish drilling the femur and we're gonna come here and drill the femur here and drill the femur here, pretty straightforward. Getting this off, you can either either use a lane or you can use the device you inserted it on to make sure it's in good position. Just lift it off like that. Okay good. Now we're gonna take the hook to get the poly out this nice little device, it just allows us to hook the poly, get it out of place like that. Now we're gonna finish preparing the tibia alright? And so usually with the leg holder I bring the leg out a little bit just to rotate those, you know the lugs to me, I secure it in place with a drill bit here, it gives me the angle of my cut. Excuse me, my love drills because they're slightly posterior angle, they're not straight up and down as you can see the drill is not straight up and down so we take this out, okay we're gonna take that guide here and again a nice little handle here, just allows us to lift this out for cement penetration. We are gonna do some drill holes in the femur and we're gonna do some drill holes in the tibia. So again, given the size the eight and nine, you know, a little bit tighter of a knee and a flexion contracture. And a bigger male. I do like to cement this in two stages. Okay, So we're going to cement the tibia, let that essentially harden. And then cement the femur as well. I think any time, you know, getting cement out of the back of the knee and things like that, I think it's okay to cement in two stages. Okay. But this was a nice case in that the, you know, it showed you the versatility of the system. We got a little bit of a flexion structure, we can take one millimeter of distal femur. Um you know, the first tibial cut in, the bigger male was too small. So we just put the guide back on and simple re cut you just drop it down and do that. So then now we're gonna cement them. Again, a lot of people are gonna say for a fixed various knee with a flexion contracture that you shouldn't necessarily do partial knee replacements, but 72. So active 72 year old with good range of motion of his knee. You know, this is this is his procedure, you know, and partial knees. We've got good 25 year results. And so we've got good long term results. You know and this allows him to have a little smaller surgery and maintain his range of motion. You know I do talk to these patients who have a flexion contracture and you have a various deformity. You know we talk to him and say hey look do you even notice that your leg doesn't get all the way straight or that your leg is a little bit bowed? A lot of patients coming and that's not what they're worried about. They're worried about the pain and so medial compartment disease with a little bit of fixed varies a little bit of a flexion contracture. Most of those patients don't even notice they have those things or they say hey I've been boat all my life and so you get them some deformity correction but you get them a smaller surgery and you take away their pain. So again we're going to cement the tibia only so we put the cement on the tibia and um the sides are beveled so they're soft tissue friendly. We do have some grit blasting on the back for good cement fixation. And you can see the two peg design with the keel as well. Um Okay and we'll show you some ways to minimize cement penetration in the back. You know some people do talk four x four back there. You know what we do is we get the key. Oh engaged, we're gonna use a Chandler okay we're gonna push down on the back of the tibia so that all of this cement squirts out to the front and you can kind of see when all of that extra cement came out to the front and now we take it and just remove the cement, okay? We start impacting austerely move it forward again. This is not like a total knee where you're wailing on it, you don't want to impact this overly. I mean obviously you do have to impact it but you don't want to crush it. We're gonna take out some residual cement after we impact it again. We have these cement curates, both of them are in the set. They're useful for getting cement out of the back of the knee which is again where most of the cement. Well some of the cement hangs out, hopefully you got most of it out through the front but there's always gonna be a little bit of cement in the back. Now the other thing I like to do is take a spacer block and use that to pressurize the whole tibia. And so what we do is we put this in the back along the tibia and we let the femur rest on it and so that we push down on that and that gives us some pressurization again. You wanna make sure that the guide or the spacer block is evenly on both the front and the back of the tibia so you're getting even pressure there, okay and take that out again and we're gonna check in the back for some more cement and well, you know, either you know tibia loosening maybe it could happen so spending a little extra time cementing the tibia. Well I think is important, you know, and what might happen as well as progressive arthritis. Well that doesn't have anything to do with this stage that has to do with limb alignment and that's the one thing that's good about a fixed various deformity, you're not at all going to have to worry about over correction, you know, you basically are leaving these guys you know where they are. Again, we're just spending a lot of time back here just getting cement out but limb alignment is really going to determine success in partial needs in terms of progressive arthritis. You know, we published our series on it and you know what we say is slight vest, just right okay, because you want to leave them in a little bit of various, too much various, put some stress on the tibial component and maybe a concern for tibial loosening if you overcorrect them, it's a concern for progressive arthritis. So, you know, I know this takes you know an extra few minutes here cementing in two stages, but the benefit is I can spend all the time, you know getting the cement out of the back of the knee then we just rest this in place, you know that cement is pretty good right now. I can go to the back table now and work on the femur. Just trying to let the cement and that's again the we're taking a little extra time. Not every patient you have to cement in two stages. I just think for you know a bigger male like this. Getting his tibia well cemented, getting all the cement out of the back of the knee is important. Okay so now we're just starting to pressurize this into the femur frere again please on it now and I usually don't put any cement on the post here con dial so we just usually put that on the femoral component. Okay and again with that valda stress here it allows us to just drop the femur in like this right there it is. Okay once you find the back hole is pretty easy to do that, we're just gonna get this cement out, cement was maybe a little on the runny side. So and take the freer use that. Let me see the hook sometimes it's a poly doesn't quite go just take a little mallet and I'll put it in place. Usually come on out, We'll just let the thermal cement dry again. That's the 33 went in pretty good. Bring it into about 45 or 30° sometimes full extension and work on letting this cement. So we'll take the basin now and we'll wash it out you know that really concludes the case. I mean we're gonna put the poly in and I'll show you how that locks in place. But um you know for this guy with medial compartment disease you know I think this is the right procedure for him. You know the journey to unique departmental needs system allows you to do it efficiently. You know this also is you can do it robotically as well. So um you know if you like like Corey you know this is very slick and smooth robotically as well. Um You plan your cuts and you to burst system and you can burn the femur and tibia and get it the same way I use manual instrumentation and I think the key with manual instrumentation here is that you're not compromising anything by doing manual fixation. We put it into flexion and it's just so so you can see this, we're gonna use this here. Okay so just get the light on here, we're gonna take a freer. What we want to just make sure is that we're not hitting the tibial spine. We want to make sure is engaged austerely. So give it a little push this hooks into the tibia here lift up and push you hear an audible click and we can see the poly is locked into place. Okay so we're done with that and now we're gonna go on the closure. So give me the bump. My closure is I do a couple number ones at the proximal and distal extent of the incision. And then I use a barbed suture for closure. We then close the sub Q. With uh you know or the subcutaneous tissue with sort of two oh vicryl. You can use monochrome as well. And then we go to mono krill stitch or a sub particular stitch for the skin. Published September 7, 2022 Created by Related Presenters Kevin B. Fricka, MD
