Chapters Video Extended Audio Description Preview (using SMN Navio) a three D diagram of a bone in operating utensil. A photo of the actual Operation Text Journey to BCS with the Navio Surgical System featuring the brawl technique. Smith and Nephew Navio Surgical System Supporting Healthcare Professionals. Disclaimer This video is for informational and educational purposes only, and is not intended to serve as medical advice nor endorsed any named institution. The video and information contained there in may not be appropriate for all countries and jurisdictions. The video may contain information on Smith and nephew products, educational content and or demonstrate certain techniques used by the presenters. 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The present ER is a paid consultant of Smith and Nephew 17,778 v. 10219 Trademark of Smith and Nephew All trademarks acknowledged video of the operation. The incision is open. A screen in the lower left shows a drawing of the foot and ankle. A green dot on the upper inner ankle indicates the medial malley Ola's point. Now we're defining the mechanical axis, so the way we do this is we identify the media. Malala's so the most prominent point immediately, and the lateral moralists the green dot moves to the other side. It indicates the lateral Manolas point, and then we identify the center of the hip on. One trick here is to make small circles. The surgeon rotates the leg in the hip joint and then keep your circle is close to the center as you can. The screen in the lower left reads hip center calculation. It shows a green circle. Ah, blue circular line at the center indicates the motion of the hip. Collect the neutral position. A drawing of a straight leg text neutral position calculator. Place the operative leg in its neutral position and hold the right foot pedal down to record. And now we're getting our baseline range of motion. The leg on screen moves up and down from the knee. Text. Preoperative knee motion collection, press and hold right pedal to collect ROM flexion 58 degrees Press and hold the right foot pedal to collect stressed rom flexion 18 degrees. But this also defines for your M. C l and L C o what they look like with the bone surfaces opposed. Now we do our stress. The leg on screen stretches straight text collect stressed rom. Apply various valda stress while flexing the leg. Now what I want to do is I want to see how much room the M C L gives us. So we did a preliminary release, so I used this zero tractor in the joint with my thumb, and I leave her the joint open and apply a stress the surgeon bends. The patients need to 90 degrees them as far as the new will bend and you'll see how much of the joint opens up. So this is telling us or telling the computer how much room the M. C. L is giving us throughout the full range of motion. Do the same thing on the lateral side, applying a bear a stress now, and he's a little tighter immediately, then laterally. But you can see by our early releases were ableto get a pretty good excursion. So now we're doing a three dimensional map of the bones to help us with our plan. You can cover the femur tracker and to stay out of the way of the tracker that you're using. So this landmark here is what we identified earlier as the center of the knee. So this is kind of where you would put your I am guide. The surgeon puts his I am guide at the center of the patient's knee joint. On the screen, a green dot marks the most posterior medial point, the center of the femur that we've identified here. A line to the center of the hip is the mechanical access of the femoral shaft. We're going to identify later the center of the tibia and a line from the center of the tibia to a 60 40. Split between the Melilla is the access of the tibia. This is the most posterior medial point, so measurement off of this gives you your reflection. Cuts on the screen, the knee center, most posterior medial point and most posterior lateral point are checked off. A green dot indicates the anterior notch point on the femur. This is your anterior point. So this is your notch point. You're 80 access. So this is Whitesides line that we've defined earlier On screen, a metal instrument indicates the femoral AP axis right in the middle of the end of the bone, and now we'll do a free collection of the femur on screen. The horizontal line is marked with, and I'm on the left and of L on the right. From the middle of the horizontal line, a vertical line extends upward in the upper right. The end of a femur is bright green. The metal instrument drops away from the vertical line text femur Free collection. You can use a lap around the zero tractor and hold it from this side. I use two hands on the pointer, and I want to keep it on the bone. Basically, this tracking the outline of my femur has the surgeon tracks the outline of the femur. The outline appears on the horizontal and vertical line diagram. Then we'll fill it in. The rest of the femur is outlined on the screen. The vertical and horizontal lines are at the middle of outline of the femur. He then colors in the outline. There's a library in the computer of thousands of C T scans of knees, and you're making a model that approximates the actual surface of this patient, and we'll use this model to make our plans. You see how picks up the data very quickly. You want to get all around this side? This this helps us with more accuracy of sizing. And again, I'm keeping my left hand on the tip of the probe to keep it opposed to the bone. If you come off the bone, it's not a tragedy, you know, the computer will average out any aberrant data right if you come off and now we're getting up into the anterior cortex. So this is what I'm talking about here. So I'm getting a nice map. So the computer says Okay, now I know what's going on with the anti ephemeral Bow on exactly what my cortex is. So when we do, our planning were nice and safe. Okay, on that's it for mapping of the femur. So if you see any areas that you think you might want more data, you can fill it in. The end of the tibia is on the screen. A green dot indicates the knee center text tibia, landmark point collection map are tibia. So here's our tibia center, which is generally between the tibial spines. This is the low point of the media tibial plateau. A green dot on the left side of the tibial head indicates the medial plateau point. Then the green dot moves to the right side and indicates the lateral plateau point. So this is just where you put your stylist if you're doing this manually, so the most important information when you're doing your tibia is gonna be the surfaces of the tibia and the medial and lateral extent of the plateau, and that will help you with your sizing. So this is the high point of the lateral tibial plateau, similar to where you put your stylist. If you're making your cut, the screen shows the femur and tibia together at a 90 degree angle. Text tibial, rotational access definition, flexion, 125 degrees transfer federal mechanical access. And then now we're gonna relax and chance for the mechanical access. So we define Whitesides line, and we put it at 90 degrees. He picks up the patient's leg and puts it down with the foot flat on the table. We're gonna drop Whitesides, line onto the tibia and link the rotation of the tibia and femur on the screen. The end of the tibia is bright green. The horizontal line has an M on the left and Anel on the right. A vertical line extends downward from the middle of the line. Text tibia Free collection. As the surgeon tracks the tibia, an image of the tibia appears on the screen. The lines mark the middle of the bone so we can map around the CL. So again, we want to really focus on getting a clear map of the medial and lateral senate tibial plateau and then as far back as you can. You can't get all the way back, you know, because the femur still there, but it'll give you an idea of what the post your slope is gonna look like. I think that's gonna be good for us. I like it. So now we do our planning screen, so we know that he's a size six. From our template, the screen reads. Place femur implant. There are four boxes. The upper left reads component various zero degrees. The femur outline appears in the box next to the left lower section of the femur. It reads five millimeters. The right side reads seven millimeters. The upper right box reads component flexion. Three degrees. An outline appears there. The lower left box reads external rotation two degrees, and the outline appears at the bottom left. It reads 14 millimeters on the right. 13 millimeters. The lower right box shows the femur head and yellow, and then we're going to center it in the bottom left screen, media lateral And then we goto our top left screen. The image of the femur in the bottom right box rotates, and we know that the thickness of the component is 9.5 millimeters, so we do 10 millimeters off the medial side, so go down a little bit and then we're gonna take the femur and just we want to match the post your con dials as much as we can, so we'll push. It is post yearly as we can, so that the federal components sits right on the anterior cortex. So just show on the bottom right screen. The implant appears on the femur. This is preliminary positioning. We're fine tuning it in the gap balancing screen. We want to make sure we're not knocking here. Okay, Tibia implant. The screen reads. Place tibia implant. There are four boxes. The upper left box reads component valdas, zero degrees. The tibia appears. On the left is an M. A nine millimeters. On the right is Ellen. 12 millimeters. The upper right box reads posterior slope. Three degrees. The lower left box reads rotation two degrees. The lower right box shows the tibia image. So Tibby implant. We want to look at the native joint line. We look at the less affected side. You wanna match that joint line, Let's move it up a couple foot. That's a good starting point, and we want to make sure we're centered and then we want to make sure our post your slope for BCS component of three degrees. Now we go to our gap planning. The screen reads Gap planning. There are four boxes. Various angles of the bones appear in each box. The top left box has an arrow on each side. The top arrow has an s the right and l the bottom and I and the left on him under the M, it says nine millimeters under the el. It says 11 millimeters. There are two rotational arrows in each of the bottom corners. The upper left corner reads left, and the upper right corner reads right. The upper right box has the word left in the upper left corner, and the word right in the upper right corner underneath the word right is a rotational arrow. On the left, it reads 12 millimeters on the right, it reads 11 millimeters. The lower left box reads Component valdas, zero degrees on the left, it reads seven millimeters on the right. 10 millimeters. The lower right box reads Rotation zero degrees. Underneath the boxes are the words preoperative eight degree, various preoperative zero degree of August. Beneath that are two boxes for extension and flexion. The extension box reads, and 1.1 and 4.9 lire. The flexion box reads them 2.9 and 4.5 lire. So the first thing I look at it the bottom right screen, that flexion gap is triangular. So we're gonna add external rotation. Thio make it more rectangular. So this is within a millimeter. I'm gonna I'm gonna accept that external rotation of about four degrees and you see, that's a perfectly rectangular reflection gap. Then we're going to go say, Okay, we're loose inflection were loose. An extension. We're gonna cut left tibia. You remove our Tibby up, and this shows us we have an eight degree various deformity. We need to balance that a little bit better. We can add a little bit of various to are a femoral component, so that kind of balances are gaps a little bit better, and we can catch up the rest of that with a ligament release. We're still a little bit loose inflection, little bit loose, an extension so we can cut a little bit less tibia. So go up on the tibia and I'm good with that we're gonna recheck our femur. Just make sure we're not notching because we did add external rotation. Take off half a degree of external rotation on the femur. This is again where you could make up time as you get more comfortable with the planning algorithms. We usually zip through this, but we're taking time with our discussion. Let's see a seven. I think it's six sixes all he can accommodate, so we're going to stick with our plan. The screen reads. Checkpoint verification. The femur appears with a probe indicating femur checkpoint. Before we cut any bone, the computer is saying, Okay, let's make sure that the model is accurate. So are the checkpoints where we told them they were in the beginning. The probe indicates the tibia checkpoint. It's just a safety measure. So when we use the birth technique, we go from the top down. So our first thing that we do is the birth. The anterior portion of our ephemeral reception on the double pronged is nice to kind of get the soft tissues out of our way. We're gonna start up top here. The screen reads femur, bone removal implant. Smith nephew to BCS size six. Cut Guide Smith Nephew, Journey to distal cut option Size six The end of the femur is purple, and if you look at the top of the screen on the right, you see what's happening to the surface of the birth. So this is like coloring with someone making sure that you color well. So if I color outside the lines, it's gonna withdraw the birth and make sure that I don't get to be that little red mark is a half a millimeter area. So what we're doing is we're going to Santiago cut, and this looks like are very familiar Grand piano sign. Ah, green area appears on the edges of the purple area. The surgeon then begins to fill in the purple area with green. So we started using the distal burning technique, which I was excited about because it did increase our speed and accuracy. But then I was wondering why we couldn't do the whole femur this way because most of the bone that you're respecting when you're doing your ephemeral cut is that distal femur. So now you're just adding the champers, so you're not taking out a whole lot extra bone and I'm doing what I can. I'm watching the screen. Mike assistant Jeff is looking at the patient, so he's protecting the soft tissues, making sure that as I proceed, I'm not tying up any soft tissues or doing anything unusual. So we just kind of march down the femur. And just like mapping, burning is something that you acquire, a skill that we looked at. This where to? Surgeons in Australia looked at their 1st 50 cases, and they got a lot faster and their first eight cases and their times continued to drop to case 30 to 40 when they reached a steady state. Has the surgeon works? The green areas turned white? You know, we're all very comfortable using the saw and says, learning how to use a little bit. Different tools were often very dependent on our scrubs to keep up with a and with this technique, you're not asking as much. And the technique is mostly this trying to stay perpendicular, use a light hand and these small circles, and that helps erase the bone. Now we're onto the post, your campers, and we'll get us much as we can with the bird in this mode, and then we'll show you the exposure mode to the speed mode transition. Now, if you look at the bottom left screen, this is if you're looking at the end of the birth, we're gonna finish what we can on this. Uh, then we'll switch to the short barrel. So it's nice is that this is a handheld tool. So I'm controlling the action and not relying on a robotic arm. Yeah, let's switch to the short. In this mode, we have a short barrel. The purple box pops up that reads change control mode. It has settings for exposure and speed, as well as a matching guard. Yellow letters at the bottom red confirm that the hand piece configuration matches the burn guard selection, and the way that robot control works is it will stop the burr when you color outside the lines or go too deep. So what I'm trying to do is just there's a trembling technique where I'm just saying right on the surface of the bone, he continues to work. About 3/4 of the bone is finished, so I'm using two hands. You this technique embracing my left hand on the patient. We're just making sure that I have good control the spur all the way through. So the computer updates as we go have a double cross. Now we can't go into the tibia. And Jeff's job again is to protect the soft tissues. The screen shows the tibia bone removal section. The top of the tibia is marked in purple. We know that the the tibia cut. That's a good model of the tibia cut. And we can dio use the saw and do a quick eyeball cut to remove what we know is gonna be a lot of bone, which is the A c l footprint, tibial eminence. So I'm just gonna zip this off. This tends to be hard bone. It takes a while for the bird to get through it. Then we can refine our model. I'm just telling the computer. Okay. Hey, look, I just took off that bone, so make sure you your model reflects that he tracks the top of the tibia again, and then the rest of our cutting becomes a lot easier. As he works, the purple section of the tibia on screen turns green than white. With this technique, we're just going right to the action with cutting as long as most of my plane or the majority of my plane is it is white. It means I'm hitting my target again. The little occasional red Davis don't matter at all. And especially if you're dealing with a new like this one. This guy has tremendously hard bone, and we're taking a pretty thin cut on the medial side. So a lot of times when you're taking your saw, cut on that medial side, the blade of sky, and that will throw your linemen off. In this case, we're doing it. You know, we're feeling very good that we're getting down to the desired depth. When we see that white. That means we're hitting our target. That's our desired cut and desired plane. And you know, this speaks to the advantages of the Navajo system. And then you get all this great information from the gap balancing, which I prioritize that information where I'm making a plan. He continues to work. You need to you can verify your cuts is well. So you have planning execution and verification and the for only technique. It works for us here, a norm mission. A friend of mine is a certain in India who does 800 total needs a year, most of them bilateral. And I was figuring that if he's doing 800 a year, he's gotto know something about efficiency. And I found this to be a nice way to do this case. So we're gonna go as far back as we can, given our exposure. And then we can use the burger with a short barrel to get this that back section. Or you can even zip the if there's just a little rim that's left even zip that with a soft. Because once you define your plane, you're just taking off a little. Win the bone in the back. It's not gonna alter the plane of your cut and you get exposure like this and translate the FEMA imperially the tibia, and clearly you can really get quite far back here. I said. So now we've completed our bone prep for our tibia and for our femur, we're gonna clean it up a little bit. We have ah tendency that really elevate the joint line with manual instrumentation. The patient's leg is bent, so the foot lays flat on the table they suction and clean. For example, the the cut is set it at 10 millimeters or 9.5 millimeters with the manual instrumentation. And then we have a pretty low threshold elevated if they have a flexion contracture. So I'm just releasing the remnant of the PCL here. Hyla. Roger. We've learned a lot from using the knave E O toole, in terms of how we're working with our joint line and preserving our joint line. I think that when you start moving in front line around, um, you're gonna put abnormal strains on your M C L on your LCL. And we took a lot of time to figure out what those tensions we're supposed to be like. Physiologically. So if you take a knee like this, that has a lot of where and you use manual instrumentation, it's gonna set your cut at 95 millimeters off the medial side. And he probably already has a little bit of where so with a 9.5 millimeter medial cut, you're actually going to end up elevators. Don't line a couple millimeters if you go ahead then and take another plus to cut, as we tend to do when someone has a flexion contracture. Now you've elevated a joint line three or four millimeters, and I think that that has consequences. So it's very important that we achieve the full range of motion loosening up that poster capsule. Get these post your osteo fights really important to getting the full extension without elevating the front line. So again, just making sure we get rid of those osteo fights that's gonna help us balance Arnie. They suction and clean. They'll take the rest of this lateral meniscus. Yeah, we use a dilute solution so we can get a broad penetration. He injects. Solution into the lower and upper knee tibia is placed manually, and basically, if you can get good coverage, you can have good rotation. We're working a little hard for exposure on this patient because of his prior surgery, but we can still see quite well what we're doing. I just want to verify that we have good lateral coverage, which we do, and they were sent immediately Short pin again, verifying we have good rotation media. Third, good coverage. It's also nice not to violate the intermediary canal because now we have, ah, way to pressurize are tibial cement slab, so the journey to femur has an up slope of the post your federal condos, so you have to get it underneath the condos and then rotate your hand up. So here we are, underneath the con dials, and then we rotate our hand up to seat it. They play some metal device into the knee, and we prepare the box. So it's nice to be able to ream through the trial, because that way you can make sure your femur centered. They were centered right on the notch. There, they use a drill to fasten the device. They're attached several devices on top of the metal box, then plunged the top section into the knee to see a 10 child, please. So this is where we're going to check our work. Let's put our ephemeral trial in. The thing about the BCS is the tibial implant is con que immediately convex laterally, and that helps drive this poster a lot of rotation. But it only works if the femur is opposing the tibia surface. That's why gap balancing is so critical. If you have lift off and these surface air not touching, you're not going to get the benefits of the design. You wanna put thes BCS knees in rather tight? Okay, good. He inserts a yellow T shaped section. A probe indicates femur checkpoint, then to be a checkpoint. And what feels good, you know, Did we do a good job? You know, we can examine it, but I really want to know the data. So the point here, please? So we're gonna just check our work. The screen reads checkpoint verification. The probe indicates femur checkpoint, then to be a checkpoint, so make sure the femurs were supposed to be so That's our femur checkpoint to be a checkpoint. The screen reads, collect post up baseline. It shows an image of a leg with the lower leg moving up and down is the surgeon moves the patient's leg up and down and arc on the screen measures mobility extension. We have full extension and we a flexion of 1 45. The screen reads post op stressed Gap assessment. It displays the make size, thickness and alignment of the implant. Beneath. That is an extended leg on the readings extension zero degrees external rotation, one degree, various two degrees. And now again, you know, we kind of got him. That's our goal is neutral alignment. He extends and flexes the patient's leg. And now that shows us we got good balance. Less than a millimeter of lift off her gap. So we like it. We're gonna buy it. What we've done here is we verified that we got full extension. We verified we had 145 degrees of flexion. We verified we have neutral mechanical alignment. We also verified that the lift off our gap throughout the full range of motion is less than a millimeter. So when we have all the information, we can leave the operating room knowing that we've done a good job. Now it's just a matter of finishing the patella and cementing the need to go back this week. Yeah, this is the fully demonstrate that is not a dull subway. This is just super hard bone. And you can imagine if you're trying to make a tibia cut in this bone that's going to sky, and then you have a shallow tibia cut, and that's gonna throw off your mechanical access. I tend to favor removing part of this lateral facet. I don't generally use oval patella. I think this improves patella tracking. He adjusts the soft tissue he extends and flexes the patient's late again, again getting our rotation correct. Even with this full, uh, media perpetrator approach, you get nice patella tracking. This is the five and one tool you can cry off the tri ALS. This is how you disengage the federal component, the remove sections of the metal components. He pumped cement into the knee. So I had a chance to pressurize that cement in there. And I put also a little bit of cement on my TV, a surface. He put cement on the metal components and then Trish is gonna load up the femur. Trish pumps glue into the femur area, so we make a little U shape on the ephemeral side. You see how the rally cement gets into this nice Joey form pretty quickly. We have cement all over the back of the femur. Just try to keep it thin on this poster. Conned ill. So I don't have to chase a lot of cement. And again, we're doing the same thing. We're hyper hyper flexing the knee, so we're hyper flexing the knee. Then we put this. Get the condos underneath. So once you get your condos underneath like this, then you want to bring your hand up. You bring it into position and the impactor has a surface so you can help rotated up and then bring it down. He hammers on the side to bring it up, then on top to bring it down. And I prefer a heavy mallet. But I grab it close to the end because I, like toe, have control over that weight. They re insert a piece of the implant that's going to give us good compression. Get yeah, really. So a soon as we get our trials confirm that we like what we're doing. We start dismantling the robot, and already the robot can be moved to the other room to set up for the next case so you can use the robot in sequential rooms and flipped rooms, even without any significant delay. Our tendency here is that we put the incisions for the pins outside of the main incision for the knee, and then we close them with nylon, and we take those stitches out at 5 to 7 days. Post op. Our skin wounds for primary knees. We tend to close the sub particular. In this case, the patients had prior surgery and any wound. We have any concern about a revision, knee or need. That said, prior surgery. We're going to use a PICO dressing, which applies negative pressure and seals the wound. He's got nice full extension. He holds the patient's leg out, straightened up, then flexes the new completely, hanging freely. He's got about 1 35 back of his calf hits the back of his thigh. That's gonna be his limitation right there. And this is super solid all the way throughout. No gapping. That's our journey to with the nah. Vo were only technique. Thanks for watching logo pedals, oven orange, flower text Smith and nephew supporting health care professionals for over 150 years. Published Created by
