Chapters Transcript Video Lateral JOURNEY II UK Surgical Technique Video Dr. Kevin Fricka, MD, performs a lateral JOURNEY II partial knee replacement. Hey again dr kevin frick. A part of the Anderson orthopedic clinic. I'm here at Harborside Surgery center in Maryland. We're right outside of Dc and alexander Virginia. We're gonna do a lateral partial knee replacement with the new journey to unique compartment needs system. We've got a 66 year old female. She's post lateral menace ectomy in her twenties. And you can see she's gone on to lateral compartment arthritis. You know best seen on a p A flexion view. You can really see where the arthritis is. Her kneecap or patella area is pristine and in this case, you know, given her minimal deformity we did do a stress view. And the key here is we can see the medial compartment is the same. The lateral compartment opens up and we you know, still maintain her neutral to slight valdas alignment as an aside here you can either do a lateral partial knee replacement through a medial incision or go lateral para patellar. In this case she has a previous lateral incision. So instead of my standard straight incision we're gonna use her incision and have it curved a little bit. Okay so we're gonna use her old incision, you know, come down and curve it essentially her to brickell is here and her patella is here here and if we draw that out that's the patella. Okay, so normally it would be sort of a midline incision through here. But with the previous incision this is how we'll do it again. So the benefits of doing it through a lateral approach in terms of when they compare them head to head was a little better range of motion and you may be able to do it through a little smaller incision, a little quicker recovery than from the medial side. When you do it through through the medial side, you just gotta make sure you don't cut the medial meniscus. So we're gonna just elevate the leg here and we're gonna raise the tourniquet. So what we see here, you know, this is key to lateral arthritis. The distal cartilage still looks ok. So when they're standing straight or you know, with their legs straight, it's not too bad. And then you go to the post here, con dial and the post here porch and it's completely worn out. You know, that's bone to bone. So lateral compartment disease usually hurts going down the stairs. You know, it is best seen on that p A flexion view that we talked about because of the fact that it's sort of a post here wear pattern. Okay, so again, different ways but this allows us to tension the joint and then set our depth resection. But you can also use it with the stylus. Again that goes in nice and easy, it's resting where it needs to rest and then we put our tibial guide on again, we set our alignment and slope and everything here. So then, you know, again, this way we use this eight that sets us for an eight polyethylene if you show me the stylists, a lot of people will also use the stylists. Again, the stylist just goes into here and you can look at the depth of your section. This comes in two and four and three and five depending on the depth of your tibial cut. But both ways are good to do. It just depends on your preference. I'm sort of used to this spoon technique and it allows us to essentially get an eight millimeter cut every time. So we slide this on and then slide it in there we go once that's in position, then we're going to check our alignment and we're gonna hold this in position to set the depth of our cut. Again one pin. We just use the one pin here to hold our tibial guide in position. Okay, take this off. Okay? And then we're gonna just I always like to check in on the lateral side. We do not want a big cut because she's passively correctable. And we don't really want that big of a cut. So we just check it to make sure we may adjust it half a millimeter or so. And then again it's a one pin technique. We just tighten the guide and we take the saw and we're gonna make our studio car so we want to make sure. So there's the A. C. L. We see the hcl on the media union, we might want are cut to be more like this on the lateral union. We really want to internally rotate are cut for the screw home mechanism. She still has a little bit of an osteo fight down here moving into the rest of good. Okay so then we can just take that retractor and protect the A. C. L. Okay I don't have a retractor over here because I want to make sure that I'm allowing myself to internally rotate this as best I can and so we really want instead of it like straight out. You know, there's the A. C. L. I want this cut to be internally rotated and a lot of people actually or some people might cut through the tendon. You know if they don't get enough internal rotation. Okay so again we're going to take this here double side of the ship. He's going to take this and make our vertical cut. Now you have to understand the lateral side. The spine is not prominent. So a lot of times your cut is very minimal. We're just gonna finish this off this way. That is an Oscar tone come out with both of those. Again, on the lateral side here, we usually want a pretty minimal cut and in this case, you know, that's what we've accomplished console. It's a very minimal cut. Okay, probably. But if we look at our alignment, that looks not bad, we might need to cut 11 more but let's see the eight spacer block. So again we have an eight and a nine. Okay if you cut too small, the red one, you know red is recut, so if you can only get a six or seven in means you might need to re cut the tibia in her case. Um You know the eight is maybe a little snug. Um but still keeps her in Vegas. That's not bad actually. Um So I'll show you the way to re cut the tibia just so you can see that. Um And we might take a half a millimeter in this system. You could if you want so we'll take the tibial jig here, okay we've locked it in place. You know you can put this on like this, you can just if you wanted to open it up, you know, dial it down one or two or a half a millimeter, tighten it back up. You know? And if you want to make that cut you can you can see we're just barely taking anything because we don't really want a big cut. Now we can take this off because we know the eight was pretty good. Anyway it was just maybe a half a millimeter tight so we're just shaving a little extra, we'll make sure that we've completed that cut all the way to the notch saw back and there we go tensile. Good, okay we'll come back down and do extension and check the gray eight, you know? Now that goes in very easy. Okay so we'll do that as our cut. Okay if I needed to we could take one more or one less femur. But in this case we're going to do the standard resection which is 6.5 millimeters. That's the thickness of the femoral component. And so we just put this guide in like this. Okay, let's have a mallet for a second. This is a pretty tiny individual. So the black guide is gonna stick out just a little bit pin driver and we'll pin this in place and then we'll cut our distal femur. So there's one pin here again, we're gonna take the saw, we're gonna cut our distal femur. Now we can take this off because we know the eight was pretty good. Anyway, it was just maybe a half a millimeter tight. So we're just shaving a little extra. We'll make sure that we've completed that cut all the way to the notch saw back and there we go tensile good. Okay we'll come back down and do extension And check the gray eight. You know, now that goes in very easy. Okay so we'll do that as our cut. Okay if I needed to we could take one more or one less femur but in this case we're gonna do the standard resection which is 6.5 millimeters. That's the thickness of the femoral component and so we just put this guide in like this. Okay let's have a mallet for a second. This is a pretty tiny individual. So the black guide is gonna stick out just a little bit pin driver and we'll pin this in place and then we'll cut our distal femur. So there's one pin here. Again we're gonna take the saw, we're gonna cut our distal femur. Alright so now we're gonna check our gaps. Again we cut our distal femur and we cut our proximal tibia. So we use the eight millimeter resected block. Okay? Again that you just go right in like that pretty easy to go in. You know, correct her deformity a little bit gets straight. We like the eight. Okay? And we come to the flexion and we're gonna do the gray eight. Okay, take the gray eight And that's easy to get into. You can see that nice and easy reproducible. The aid goes in so we're balanced an extension And flexion at 8 mm at this point. You know sometimes now you're going to just make sure that your femoral cut was all the way through. We're gonna take out some Osti fights along the femur as well and we'll use that. Now again two different ways to do this. You can either use the spacer block and attach this to it and then slide that on like that or you can use the T handle which is what I prefer. You just grab it in the center and then you're going to just put it for your femur. Now here I was wrong, it's probably a five on the lateral side. However you don't want it to be too tall because you don't want to impinge on the patella. But we still have, we could probably do a five. So let's see what the five looks like. Again, the nice thing is four and five. Right now the lug holes are the same. So whatever block I cut with it can still work. Okay I think I like the five a little better but we'll finally size it again. One key thing on here you can see is you can see where the four is as well. So if you look closely on here, there's a black line around it which indicates where the four would be. Um So you know just a way to do it. Now we want to make sure our post, your femoral cut is parallel to our tibia, which it is. We're just gonna finish pinning this guide one out here and then I pin it with three. You could probably get away with pinning it to. But okay now again we could drill our lugs right now because I'm pretty confident this is where we want to be. But this system allows you to move the femur, medial or lateral, you drill those two holes and that's the set point for the femoral drill through trial. So you don't have to commit to your medial or lateral position. Good finish that come up here, pin driver. Okay. Stephanie's gonna grab these pins and just the process and taking pins out but we're gonna take our sizing stick again, we're gonna hook it to the back and look It looks like a four or 5. Let's see that. Now again what we look at here is these are and I don't know if the camera see but they're they're short but fat. So that's the lateral side is short and fat. So there's the five and we look at a four here and four looks spot on in the previous Yunis, you might have some overhang in the front. But in this case you know we know we no longer have that because again we're a short component but a wide component. Okay And we're going to just impact this into place. Again I I do it this way some people are gonna prepare right away. I like to get the trial in. You really gotta just hit a little bit to get the keel down, okay? But again we see we're not over hanging in the front. Okay, here's the bow b now we're gonna put the femur in and again the spikes. So we see those spikes, that's that home position and you can see back here how it allows the femur to move, you know a few millimeters so we find our home position which is here, take the orange impactor which is there. I want to see this from my time there, you have a tibial impactor to be a trace. Just lifting just a little our lines line up pretty good. I don't think we really need to move it much but you can move it just a little bit there. If you needed to orange impactor be secured in place with the pin just make sure that it's fully flushed. And now we're gonna take the eight trial. I'm gonna put a trial in place to bring the leg out to extension. I'm gonna see there again if we look here she's fully straight. Okay? She still is in slight val Ghous you know we've got good correction. We're gonna again check with an objective measure two millimeter thick on the amber guide on the thin side, Three millimeters on the flexion side. So an extension. We want this to go in. Pretty good and extend in inflection. You know we want the three to go in. Three goes in very easily. We can check the two that we know the two goes in and again the two and extension easily come in and out. So we like what we have here in terms of position. We can see that the tibia is not. Um So the screw home mechanism and I don't know if you can see this here if you come over the top of it or not. But you can see that if we didn't rotate this tibia right now the femur is right in line with the tibia. If this tibia was rotated externally, those two might not be right on each other again. You want to make sure that's internally rotated a little bit and again our femoral component is not overhanging the cartilage so it's not at all going to impinge on the patella. You can take it through a range of motion, we like that we like our stability. So we're gonna open up those pieces. Let's have this pickup. We're gonna get rid of a little bit of this fat just for visualization. And we're gonna use this tool to secure the femur, slide it off. We're gonna slide our eight polly out. We're gonna take our drill and we're gonna prepare our tibia again I like to some people use that little spike but I like to just put the drill bit in there. It's a visual reference for the way these lugs are drilled again they're slightly posterior. They're not straight up and down, drill that. And then we're gonna use the drill to then she's you know the tibia is the most important cementing part. We're gonna again cement in two stages. So we can have two half batches of cement open and put it on the tibia. You I use an osteo tone too spread it around and good prayer. Mhm. You can put it on the tibia Stephanie you can put it on the tibia again pressurize your lugs you know you want cement you don't want a ton of cement because you don't want it stuck in the back of the knee. So usually take this aussie tone and sort of scrape some of that off. Good. Same thing on the tibial component. Again you want some cement in the back but not a ton of it. You're going to put this in, We start first with a Chandler pushing on the post area aspect of the tibia. Okay we push that down and then we work it to the front. You can see all of that cement you know come out the front and I think this really shows it here nicely. We have no overhang of the tibial component on this side in the past when we might have had the other the medial side onto the lateral side, you would get a little bit of overhang of that. We're going to use that. I'm also gonna take the smaller tibia. one smaller impactor for the tibia. Good. You can use either that microscope or this one to impact the tibia. I just wanted to get a little imp action in the back. Then I use the spacer blocks to finish pressurizing the tibia. Okay, the lateral side is looser inflection. So a lot of times you can be one higher on that spacer block but that allows you to really help with pressurizing that we're gonna finish cleaning that cement but we don't have to worry about sizing and overhang here but because these components fit very nicely on the lateral side. Again we just spend time in the back of the knee with the scrapers scrape around the tibial component also is beveled so it's soft tissue friendly. And also allows for getting the cement out pretty easy. It's a little lower profile post nearly as well. So you can see some hidden cement back there as well and it's always hidden in this corner. Again with this smith and nephew journey system it's very easy to do manually but also its robot friendly as well so you can do it with the robot need the jigs. But manual instrumentation allows you to do it perfect every time the robot does as well. So you can choose how you like to do your partial knees. We're in a we're in a surgery center right now so you know but the nice thing about Corey is it's surgery center friendly. You have two rooms you can move back and forth. You know that's the robot platform. So it's an option if you want to do it. I'm just saying we we here have done manual instrumentation for a while so we're going to pressurize that into these holes. Good we're gonna put it on the femoral component and the partial knee is a sc friendly. All of us want to be doing joints in a SCS. Well the easy way to start is with the partial knee. These people go home they don't stay and they don't you know have as much pain as a total need. It's not no pain but they just don't have as much pain as a total knee. Okay we're gonna then cement the femur. You're gonna see oxen EUM come in here. Yeah using impactor always keep my hand on the tibia just to avoid any lift off or anything. And Stephanie, will you hit this? Stephanie's been working out lately? Join me. Excellent job here hitting this someplace good. Okay career clear out this cement, get it off the oxen E. Um Let's see the eight and a lot of times cement will hide you know down here. Orange Good. Come on now we're gonna take this, put that in place, bring it back here, come on out. Well good amber guide. And now we're just gonna pressurize and allow the cement to cure pretty straight. She's still slightly in Vegas, we're gonna go ahead and take the polyethylene. We can put our hand in here as well feel the I. T. Band and the I. T. Band should have a little bit of attention to it and we're just gonna let this cement dry and then put the final polyethylene in closure. Standard number one a barbed suture for the capsule to os and then monta krill. Um So you want to make sure it's engaged, you cannot push it back further and then you just take the handle, you hook it into the front here just like this squeeze down, locks it in place. You hear it click. Ok? There's our knee again. If you look here, we've got, you know, the excellent component, component position were right in line with each other here, the interpretation of the tibia and you know, she's got excellent flexibility as well. So, you know, another successful partial knee. Let's have the bump and we'll start closing because we already wash right. Published September 7, 2022 Created by Related Presenters Kevin B. Fricka, MD
