Chapters Transcript Video Dr. Kevin Fricka Performs a Live Surgery of a Medial UKA Procedure Using the JOURNEY™ II UK System This video is a surgical technique overview of a medial technique. Good morning everybody. Kevin Fricka, I'm part of the Anderson or be clinic and we're here at Harborside Surgery Center. We're going to do a journey, two partial knee replacement or unicondylar knee. The gentleman here today is a 72 year old. You can see medial compartment arthritis, a pristine Palo the joint and our P A flexion view shows again, significant medial arthritis. He has a little bit of a flexion contractor, but that doesn't deter us from doing a partial knee replacement. We'll go ahead and get started. We have his patella and his tibial tubercle. Usually the incision goes the length from the superior pole, the patella to the tibial tubercle. We'll make it a little bit bigger just for the camera. Take that meniscus sort of back to the rim and really identify the meniscus here and take that all the way back, which will help with meniscal removal later. Ok. 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 medial release, but in someone with not much deformity, we're probably not going to do as much of a release. I like to do, give me a half inch OS to is take out the notch osteophyte. So here's the AC L but he does have a notch osteophyte. Stephanie is going to hit this for us just to remove the fight. Go ahead. Stuff you can hit good. We just give the AC L A little room to breathe there so that we don't have any late attritional ruptures related to sort of impingement. So now the AC L has plenty of room to breathe and we're going to now begin the partial knee replacement. So I'm going to use the spoon technique which allows us to set a depth of resection for an eight millimeter polyethylene. Most of the time, what we do is we set this spoon underneath the con dial, OK? 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 going to take our tibial guide here. So we're going to set this up and we're going to match his slope. He has a little bit of a flexion contractor. 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 going to be for various vagus and this will be for slope. So we're going to just dial maybe a little bit more slope in, OK. And then bring this up. Now, 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. OK? 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. OK? So now what we're going to do is set our position here. OK? David is going to hold this over here and 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, OK? And I can check my cut. He's a little bit snugger because of his fixed various deformity. So we're going to then take an angel wing and just look at the depth of our reception here. Now, there are other ways to do this too. 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 millimeters section. We also have a three or five millimeters section but sets us for an eight millimeter polyethylene. And I just checked 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. OK. Ron first. So there's a couple osteophytes here which we're just gonna take out. OK. 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 AC L was, there's an osteophyte. A lot of times there's an osteophyte here. And if you don't remove it, it will be hard to get your vertical cut completed version of the AC L. We're going to make the vertical cut and I just sort of mark it with the Bovi or Sips saw, please. And then I'm gonna take the cut. Now I use a double sided recip because I can cut forward as well. But some people prefer a single sided recip. It just allows us to go in and then mm move back and then we can come and also finish our cut this and this is a pretty thin cut. So he has a little more of a post your meal wear pattern than anti media. And so the benefit here is the recut is very easy. We just put this guide back on, we take this and we undo it and then we just lower it all the way to do the rec here. So the tibial recut 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. Ok? So we wanna get the eight in. That's a give me a plus one, given that he is a little bit tight in 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 this flexing contractor, you know, that will help as well mallet. So we get that block in there, get it lined up good. And so someone with a flex in tractor, I'm also going to take the bump and we're going to put it under his heel. We're trying to get rid of most of that flexion contracture and then we're going to pin this in place. So as we can see, we're lined up with the tibia and the femur and we're going to make our distal thermal 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 are gonna take this out now and then finish our cut, ok? And we use the path of the previous cut and break that off console and this is our digital thermal cut again, millimeter vicar just to give us that little extra space, put our hand in there. We know our MCL is 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. Ok. Now, we're not correcting this guy's flexion contractor. We're not going to 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 going to take the gray eight. Now we're going to 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, ok? You know, it's not hard to put in, put it in nice and easy. So that means the aid is balanced. OK? So now we're gonna come finish sizing the femur, ok? Roger for a second. Just have a little lip on the femur here. Let me check. OK? A couple of different ways to do this when it's tight like this. I prefer it with just the T handle. OK? 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, OK? In this case, he's a little snug in the back. So I'm not going to do that. And I want a size eight, the eight is what we're going to start with. Now. Four through seven are the same cutting guide. Eight through 10 are the same cutting guide and one through three are 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. OK? And so once that's in good position, all I concentrate on is putting the top pin in, OK? 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 to your thermal cut. So a lot of times we're going to turn the handle. And if you use the other technique there, 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 going to 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 going to 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 media, 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, media lateral to the femur with these cuts. OK? We are committing to our rotation. So it's important to get that. So we start first with the post, the cut good. And now we're gonna start with the answer. Now there's no pins in the way for those cuts. OK? So now we're going to take the sizer. So I just take the hook and on it, it has different sizes. We're going to hook the back of the tibia and read the front. So the front is reading an eight or a nine, OK? We want to make sure that he doesn't have any significant osteophytes 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 to lateral rather than front to back. So if we look at the eight, the eight looks a little small. So we're going to look at the nine and the nine is pretty good. There is a paper that talks about, you know, you don't want more than two millimeters 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 before I put this in, I'm just going to talk about it. So there are a couple ways to do this. One is, you know, the old method where we just hit the keel in. OK. 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 osteotome that can pre make your keel and then drill your lug 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 them out and we put that down, ok? And that also then allows me to get it in place securely. We may need to move it back a little bit. So we that now I prefer it to be sort of right on the front rim as is here, you know, some people are going to 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 to 3 millimeters of medial excursion if we want. So we get this lined up with our holes. Is that line that bad? Yeah, we're lined up with our holes and then we hit that in place. OK? I do give it a final impaction with this. OK. And at this point, if I wanted to, you know, I could move the femur. So um you can either hit it with this to move it mount 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 thermal line line up with the tibia line, ok? And that means we're in pretty good position. We're close to the notch. We don't really hug the condi, we hug the notch. We're going to take an eight Polly, ok? And take this a poly 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 his various deform it a little bit, but we haven't over corrected. Most people prefer two in extension and two inflections, ok? 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 vagus 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. OK? And two millimeter guide is pretty good. So I know I'm happy if, if and again, we knew this guy was a little bit tight in flexion. 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 snugger, but I'm not going to 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. So 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. Ok. So we're going to now finish drilling the femur and we're gonna come here and drill the femur here and drill the Feer here, ok. 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 and just lift it off like that. Um Good. Um Now we're gonna take the hook to get the Poly out. Add this nice little device, it just allows us to hook the poly, get it out of a place like that. Now, we're going to finish preparing the tibia. All right. And so usually with a leg holder, I bring the leg out a little bit just to rotate those, um, you know, the lugs to me, I secure it in place with a drill bit. Here. It gives me the angle of my cut or 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, ok. We're going to take that guide here and again, a nice little handle here just allows us to lift this out for cement penetration. We are going to do some drill holes in the femur and we're going to 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 flexing contractor and a bigger male. I do like to cement this in two stages, ok. 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 OK to cement in two stages, ok? But this was a nice case in that the um you know, it showed you the versatility of the system. We got a little bit of a flexing structure. We can take one millimeter of distal femur. Um you know, the first tibial cut in a big male is too small. So we just put the guide back on and simple rec cut you just drop it down and do that. Um And so then now we're going to cement them again. A lot of people are going to say for a fixed various knee with a flexing contractor that you shouldn't necessarily do partial knee replacements. But 72 so active 72 year old with good range 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 uh so we've got good long term results 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 flexing contractor and who have a various deformity. You know, we talk to them and say, hey, look, you even notice that your leg doesn't get all the way straight or that your leg is a little bit bode a lot of patients come in 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 virus, a little bit of a flexing contractor. Most of those patients don't even notice they have those things or they say, hey, I've been bold 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 the sides are beveled. So they're soft tissue friendly. We do have some grip blasting on the back for good cement fixation and you can see the two peg design with the keel as well. Um OK. And we'll show you some ways to minimize cement penetration in the back. Some people do talk four by four back there. You know what we do is we, you get the keel engaged, we're going to use a Chandler, ok? And 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 all of that extra cement, you know, came out to the front and now we take it and just remove the cement. OK. We start impacting poster. 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 going to take out some residual cement after we impact it again, we have these cement curettes. Both of them are in the set. They are 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 going to 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 how do we push down on that? And that gives us some pressurization again. You want to 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 and take that out again and we're going to check in the back for some more cement unwell, 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 is 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 varus deformity. You're not at all going to have to worry about over correction. 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 and partial needs in terms of progressive arthritis. We published our series on it and you know what we say is slight varu just right. OK. Because you want to leave them in a little bit of Varis too much Varis puts some stress on the tibial component and may be a concern for tibial loosening if you over correct them. It's a concern for progressive arthritis. So, you know, I know this takes an extra few minutes here in two stages. But the benefit is I can spend it all the time 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, we're taking a little extra time. Not every patient, you have to cement in two stages. I just think for a bigger male like this getting his tibia well, cemented, getting all the cement out of the back of the knee is important. OK? So now we're just starting to pressurize this into the femur rear again, please on it now. And I usually don't put any cement on the poster con dial. So we just usually put that on the thermal component. OK? And again with that do stress here, it allows us to just drop the femur in like this right there. It is. Ok. Once you find the, the back hole is pretty easy to do that and we're just going to get this cement out was maybe a little on the runny side. So, uh, and take the freer, use that and you see the hook, sometimes the poll 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 degrees, 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 going to put the poly in and I'll show you how that locks in place. But, you know, for this guy with, you know, medial compartment disease, I think this is the right procedure for him. You know, the journey to the departmental knee system allows you to do it efficiently. You know, this also, you can do it robotically as well. So, you know, if you like coy, you know, this is very slick and smooth, robotically as well, you plan your cuts and you to burrow system and you can, you know, burrow the femur and tibia and you 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 in deflection and it's just so, so you can see this, we're going to use this here. OK. So just get the light on here. We're gonna take a freer. But what we want to just make sure is that we're not hitting the tibial spine. We want to make sure it is engaged poster. We give it a little push this hooks in to the tibia here, lift up and push you hear an audible click and we can see the poly is locked into place. OK. So we're done with that and now we're going to 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, the sub tissue with sort of 20 vil. You can use Monocryl as well. And then we go to a monocryl stitch or a sub particular stitch for the skin. Published Created by Related Presenters Kevin B. Fricka, MD
