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AAOS 2025 Annual Meeting: Knee Arthroplasty Feature Products

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A comprehensive overview of a product team’s portfolio.

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Visão geral e abrangente do portfólio de produtos de cada segmento.

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Arthroplasty and Shoulder Fracture - Next Generation in Repair and Reconstruction

Arthroplasty Knee

A document containing information about Arthrex products and product lines.

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Documento que contiene información sobre los productos y líneas de productos de Arthrex.

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Knee Arthroplasty New Product & Technique Highlights iBalance® UKA System An Evolution in Unicondylar Knee Resurfacing Fixed-bearing tibial onlay design Cobalt chrome femur with 6 sizes Cobalt chrome tibia with 6 sizes Vitamin E ECiMa™ poly in 1 mm-increment thickness Two unique instrumentation features: Disposable tibial cutting guides 1 mm gap balancing ECiMa is a trademark of Corin Group. Poly Matters Our goal is to help you preserve the patient’s native bone, which is why we’ve created a thin but reliable poly. We offer 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, and 14 mm thicknesses. The disposable tibial cutting guide enables both precision and accuracy in bone preservation. Actual Thicknesses 8 mm 8 mm 9 mm 10 mm 11 mm 12 mm 14 mm of patients have an 8 mm or 9 mm bearing when the disposable tibial cutting guide is used Disposable Tibial Cutting Guide An Evolution in Unicondylar Knee Resurfacing Tibial Cutting Guide Off-the-shelf instruments and no lead time No capital expenditure Neither CT scan nor MRI scan required Neither plan approval nor preplanning required The Ideal UKA Tibial Resection Patient-specific slope 2 9 mm resection space 3 Fully protected vertical resection 4 Independent control over varus/valgus 1 Patient Outreach and Education Watch 3D animations of the latest treatment options for orthopedic injuries and arthritis. What might my incision look like after surgery? Postoperative appearance is patient specific and dependent on the surgical procedure. Individual results will vary based on age, skin color, health conditions, and the wound closure technique performed by your surgeon. Scan to see additional patient outreach and education tools for our arthroplasty portfolio. JOHN DOE, MD ORTHOPEDIC SURGERY AND SPORTS MEDICINE Practice Logo 555-555-2022 55189 Sports Medicine Blvd | Naples, FL 34108 drjohndoe.com DrJohnDoe_Arthroplasty KNEE IMPLANT IDENTIFICATION CARD Patient Name: Device Type: Hospital: Date of Surgery: Patient Journey Cards Postoperative patient journey cards with an engaging, 3-tilt holograph to help the patient tell their story. Customizable to your headshot, practice logo, website, and more for continued follow-up needs. A Campus Designed for Orthopedic Surgical Skills Education The expanded Arthrex world headquarters, located in Naples, FL, is an innovative, 80-acre, university-style campus designed to deliver an immersive and engaging medical education experience for visiting health care professionals. The Arthrex campus provides a one-of-a-kind learning environment for surgeons and health care professionals. arthrex.com © 2023-12 Arthrex, Inc. All rights reserved. evBR1-002925-en-US_C

Knee Arthroplasty New Product & Technique Highlights

Mark D. Campbell, MD (Phoenix, AZ), demonstrates how to use the iBalance® UKA disposable tibial cutting guide. This innovative guide provides the patient-specific slope and tibial bone resection level, helping to ensure a more reproducible tibial resection. It further simplifies the iBalance UKA technique by minimizing variability in tibial resection.

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

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Surgical Technique Videos

iBalance® UKA Disposable Tibial Cutting Guide

My name is Mark Campbell. I'm an orthopedic surgeon from Phoenix, Arizona. Today we are going to perform a Arthrex iBalance medial unicompartmental arthroplasty. We are going to be demonstrating a new tibial cutting guide. It's very unique. It's a disposable guide that uses patient specific slope and depth of resection, and really simplifies this procedure to give a reproducible flexion extension space. And now if you look we have very nice exposure of our joint. We now take the disposable tibial cutting guide. And it's a two part guide. We've got the guide itself as well as the stylus that will help set our depth of resection as well as our slope, and match that to the patient's specific anatomy. So I will place it in the joint line and advance it between the tibia and femur. And once I can feel it go right past the tibia, at that point I rotate it 90 degrees. I pull forward and it catches on the posterior condyle of the tibia. So now, in order to determine our various valgus positioning, and I drop a drop rod through the cutting guide, and then I'm trying to line this up and make it parallel with my marks I made on my anterior tibial crest. The last thing I need to do with the guide is just set my medial lateral position and rotation, and I use this ruler that's in the set. There's also a Angel wing that can work as well. I'm going to put this in the vertical cutting slot. And then from that determine my rotation and position. Now one thing I do is I utilize the lateral aspect of the medial femoral condyle is where I'm going to be aiming. It's a patient specific cutting guide so to speak. I use an osteotomy first just right on the bone just to make sure soft tissue attachments are released a bit so it doesn't tether my saw blade during the saw cut. So that opens up a little area. Now that I can take my ruler, I can actually set it in the vertical capture and set this right up against the lateral aspect of the condyle. So it's sitting right up against the condyle right there. I know that's going to be my rotation and my position. So at this point depth of resection and slope has been determined by my pen. My varus valgus has been determined by my drop rod and my rotation and medial lateral position by my ruler. So everything is set. Now we will place in pins in order to hold it. Now I will put a single pin in to start with. The pins themselves are actually above the level of resection, so it stabilizes that piece. And we'll show you that there's a way you can actually get it out as well. So I'm also going to a hinge pin in. Now the hinge pin is very nice. And that helps protect your saw blade. And there is actually a third pin. Now in order to get that one in. We're going to take our stylus. We actually bend it straight up. So what that does is it gets out of our way for our last pin and for our saw cut, but at the same time helps maintain fantastic stability of this cutting guide. So I'm going to put the last guide pin in. So now we are set for our saw cuts. We're going to start with our vertical saw cut. And again because we line this up so well this saw blade fits right up against the lateral aspect of the medial condyle and fits right down into my slotted size. So you can see I've cut down very nice positioning. And my pin right here is protected me from undercutting that. So once that's done, we can switch to our horizontal saw cut. One thing I will point out that even though it's captured, we do want to have a retractor protecting the MCL because the blade can go past there. And we certainly don't want that. We are protected from the lateral side by this hinge pin. Now I am done with this tibial guide. I can remove that. And actually if I remove it all together, depending on soft tissue attachments it may actually bring my bone out with it. And if you look there's my cut very nice slope depth of resection. There's a very nice cut. All came out in one. You see how that did that. The pins were in the bone itself. And again my stylus was holding right in the back of the tibia and was able to pull it all out. Once we've made our tibial CoolCut. We have now developed a space. We need to know what that space is and make sure it is adequate. We have a adjustable spacer guide here and this will help us measure that. Simply place the end into the space and we have a laminar spreader that will help tension this to the correct side. Now I will tell you this again is a measuring device, not a device meant to GAP open the space. So we will manually lift open the space, and then we gently will elevate it until it measures the correct space. And you'll hear a click. And every click is analogous to one millimeter of space. It's now tensioned in that spot. And in this space it's nine millimeters. We want a minimum of eight millimeter space here. And a nine clearly is right where we would like to to be at. So once we have measured our flexion space we take out the tensioner and we will extend the knee, and we will now measure our resultant extension space. We again place the the adjustable spacer block in laminar spreader will place it. And again we tension it to the same tension that you tension it to in flexion. And when I do so it has the same three clicks. Again it happens to measure nine in this instance. Now it's important to know they do not need to be the same. And they often are not the same. But this gives us our extension space at this point. So I'm going to put a distal femoral cutting guide in. And it slides right over the spacer block. And once that's into place I can place a couple of pins to help stabilize it. One thing you may notice is we want to make sure we're not extending or hyperextending the knee. We can look in the notch to clearly see there's no impingement. And so that's a good position for that cutting block. Once that's completed, I can take out my spacer and my cutting guide. Once the guides are out, you have better visualization. There may be a little bit of bone that needs to be continued to be cut, and that can easily be done with this exposure. We will flex the knee back up in order to get back to our flexion space. So I'm going to use a posterior femoral cutting guide. This again slides over the slots in the in the spacer block. And it sits down right on the flat distal femoral cut you made. Now it's important that this fit flush to it in the way that it will fit. Flush is a variance of flexion and extension. So I will flex and extend this until it sits flush on the distal femoral cut that we had made. And you can see through this window in the guide that it is flush down on to the bone. And once it's in the correct spot, then we pin it into place. It is a slotted cutting guide and it is captured on the lateral side. The medial side you have a retractor protecting the MCO. So now we can remove our guide. And again if we have to do some freshen up cut we certainly can if we need to. And so now a very nice visualization. The cuts almost completed. There's just a little lateral bridge of bone that I will finish with the saw. Here's an 18 millimeter static spacer block. And I'm going to fit it in. And it fits absolutely perfectly with perfect tension. So our flexion space has been set. We will check our extension GAP. And in this case the block fits in perfectly. Now I will say I no longer do this step. The reason I don't do the step is because it is so reproducible. Reducible. If you have a fixed space and you cut a fixed amount, it is going to be that total amount every time. Now it's just a matter of preparing and placing the femoral and tibial component. I am going to place on a five to start with and do so. It just fits right in now. I can see it fit right there. One thing I want to do is one I want to feel into my notch. It's right perfectly centered on my condyle. Then I'm going to take my army Navy and look up top because what I want to do, and it's hard on the video to see this, but I do have a couple millimeters of cut bone anterior to this, this guy. Now that's very important. You don't want oversize. You want a little bit of bone to be remaining. So this five actually looks really good. Two things this guide will require one. You need a drill for your lug holes. The other you will use a saw blade to cut your chamfer cuts. Always drill your lug holes first. And the reason for that is, once you've made your chamfer cut, that piece of bone is missing in the in the guide will not be as stable. So this is the most stable it can be. It's got a positive stop. You drill those two. Now you go to your chamfer cut. Chamfer cut is captured. The only area that it's open is on the medial side. And again a retractor will help protect that. It is captured and blocked on the lateral side. And the other side of the guide keeps the blade from going in the tibia. So it's very, very safe and well protected. We can remove our pins and our femoral preparation is now complete. Once that has been completed, we can go on to our tibia. We can look at sizing our tibial side. Now that ruler will do the same thing on the tibia that it did on the femur. And again the sizing. So as you'll see, as I capture the back and pull out, in this case, it measured approximately a four. And again this is an anterior posterior measurement. What's very important you don't want to overhang medially, but thankfully you can see that visually quite easily. So we'll now select our tibial preparation guide to correspond to the size that we measured. In this case it was a four. And we're going to see how that fits in there. I set it right up against the vertical wall. And so it's sitting right on the anterior cortex. When I do that there's two spikes that sit down into that tibial bone. I then take a freer elevator because I can feel around the side, and I can both visually see and I can feel that we are absolutely flush with the cortex there. So this is a perfect size. It's perfect. Around the tibia there's a single pin that goes in. Now I hold this with the handle while it's pinning into place. So our stability now is compromised. Those two tines on the bottom of the guide. And this pin as well as I hold it with my handle as well. Once I've done that, I am going to punch for the fourth keel punch. This has laser lines that tell you when you're deep. I stabilize this with my hand and set it in. I then tap this down and the video won't show up, but I can see those laser lines disappearing in the guide, so that is set down. Now, while that keel punch is in, we have the ultimate stability of this guide, so I keep it in there for the next step. I take my lug drill and I sit it in the more medial slot and I drill it down. It's not 90 degrees down. It's got a little of an angle to it and it's sitting nicely in that. So I know that is my angle. At this point I pull my keel punch out, and that will allow me to see my other lug hole, which is exactly the same angle. So I strictly bring this straight out, put it straight in the other one, put it straight down without any tension on the guides. So once our tibia and femur have been prepared, we're going to go on to cementing. When I cement, I place just enough cement on the bone itself to fill the lug holes and the keel punch. I then place a light amount of cement on the undersurface of the tibia component, covering the cement pockets. If you'll notice, I put a put a light amount on posteriorly, but the way this goes in with you see the posture oriented lugs and the keel. And using our initial impactor, it actually catches the back and pushes the back down first. In doing so, any cement is forced forward to the front of the knee, making removal of the extra cement very simple. So we will set this in. And I set the keel hole right in place and the lugs will fall right down in place. Now it's up in front, but I'm going to set this again until that captures the posterior aspect of the rim of the tibial component. And once it's on there, I'll gently tap it. And what that does is that put the poster back. Then I walk it forward a little more and you can probably see look at the front as it closes down as I come forward. What that also does will allow any cement to come out the front for easy removal. So our tibial component is now in place. I cement the femoral component very similar technique as I did with the tibia. I start by placing cement into the lug holes on the femoral bone itself. I then coat the back side of the femoral component, covering the cement pockets. I leave the lugs free for visualization. The technique is such that the first thing you need to do is get the posterior lug lined up with your posterior lug hole. Once it's in that position, I gently extend the knee while the while the assistant is pulling the patella laterally. Once the patella is pulled out of the way, you can rotate the femoral component over and into place, and then you can flex it back down because the patella is no longer in the way. We have a impacta that sits in line with the lug holes. We just gently impact it in. I generally will do a gentle anterior impact or and posture as well. In this case it's going to be very easy with different levels of flexion extension to get your extra cement out. At this point we'll put a trial polyethylene in. I find that it's easy to gently tap this down from the anterior medial aspect until it sits right in. Once the polyethylene is in place, I can check my flexion extension. One thing you'll notice is very nice alignment between the components and the knee flexion extension is very smooth. I get fully straight and then I'm going to check my tension in my medial compartment. I want a couple millimeters of play. If I feel it's a more play than I'd like, I can always put a bigger polyethylene in. This one here feels perfect just with the eight millimeter poly. So once the cement is hardened and you want to put the real polyethylene in the trial, polyethylene is removed very easily using this device. It fits into the hole on the trial polyethylene. You just flex up pull straight out nicely pulling that out. Once this is done, you put in your real polyethylene. Once the real polyethylene is in, we use a pulse lavage to copiously irrigate the area. We close the retinacular opening, my choice being oh vicryl we use three zero subcuticular monocryl under the skin, I use staples. Some people will use skin glue. Either one is fine.

Knee

Steve D. Lucey, MD, (Greensboro, NC) discusses with Alex Bautsch (Arthrex Group Product Manager, Knee Arthroplasty) his experience adopting the iBalance® UKA system for knee arthroplasty procedures.

A video recording of a panel discussion with a surgeon along with either a product manager, a medical education team member, or other surgeons.

Vídeo de um painel de discussão com um cirurgião, juntamente com um gerente de produto, um membro da equipe de educação médica ou outros cirurgiões.

Vídeos do segmento do cirurgião

Video de panel de discusión con un cirujano junto con un gerente de producto, un miembro del equipo de educación médica u otros cirujanos.

Videos de segmento de cirujanos

Surgeon Segment Videos

Adding the iBalance® UKA to Your Practice

This animation demonstrates unicondylar knee resurfacing using the iBalance® UKA system, which helps improve operative efficiency due to the expanded flexibility and reproducibility provided by the new adjustable spacer block and the disposable tibial cutting guide.

A general overview including the relevant steps of an Arthrex surgical technique. These animations always include a voice-over explaining the process.

OP-Anleitung Animationen

Visão geral incluindo as etapas relevantes de uma técnica cirúrgica Arthrex. Essas animações sempre incluem uma narração explicando o processo.

Animações de técnicas cirúrgicas

Descripción general que incluye los pasos relevantes de una técnica quirúrgica de Arthrex. Estas animaciones siempre incluyen una voz en off que explica el proceso.

Animaciones de técnicas quirúrgicas

Surgical Technique Animations

iBalance® UKA Technique With Disposable Cutting Guide

Richard E. Robichaux, MD, (Baton Rouge, LA) presents a 48-year-old patient in need of bilateral UKA surgery highlighting the newest iBalance® UKA Instrument System available.

Bilateral iBalance® UKA Reconstruction

Doctor Richard Robichaux. We're going to be doing a bilateral partial knee replacement on this 48 year old male presented a few months ago with bilateral knee pain, worse on the right than the left. He has a long history of right sided knee pain. He's been limping, and it's gotten to the point that it's been bothering him at night. He's been taking anti-inflammatory medicines, he's had cortisone shots, and he's known he's had a problem with his right knee for years. Recently, his left knee has gotten to the point that he's uncomfortable. He's limping, having night and chest pain. He's got an obvious problem on the right knee, on x ray. And when we did an MRI on the left knee, although regular x ray shows that he's got a little bit of joint space on the medial side, the MRI shows that he's got erosion of articular cartilage down to raw bone on the medial side, along with marrow edema. And when we talked about various treatment options, he's less than 50 years old and thinking about doing a total knee on on a guy that's still got to work ten or 12 or 15 more years and do a total and expect that to last a long time is not such a great idea. In my opinion, I don't think tibial osteotomy is a is an option either. And I think partial knee replacement and get this guy to 65 where he could. If he needs to get a total knee, then that should last the rest of his life. So that's the plan is to do bilateral partial knees. Now making the incision I feel for the tibial tubercle. We have the patella. So I'm just going to do a medial patellar incision. Skirting the medial edge of the patella. Got an inch or so of the of the tibia exposed here. Now, just as a general rule, I'll palpate down here, get the crest of the tibia, get an idea where that is. And then here's the big toe. We'll probably go down to where the second metatarsal is. The whole key to the operation is to get this the first tibial cut. Perfect. Even if you have to cut it a couple of times just because all the other cuts are based on on that. Cut off the proximal tibia. Approximately. I like the the the top end of this guy to be right at the footprint of the ACL. Okay. Okay. Let's see. Okay. Back that off now. You're just going to put a mark here just to see where the where the tibial surface is. That looks good slope wise, I think. [00:03:42] Okay, let's see what other people put up now. You know, small OsteoAuger. I don't think this is going to be enough on this first or section. You got the coker. [00:04:19] Okay. That's it. Okay. That's eight. Now, the key to this on this this extension GAP, is to make sure that you get the knee straight. You don't want to over tension that MCL. And we'll check that extension. Yeah. So that's the nine. That looks pretty good. [00:05:15] Great. Great. One time. So yeah. So there we can just leave the block in there and just slide this distal femoral cut block right over the right over that spacer block. Okay. Want to pin it down? I see, Okay, good. Anyway, we'll do this first. Gap. So there it is. That's the 17 block right there. We got the knee in full extension. The alignment looks about right. So this looks good. Now, to get our gaps balanced we're going to make this posterior cut. Want to get that nice and flat that looks about perfect. Let's see. Next we're going to use a headed pin here. There it went okay. [00:06:53] Good. Got the drill. Asked you to him first. Watch! Water! Thunder! Over here. Good. So here we are checking the. We're going to check the flexion gap. Make sure that that's at 17. So there we are right there. So we have the flexion extension gaps balanced at 17. Next we're going to size the the femur. Fortunately, it looks like our cuts are about perfect. It looks like the. This sizing guide here is flush both on the distal femur and posteriorly. So I want to make sure that we've removed osteophytes. So we're not going to have the femoral component resting on osteophyte. We have a native bone there. We have it centered on the condyle. It's a fairly big guy. This is a four. The five fits pretty well. Matter of fact it might be a better fit. So let's go ahead and do this. We're going to do the five femur. Once we do this final prep on the on the femur we're going to have a chance to clean up the meniscus in the back of the joint. We're going to put the threaded pin up at this top corner here. It's a little recess in that femoral guide indicating where the straight threaded pin goes. And this is going to be a a smooth pin. [00:09:15] Drill. Starting with the five trials. Oh, yeah. I forgot about the. Three quarter. Now we're done with our our femoral prep. And stretching that out. You got a laminate spreader. Now we're going to take the time to clean up the meniscus And then start working on the tibia. Laminar spreader is helpful. There we go. And there's often a little wafer of bone in the back. And I think we're going to have to get one of those out. But I think we made up all of our cuts. The the femur looks good. Let's do a trial on the femur. Let's tap it. Looks about perfect. Now we sizing the tibia here. It's important that the, the tibial tray not hang over the, the medial edge of the, of the tibia. And you want to be careful not to be too aggressive when you're debriding the osteophyte there to trim away some of the tibia. We have the edge of the tray right on the edge of the tibia. We've put a saw blade on the medial side here. To facilitate removal of cement. Once we're submitting the implants in because in order to engage the the polyethylene into the tibial tray, if there's any cement riding up above the edge, you're going to have a difficult time getting the the polyethylene to engage in the tibial plate. So this little bit of of space here is a good thing to use. Sometimes I don't use it if the situation is tight, but I'm always careful to get all the cement out. Right. So we have a four tibia and a five femur. Okay. So we're going to do our trowel reduction here for tibia with an eight bearing and then the five femur for eight. So here we have the the trials in place. Five FEMA four tibia extension. It opens up just a little bit, which is what we want. We don't want to overstuff it. [00:12:12] Oh yeah. Yeah. Great tip. You got that impactor and then the mallet. Okay. Got that seated well. Okay, good. Great. Okay. And then the plug. And then the shizzle. So this is the punch for the keel. So you need to make sure that as this thing is being impacted, the etchings on the punch are completely buried below the top layer of the, of the guide. Right. So there it is right there. It's completely buried. And there's also a stop on it that will keep it from going too far. Yeah. Okay. Irrigation. [00:13:43] Okay. All right. All right. Bioacl. All right. Here. We go. Okay. Thank you. Alan. Okay, good. It always helps to have a big, strong assistant lift up the the thighs. We're getting the cement out of the back of the joint. And here I have a clear shot of the back of the joint here. Okay, you got that impacted one more time. [00:14:45] Okay. Yeah yeah yeah yeah. Round and round. It looks okay. [00:15:31] Right. Okay. You got that eight bearing the trial. Here it is. Now here we are. One last little maneuver here. See we have full extension. Has a good end point just like a normal knee. A patient's asleep. Boom! There it is, right there. And just a little bit of opening. Maybe a millimeter or so in full extension. Garrett's going to be closing this, and we're going to start on the other knee. The osteophytes on this side are much larger. And so I'm going to go ahead and work on those now before we actually put the the tibial guide up there, because they're going to get in the way of of the guide resting up against the front of the tibia. And this guy's medial arthritis is much, much worse on this side than the other side. You can see that he's got raw bone right here. And then he's got a big area of raw bone right here on the tibia as well. And then it's worth pointing out the the osteophytes on the femur. He's got fairly large osteophytes. I think I referred to before that, that MCL which originates here in the femoral condyle, that MCL is stretched across both the Both the femoral and the tibial osteophytes. So in order to get the gaps balanced appropriately, we have to debride these in order to get the proper ligament tension. So this is a new extramedullary tibial guide. And we're going to before we get too much further I'm going to put the same reference points on this. So here's the big toe second metatarsal B right about here. Crest of the tibia here and here. The one thing I want to make sure that we don't do is over resect here, because on this particular guy he's got a lot of varus in his tibia. And so I want to be careful. So we're actually going to be dissecting not a whole lot off the extreme medial border. Now, one of the things I think we're going to have to do here is to get the osteophyte off the lateral side of the medial femoral condyle. We're gonna have to do that with an osteotomy. [00:18:10] You know how you know? All right. That's the first messed up. Joker. So I've made. I've made my room for my joker. There we go. [00:18:54] That's Chris. Yeah, that last cut, that was five years of residency and 35 years of OrthoPedia. See, that's that's it right there. Okay. Yeah, that's a ten. [00:19:14] Four. Hundred 32. Yeah. Okay. All right. Okay. Now, we still have a lot of osteophyte to work on here. We might take a minute to clean a little bit of that up. Once again, got to make sure that the knee is straight. I think I think this is going to do it here, fellas. 12. Okay. Now here we can just slide the handle off. [00:20:01] And match it up. There we go. That goes on there nicely. Now we got to make sure that the guide stays flush on the tibia. Okay. Got the other pin. So we're going to go to 18 here. And there we go full extension. So we have this gap checker flush and sitting perfectly on the tibia. And then we have the the femoral cutting guide here flush on the distal end of the femur. So that should make our gaps balanced once we make this cut balanced at 18. Wash water. Good. And here we are taking the last little bit of meniscus out. Okay. Let's do a trial reduction. Let's see that femur again. Yeah. That looks about perfect. Okay. And you got the Let's try a ten. Ten is probably going to be at this time. Okay. So there we are. We got the legs straight. It's out of virus. Might have to do a little massaging on the tibial side, but it looks pretty good. There we go. All right. Yeah. See? Now we got it. We got a room for the four. So we're going to give this guy a matched set of implants, except for the polyethylene. Okay. Impactor. [00:24:00] One. Go ahead. Go. Okay. Cross pin. Okay. Put down your lunch box. Wash water. [00:24:49] That's good. Okay. Good. Okay. Okay. Good. Shit. Okay. There it is. And give me the shim. So this is the same maneuver I do making sure that the knee goes flexion extension. Good end point. Here it is. It opens up less than a millimeter. But there's no impingement of the of the bearing anteriorly. So it looks like we have everything sized and positioned appropriately. It looks really good that I'd usually close interrupted one layer and then oversew it. I get a watertight closure for an incision like this six interrupted sutures, and then overrun it with a running suture of number one vicryl and get a watertight closure. Any wound issue tends to be eliminated by that, because the hematoma, all the blood is kept in the knee joint, and it's not getting in the subcutaneous layer, which might cause a problem. So get therapy twice a day. The first day post-op. Because this guy is fairly young and strong, he may be able to go to rehab on the first day, post-op, op, maybe second day, and then he'll spend 4 or 5 days in rehab, I suspect. I always tell people that rehab for bilateral knees is like staying in a hotel with physical therapy, so that they don't have to be cared for at home so intensely, and they get therapy twice a day, and then once they make it home, they're able to get up and out of bed and manage pretty well. So going to rehab for a few days after bilateral knees is the routine. And if a single knee, 95% of them go home the next day and then they get home health physical therapy for a week or two. And and the advantage is it's one trip to the operating room, you know, one recovery period. Yeah, the recovery may be a little bit tougher, believe it or not. Sometimes we take the staples out and they don't come back. It's usually a matter of me being a coach after the first visit. You know, they get instructions and then, you know, it's like, hey, you got to work hard at therapy, do this and that. You know, most people just need a little bit of encouragement.

Cory Edgar, MD, PhD, (Farmington, CT) discusses complex patellofemoral pathology and solutions using tubercle osteotomy and the iBalance® PFJ system.

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Treatment Considerations for Patellofemoral Arthroplasty

Welcome. My name is Doctor Cory Edgar. I'm from the University of Connecticut. Today I'd like to talk a little bit about treatment considerations for patellofemoral arthroplasty. One thing I'd like to talk about is the more complex patient. They can do very well with patellofemoral arthroplasty and allows us to do very beneficial things for these patients. Oftentimes they have significant dysplasia within the distal femur and the trochlea. And these patellofemoral arthroplasty is especially the only ones allow us to really change the morphology. So remember these patients have risk factors for their chronic instability that have now led to patellofemoral, arthrosis like dysplasia, malalignment, hyper laxity of the soft tissues, and certainly patella Alta. This is a prime example of a patient that has chronic patellofemoral instability. As a young girl, she has progressed into her late 30s. These are X-rays. Now at 41, she has severe patellofemoral arthritis, lateralized patella tracking, increased tibial tubercle angle. On this left MRI image you can see their TG distance is 22.6. You can even see our patellar tendon rubbing against the whole lateral side of her trochlea. You can see the progressive wear and tilt pattern for patellofemoral joint on the right MRI image. I think these patients do very well if you treat them like patellofemoral patients. Just doing an isolated patellofemoral replacement might help with some of their anterior knee pain arthritic symptoms, but the instability may lead to sort of long term issues in terms of their their native anatomy. Malalignment. So I do think treating these patients. This is an example of mine that had a tibial tubercle osteotomy allows you great access to the patellofemoral compartment. And then you can adjust their patellofemoral tracking with this. Additionally, it's important to make sure you take enough bone. Soft tissue balance is important as well as, in my opinion, making sure that the patella button is as large as possible centric or even slightly lateral. Again, all we're talking about is this lateral force vector, which is what the quadriceps angle is, which is what we're quantifying with tibial tubercle trochlear groove distance off of images. Now this can be measured and it's within a well range. And remember that just because people have lateral tilt, that doesn't beget tightness. It could just mean that there's some malalignment issues. So we have to think about this with our approach with these patellofemoral patients, and realize that some of their pathology may be a little bit more than just simple patellofemoral arthritis. Trochlear dysplasia is typically based on lateral x rays. That's why I usually get them. But I think with patellofemoral dysplasia specifically with the inlay systems you cannot adjust this. So even though you might have a lower de jour, meaning a less dysplastic patient, you often have moderates which could do well with a en laye type of system, but certainly in the person that has a much more severe patellofemoral dysplasia, the ability that we have to manipulate the anatomy of the trochlea with a onlays system is much better and allows us much more opportunity to adjust their native morphology. Again, this is an example of a patient that has severe patellofemoral dysplasia. The younger patient doesn't necessarily have arthrosis, but it highlights the highlights the point of the anatomy of a dysplastic patient in the distal trochlea. You can see how small the surface area is. So simple inlay system does not adjust this. It doesn't affect the length. It doesn't affect the depth. Adjusting this with an inlay system allows us to manipulate their native morphology much better. Regarding the medial approach, sometimes we forget that there are various force vectors on the medial side. Oftentimes we talk about mpfl reconstruction for the non arthritic patient with lateral instability. However, there are various variable force angles that are looked at here with the anatomic studies. So over tensioning this medial side can affect your patellofemoral compression forces with the medial arthrotomy approach. Quantification of their malalignment typically is done with this concept of axial relationship between the tibial tubercle and the trochlear groove. Typically, with instability patients, we think a normal range in males and females are slightly different, but anywhere from 9 to 13 is well within the normal range. Things above 15, and certainly greater than 20, are considered highly abnormal and may need to need to be considered as something you have to address when dealing with malalignment and a patellofemoral arthritic patient. Addressing this malalignment is actually not that difficult. Tibial tubercle osteotomies are implemented for a variety of reasons, and even patients with pre significant arthritis with lateral cited pain osteotomy can even be done. The goal of the osteotomy is obviously to correct the functional q angle and adjust the patella tracking. Variable cuts can be made. In my opinion, a reasonable oblique angle of about 30 degrees provides enough surface area two screws, and this for my patient population does not slow down by any means the amount of postoperative rehab I allow them weight bear fully. They can initiate range of motion as soon as they tolerate, usually by two weeks. They're walking without a brace after patellofemoral replacement with a tibial osteotomy. Again, the tibial tubercle osteotomy can also address the angle at which the patella engages. So obviously we have patella Alta. A high riding patella just takes longer of knee flexion until the patella is captured within the trochlea. So by either adjusting the patellofemoral implant, creating a longer trochlea, you're adjusting that earlier capture, or by doing a tibial osteotomy where it helps that balance of a high riding patella, Alta. Lastly, I want to talk about the complex dysplastic patient with chronic instability. So this is a particular case example. A patient of mine who's had chronic patella lateral instability with multiple dislocations from a very early age. She's got bad morphology, bad patellofemoral tracking now in her late 30s, early 40s, she's severely limited, can no longer even work as a nurse, as you see on her lateral x ray. She's got a tracking patella with not a true lateral x ray, but she does have patellofemoral dysplasia. This is her merchant view, and you can see what looks to be like a good relatively patella captured in a lateral compartment. However, if you look at this through a wider range, she actually has a preserved trochlear groove. She has completely worn away her lateral trochlear ridge with a severely malaligned patella from a compartment she had native trochlea dysplasia. Now, with lateralized, tracking has literally worn into her lateral facet, now with more significant patellofemoral arthritis and instability. Her complaints now are instability and patellofemoral pain secondary to arthritis. Tibial tubercle, trochlear groove distance, as you would expect, is fairly high and I would say in a pathologic range of 25 for her. She also needs a tibial tubercle osteotomy because of her soft tissue, which was hyper lax. She did have a medial repair through a lateral approach of the arthrotomy that allows me to do a primary repair on the medial side. Some cases I've even done a medial patellofemoral ligament reconstruction. Obviously, we do a tibial tubercle osteotomy to get her alignment back into a much more normal range. And certainly an onlay patellofemoral prosthesis allows us to adjust her patellofemoral morphology, which was part of her problem in the beginning. As you can see with this on her contralateral side, which was less symptomatic but still has the same anatomic issues you can see on her patellofemoral replacement or realignment size that she has much better patellofemoral tracking. She has full capture of a distal femur. She's quite happy in both her patellofemoral instability symptoms and pain. Symptoms are gone, and she's been progressing well and actually returned back to work as a nurse. As a patellofemoral surgeon. There are many ways you can approach this from an arthrotomy standpoint. The classic way. As we're all taught, doing total knees is through a medial side. I think there is real benefit in doing a lateral approach, especially for people with more complex patellofemoral problems that we're trying to treat with an patellofemoral arthroplasty. First of all, it allows us an ability to titrate through our lateral approach by doing a step cut lengthening. So when we do our arthrotomy closure, we can actually titrate our closure. So we can actually create a patellofemoral lengthening on the lateral side that gives us soft tissue balance. Certainly that helps after we've made sure that we've adjusted our patellofemoral implant so it sits central or even lateral. Our Patellofemoral button has to be placed either central or potentially even lateral. This is difficult because it's difficult to cut the patella in particular with these patients, because oftentimes they have significant lateral cited where oftentimes when we do our cuts we're trying to trying to maximize the amount of patella bone that's left. Oftentimes with these patients, you even have to build up the lateral side with cement to make sure the button is placed perfect. So the cut underneath the patella is important. I believe from the lateral side it's much easier to approach this problem. Additionally, from the lateral side, in my opinion, I think it's much easier to visualize the femur the distal femur. We're making our cuts, so that way we can adjust the rotation and the position on the distal femur that we're putting our onlay arthroplasty. So an example of this is a patient that had bilateral patellofemoral replacements. No significant malalignment but classic lateralized patella tracking with adhesions within the lateral retinaculum. The left knee was done through a medial approach. Right knee was done through a lateral approach. You can see there are slight differences in where the button is placed, slight differences where the implant is placed. More importantly, there's a much bigger difference in the titration and the tracking of the patella. Same flexion angle on the x ray. Done. Bilateral merchant view.

iBalance® Patellofemoral Joint Arthroplasty

The Arthrex iBalance FJ system is designed for the treatment of localized or diffuse arthritic changes in the patellofemoral compartment of the knee. The completely instrumented technique focuses on creating key reproducible transition zones, reliable rotational alignment, and suitable femoral resection every time. Patellar preparation may occur prior to or after femoral preparation, depending on surgical preference. A caliper is available to measure the thickness prior to and after resection. The size of patellar component is assessed, and lug holes are drilled to accommodate pegs on the domed patellar component. Soft tissues are elevated slightly using the blunt end of an extramedullary guide as it is inserted, ensuring it rests on the interior surface. A five millimeter Intramedullary hole is drilled, matching native flexion. The entry point should be at least 20mm posterior to the deepest aspect of the trochlea. The guide is removed. The side specific base is inserted into the intramedullary hole. Rotational alignment is established and a pin is placed medially. The cutting guide is attached. The level of resection is established by a single stylus representing the thickness of all size components, which minimizes the risk of overstuffing first at the depth of the trochlea, followed by the anterior aspect of the lateral condyle. This captured guide may be pinned into place and the resection is performed. The cutting guide and all alignment instrumentation is removed. Proper component size is established through size specific finishing guides. A proximal position stylus rests on the articular cartilage, defining proper proximal distal position. Proper size ensures the component will not overhang at the anterior lateral aspect of the component, as represented by the shape of the finishing guide. Headed pins secure the block into place. The stylus is removed. An optional pin may be placed posteriorly for added fixation. Reamers are used to create the radius of the trochlear component both distally and proximally. The radii created by the reamers are then extended using a series of guided osteotomy. Osteotomies are first used distally. They are then used proximally. A final osteotomy is used to create a clean up punch in the middle. These single use osteotomies are custom shaped and hollow ground, maximizing precision on both the medial and lateral sides of the trochlea. The finishing block is removed. Ephemeral trial is used to test establish proper transition zones. Transition. The trial is pinned laterally. A lug guide is positioned, then pinned medially, ensuring proper fixation. Three lug holes are drilled. Removal of the trial and lug guide may take place. An optional trial may be used or one can proceed with standard cementation.