Dr. George Guild performs a TKA procedure with the CORI™ System, featuring JOURNEY
™ II ROX ™ Reverse Hybrid with CONCELOC ™ and OXINIUM ™ Technology. Good morning and welcome everyone to Atlanta Emory University. We got the team. We're gonna show you a right total knee replacement. I'll just introduce our team real fast. We got art, our tech Ben, our first assist, Sonia is our orthopedic fellow, total, joint fellow. We got Chris, our C R N A from anesthesia and we got Ashley, our circulating nurse over here. I'm George. Um This is going to be a journey to knee oxen, femur, cement tibia and cement patella. We're going to do a P S knee. She has a P S knee on the other side. Um I don't know if you guys can pan up to her X ray, but she's got a valgus knee going on here. We're going to use a coy robotic assistance and she's under spinal anesthesia, lita cane block. We are using a tourniquet and she's going to get a medium perate arthrotomy. She is super stiff inflection. She shouldn't bend very much. She's got some thigh calf impingement all day long. I'm going to feel her tubercle incision. Right. Thank you. Then bronzer. We do get, go ahead and get the super condor pouch evacuated. We're going to be sizing it. So it's a little out of order, but we do it for efficiency. She is going to have a standard media exposure to mid Coronal with her valgus knee and I'm going to take out some of her fat pad about 50% for exposure purposes. I don't like taking all of it out. I don't want to see a naked tendon, so to speak. So this is not going to be an I S incision just for this particular patient. There we go. That was the release we needed. My first step particularly with core, I'm going to come around the medial side like that. Hold that. Vin grab the pens on you, then is going to put that just superior to the epi condo. I'm going to take the double barrel. Let's go right there. We want to make sure we don't hit the box on our P S. So I just translated that superior a little bit second thin, this double barrel will help hold the soft tissue out of the way. So is gonna make sure we're hitting bone and then she's going to hook up the array. Don't want to fly off. OK? Double barrel. OK? I'm gonna come and do the tibia about a hand's breath below. I'll make two marks. I still am doing a poke hole with a 15 blade. Some people just go straight through the skin which is fine, but I'm gonna just poke through there if I can see the other one. Ok. Drill that one. Ok. And then tubular bracket, metal bracket, that way we got it. Ok. The I'm going to do a little o if I at work while Sonia and Ben are tightening up our, you do want to get these osteophytes out to size the bones correctly with Corey. So Corey compared to some other systems does not require an image which is super helpful. Sometimes these images aren't getting approved by insurance. You have to manage that, but it does mean that you want to take the osteophytes off. So that when we register the bone, we're getting an accurate size. So your registration is important, just like anything. I'm gonna do a little bit of a notch plasty, she's gonna get A P S. So I'm gonna make a little room for us to get out the cruets. You want to take the cruets out if you're doing P S before you get going on the knee because Corey is going to want to know what the knee balance is without the cruet. So I'm going to go ahead and get that MCL. I don't always do A P S that's changed a little bit since I have adopted robotics. I certainly was trained as a P S surgeon but patients, younger patients, I think don't like the noise of a PSD as much. Now, granted, we're getting our PSD even tighter now and that noise has become less but younger patients in less deformity. I'm considering more of ac this patient with her vagus deformity and the fact that she has a P S on the other side, we're going to do a repeat P S here for me. If I am going to do C R, I think the polyethylene shape matters and there is good data to support that, that you want to have some sort of congruent polyethylene, whether that's a medial pivot or a deep dish to give the patient a little more resemblance that their cru sheets are intact. So this is our initial exposure we're going to get going on Cory now. So we're getting our hip center now then when you back off on that. So if you are using a side post, you want to back off on it, see if I can get it to behave. Let's start over again. OK. We're going to do a neutral position collection then an unstressed range of motion. OK? And now we're going to register Corey. We are essentially going to create a virtual cat scan or a 3d image registering this. Kick me the pedals, please. OK. So when I'm registering the femur, I'm going to outline the femur, she has a super tight extensor mechanism. So we're just going to get it out of the way a little bit, but you're gonna outline the femur and then you're going to fill it in. That seems to be an efficient workflow to get this knee registered. And I'm looking mostly at Bone. I'm really not looking at the screen when I'm doing this. And once I think I'm pretty close to where I need to be, I'm going to have to flex her up to get the back. I think I'm going to come off the button and see what I missed. So we got a little blue light blue that we got to register and we got a little poster media, which is not real surprising considering how tight she is back there. OK. I'm gonna come up top and register a femur. This is letting Corey know where she's going to notch or not. So you really want to dig in here and that is the ephemeral rotation. It's a four degree valgus, eight degree contracture. It's going to call for special points. I'm going to draw out the media lateral eon white sides lined and then we'll be on to the tibia when you're registering the tibia. Corey prefers a little more media registration. So preferentially start on the medial side. It really likes the transition zone between the plateau and coming down the tibia and then a little less lateral. And then I'm gonna check and that is the tibial registration. So these implant planning screens that stand is working through. I don't do a lot on these implants. This is a good preliminary check for me on what size we're going to do. But I am going to change the implant positioning in just a second based on the gap. So I don't spend a lot of time on this screen. It just gives us an idea on what size we're going to be. If they need to open the five cutting block, we're not sure yet. So let's go to the next screen. This is the stressed gap balance or stress gap assessment. This goes in at about 20 degrees Z shaped retractor. I'm going to give a little tension here. You can see she's really opening up media like you might expect on vagas. I'm gonna come in the lateral compartment. I do two passes just to make sure we're getting a good reading here. And now we're probably at the most important screen here, which is how we're going to move these implants to help us balance this need. She had an eight degree contractor. Is that right? If we're going to raise her joint line just slightly, if you just take a 10, 5, there, only one millimeter of elevation there will get six or seven degrees out of that. So once we do that, if you look at the bottom of the screen and extension inflection, we're kind of globally loose. So we're gonna raise the Tibby up so we can see where we are and we're going to stop there. So we are symmetrically loose medial as you might think you would be for vagas or you could say symmetrically tight lateral. So we're going to do two degrees of valgus on our tibia to help us with balancing. And that got us pretty close. We're only one millimeter off an extension. So we're going to do a little on that distal femoral cut, perfectly balanced and extension now and we're going to drop the tibia one, anything above that white line is going to be loose. So for me, most of the time I'm shooting for about a millimeter loose in extension our extension gap, it's pretty good although it changed our section. So let's go back to 10 to 5 and then raise the tibia back up. Perfect. So we're right back to where we were on a 10 5 distal femur section. Now we got our flexion gap. So we're loose media, we're actually going to internally rotate our femur slightly journey two has excellent patella kinematic. So I don't worry about patella thermal tracking with this implant even internally rotating slightly. And then I want flexion to be a millimeter tight. So we can't quite get there with the five. We're going to flex this are we already at five, so maybe go to six. OK. We're going to have to extend probably back to three with the six. See if you can get it to about 1.2 tight stand. Yeah, right there. It will be a nice flush cut interiorly here. So we went to 11 on the distal femur, let's drop that back to 10 5 and then lower the tibia one and now post the rise, the femur one. And this is the beauty coy. I could never do that manually. I could never know the extension gap, the flexion gap flex the femur a little more to posterize the femur to catch up with flexion. You can't do all that manually. You're making a lot of assumptions manually. This is a perfect balance for me. We're going to go ahead and proceed here for me in a workflow standpoint for efficiency. Getting through the day, Corey has a small footprint. We have eight cases today. Six of them are knees. We're bouncing back and forth with this machine. So I'm really in tune with the rep. They know my preferences on balancing. So Stan is going to dial that in a lot of times without even me telling him it is my preference that I have some assistants running that you certainly could do it on tablet and run it yourself. But it would just be a little extra step for you. Uh It's, that's based on your preference, but either is available. So we're gonna re register to make sure nothing has moved, so to speak, here and here. And then we're gonna go ahead with Corey. Corey is a handheld. It's gonna talk to our cameras. The Burr at the end has a 12 millimeter excursion flat hammer. Here's the punch tool setting our rotation. So is going to slap that out coming right in with our journey to coding block the first time. The I need a rake medium. Yeah, we have a big stiff knee here. OK? And that OK? One more pen in the soft. So Journey two has a five in one cut block because the angle of the poster conor cut is sloped up 15 degrees. So it's gonna roll on. It requires 1/5 cut for that. And I am gonna put a retractor around the M cli definitely don't want to get into that on any knee, particularly a valgus knee. And we're gonna do this poster conne or cut thin puller and a slap hammer. OK? There are many different ways to prep the tibia with Corey. My preference is to use this top hat and float it. So I'm just looking at the screen, go ahead and pin that Sonia. So on the left is Vera Vagas compared to plan getting used to floating. This took about 10 or 15 cases to kind of get to time neutrality, get up to speed efficiency. So I'm real happy here. We've got bears vagus on the left depth of restriction in the middle and slope on the right. You want all those under a millimeter, we're looking good there. I am going to protect our MC L again as I make this tibial cut, she's gonna get a little on that cut for sure as planned and she has a little vows on her contralateral to help with that balance. My balancing strategy for Valgus has changed over time. I used to really be a strict believer in Nero mechanical axis, in particular Valgus and I would release the lateral structures to get it balanced. But I found that just a slight vows will really help you balance it and you don't have to release much of anything Coker please. And that seems to be a better. So a lot of these moves at this point are carried over from my manual technique, which I like some robotic systems. You do seem to lose some of your arthroplasty skills where this has been a nice combination between robotic and maintaining some of your normal arthroplasty skills. This patella we've been fighting the whole case. This might have been one. If I could go back, I would have cut it off the rip. Um The only concern I have doing that, we're going to do a cement patella. So if you do cut patella first to help with exposure, you just have to be careful that you're not beating up your Patel or bone during the case. So that's for this case. Well, I've chosen to kind of leave her patella uncut for a second. OK. Injection. I'm going to do a brief spacer block here because we're not gonna, we're gonna put the real cement tibia in without really trialing the knee. I just want to make sure we're coming to extension and looking good before I put a real implant in. So flexion, it's perfect laxity. No concerns there. Extension. I want to make sure it's, you know, easily coming into extension core. We've got her down to a three here. So I'm really not concerned we can go ahead and proceed with putting the real Tibby in, particularly for a knee like this. That's a little bit hard to expose if the is in the way, I don't want to bring the patella forward twice. If I don't have to a little bit of bone. This pesky and Terri bone that we all get. All right, tibial base plate. This is an asymmetric tibial base plate bigger on the medial side. We have a four here and let's see. I'm gonna just flex it up a little running into her a little bit. Go ahead and pin that for me. So I'm looking at curve on curve medial third, grab the bur you're going to prep one in the front, you're going to ride these rails to prep this cement tibia. Sonia is gonna grab the tower and I'm gonna really her on a big knee and try and get that in there. Yep. All right. Keel prep that for me. Open the three, excuse me. Four cement tibia. Yep. Ok. Perfect. And come out with that tens out. This Tibby is cancel lock, porous central keel with pegs for rotational control. You see it's a little bit oblong. It just helps with better fixation and rotational control. This particular tibia is not very hard to hit down, which is a great benefit. You really don't want to have to hit these Tibby so hard that you just can't get them down. The struggle with her just because she's big, kind of wiggled it in there. We've got one little piece of fat out of here. So, so you just kind of hit this down a little bit here. Excellent. And you can see it's perfectly down already. We have no gaps. I mean, I have no concerns about this done and now we can go ahead and put our fem on. So our Tibby is done. I love that for efficiency only bringing the tibia forward like that one time during the case. So just like we talked about with the five in one cuts, we're going to roll this on. Go ahead and ream OK. Come on now. Right. Hockey park. And uh so this method of uh preparing the box is efficient. It's also nice because the two condos aren't separate. You still have a nice bone bridge in the middle and it's not a large box cut. So the chances of you having an intraoperative con fracture are quite low. We'll take a nine polly that always takes a little tap to get it down. This poly is essentially media congruent with a post. It's got a little lip in the back. It's got great stability. You're gonna get it under the lateral con and you gotta kind of snap it under the meteor. All right. So I'm just kind of taking a look at it. She's coming straight and she has a little bit of laxity with this nine. We, um, had prep for a 10 polly and so we probably need to go up. I may go up to an 11 poly here trial. So I think we may have plan for a 10 and we may get an 11 which for a knee, I'm pretty, pretty happy with. So we'll see if this 11 will be the one and there's that little click inflection. OK. So before I even check Corey, I'm just going to look, do we come straight? Yes, we have no opening and extension. We have almost no opening in mid reflection. And then in 90 we have no A P translation. So this is what I want. Now, I'll see what Corey says. Go ahead and mix cement and open that Corey says we got her straight to zero and we're mixing cement now just for work flow, we're going to be doing a lot of other things while that cement is mixing and as far as laxity here, and we're basically under a millimeter, almost the entire knee with a straight leg. So and this is kind of how most of these cases go even for a bigger knee with the flexion contracture and vagus. We're able to use core to get our implant position to balance the knee no releases. And essentially the first poly or the second poly is going to balance these knees. And just through the course of the day that makes it a lot less stressful for me as a surgeon, multiple cases, it's better for patients eliminating that variability. So that's been a win for us. Let's go ahead and get this stuff out of there. So as the cement is mixing, we'll go ahead and take these pins out and I'm gonna start getting ready to prep the patella just depending we can do it after as well. Finally, we'll get this patella, which is just super tight. The whole case. I think this would have been a tough one to avert even if you're an inverter without putting too much stress on that Patel or tendon Patel is a still free hand. I am going to measure composite thickness which is not that thick here. She is a 20. So please. OK. Let's get the Ella prep here, right? Nice and flat. Go ahead and prep that. So a few things about reverse hybrid fixation. You know, we've got good data from the American Joint Registry showing excellent survivorship. Short term, actually, males and females, different age groups that the cement tibias are looking good. This reverse hybrid, you're able to still get the benefits of using an oxy femur with lower wear. It's hypo allergenic. You get all the benefits of oxen with the benefits of a cement tib. Yet we put it in two degrees of valgus. I think there's a chance that cement technology may help that tibia hold on a little bit better long term. And the patella, there is some data from Dr Haas at special surgery that some of our patella aren't looking so good with regard to fixation. There's been some concerns if we're getting some anterior knee pain on the tele fixation. So there's some good data that's showing a cement patella. If you've ever taken one off, they're pretty well grown. We're gonna roll this back on. You got a hit in multiples of seven, of course. OK. And her balancing was interesting, you know, I think she was a size five on her other knee. But with Corey, we understood we had to go to six to get her flexion gap stable enough. We were able to flex and posterior it enough. Those are just things I can't do with manual instrumentation. Once again. Now, we could have done a cement femur as well. She has good bone, but you really, if time is a concern, you really don't lose a lot of time cementing on a femur. You know, we're, we're done with the cement there. So I'm just going to make sure we don't have anything in the locking mechanism here. Once again, we're gonna get that and snap it in, bring it to extension and then we're gonna get a little cement squeeze there. We're gonna put our Ella on and, and that'll be it. This particular one is oval shaped. She has a bit of an oval shaped Patel. As many of them are. We've got three prong cancel lock here. And once again, it gets a good press fit without you having to hit it or crush it. They typically go straight down so it's completely flush on the in growth part of it circum friendly and that's it. So pin out Basin Beta. I don't know how many minutes we're at here. We're at 42 which is reasonable. Not that speed is everything, but you do have to be efficient to get cases done. That's kind of part of what we do and overall you look at her knee, we gave her three degrees of a and um just eyeballing it. I can't see it. So, you know, folks really don't like the appearance of a knee and just those three degrees really helped this knee balance. Well, we are done here. We're just gonna close her up and I just wanna say thank you to the staff in here for helping us out get this case together and having a great case. I'd like to thank Smith and nephew for coming in and, and making this video with us and uh you guys have a great day. Thanks a lot.