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Robotic knee replacements, Cases: complex arthroplasty, FRCS shorts and beyond | Timothy Parratt



This on-demand teaching session will explore the pros and cons of robotic surgery, a growing trend among medical professionals. The discussion will cover everything from the technical aspects of the operation to its implications in terms of research and innovation. Participants will receive guidance on the best way to use their instrumentation and will be walked through a live robotic surgery to gain useful insight. At the conclusion, there will be an opportunity to debrief and discuss the pros and cons in greater detail.
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The PFJ and Principles of TKR

0930-1000: Principles of total knee replacement | Arman Memarzadeh

1000-1030: Sport injuries in elite athletes | Arman Memarzadeh

1100-1130: Break

1130-1200: Patella instability, BOAST and planning for treatment | Iain McNamara

1200-1230: Debate and journal club: to resurface the patella or not - NICE guidelines |

Chair: Iain McNamara. By Charis Demetriou and Madeline Warren

Lunch break

1330-1400: Principles of balancing and pitfalls | Jehangir Mahaluxmivala

1400-1430: Principles of alignment in knee replacements | Jehangir Mahaluxmivala

1430-1500: Debate and journal club: to HTO or uni in medial osteoarthritis of the knee

By Ignatius Liew and Luke Granger

1515-1530: Robotic knee replacements| Timothy Parratt

1530-1600: Cases: complex arthroplasty, FRCS shorts and beyond | Timothy Parratt

1600-1630: History of total knee replacements | Frank Foley from Smith and Nephew

Learning objectives

Learning Objectives: 1. Explain robotic surgery and its advantages in terms of planning and personalizing operations. 2. Describe the steps necessary for successfully setting up a robotic surgery procedure. 3. Evaluate the pros and cons of robotic surgery compared to traditional instrumentation techniques. 4. Identify techniques to compensate for tightness and looseness when preforming robotic surgery techniques. 5. Analyze the alignment, gaps, and range of motion of a robotic surgery procedure to determine optimal outcome and quality of results.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

So, um yeah, you guys are probably going to come across this sort of stuff quite a lot, you know, in your training when you become consultants, it's the kind of sexy thing at the moment. So, I mean, I, I guess the point about robotic surgery is, um, is it just a fleeting kind of fad or is it here to stay? Um, basically, I kind of got involved in it essentially because it was a young consultant, still consider himself young. Um And uh, you know, we want to do some different stuff, we want to do some cool stuff. And so it wasn't just necessarily um doing the cool surgery. It was things like how can we look at new areas of research, new areas of innovation, you know, potentially attracting new staff showcasing basically yourself and your hospital. Um, and all these sorts of add on. So, I mean, it's quite um not to mention, of course, that hopefully you're going to get better outcomes, but of that we don't really know at the moment. So I thought, I mean, has, has anyone got any experience of, I know somebody who done the course some of your work culture's there. Um But I'm assuming that most people are fairly inexperienced with regard to what robotic surgery actually is, would that be, would that be fair? Probably, um Essentially the robotic part is what the implant companies put onto it to make it sound sexy. So, um the actual really useful part is in terms of planning, in terms of sometimes personalizing the operation to that particular patient. Um and uh also to, to leave an audit trail to sort of walk away from the table knowing basically exactly what you've done. And I think you're lucky that Frank's coming later on. Frank's really, um, knowledgeable and all this stuff. But at the end of the day, um, there are errors within instrumentation and I'm sure that you've all, uh, or, or you maybe do yourselves have little tips and tricks about, you know, this instrument does this sometimes and, you know, you've got to watch that this one doesn't slip a bit and blah, blah, blah. And that's because there's a bit of an error and instrumentation and you don't tend to get that so much of this. So I thought, well, do anyway, very quickly, just run through what we actually do in a procedure. Um, and then probably at that point, just sort of skip on and then we can have a bit of a chat about the pros and cons of it. Maybe if we've got five minutes at the end after the case discussion, would that be? All right, thank you. So, essentially what you do is the first part is a bit like a kind of old fashioned navigation and you want to tell the computers brain basically about what that patient is like. So you put a couple of pins in the femur, a couple of pins in the tibia and you put a raise onto those pin onto those pins, uh, that your camera, which is this thing up here can pick up through the procedure. So the sorts of things that you're telling it are the sorts of things that you, you yourself may record with instruments. So, um, you want to put checkpoints in. So it knows where the femur and tibia are. Basically, you then want to tell it where the ankle joint is okay. You then want to tell it where the knee center is both sides and then you're gonna tell it where the hip is and what the range of motion is of the hip. So this tracing here is, um, basically your, your hip center tell it where the leg is in neutral. So in basically full extension or as much extensions you can get and then you run it through a flexion range as well. So it's starting to build up a bit of a picture about what this particular patient is actually like. Um the other thing that I've missed a slide here. But at that point also, you can tell the computer how much various and valgus laxity in the corona plane is in that joint. Um that may or may not be particularly accurate if any of you have ever tried doing it. It's basically like putting a valgus, you know, testing the MCL but trying to do it through a whole range of motion, which is quite difficult. So normally what we do is put a kind of Xiidra tractor in um and stress the medial compartment right open and then run it through its range of motion. So the things you'll see later on the things basically getting an idea of what are your compartments like lateral and medial in terms of your tightness or looseness, relax to uh throughout the range of motion, not just our conventional kind of what's it like zero and 90 degrees with the spacer block. So after that, you basically get your probe and you run it all over the surface of the bone. And so you're painting the surface of the bone. So it knows what the contour of the joint surfaces like you can define your femoral rotational access, you do the same on the tibia. And then this is probably where I think it's um starts becoming really useful. So at this point in time, what the computer is doing is it's saying right here's uh size seven femur six tibia, a nine millimeter poly and everything's kind of put in at around about zero degrees. Basically Okay. So this is your sort of best if you can get your instruments to work as accurate as possible, assuming you're not going to be wanting to put constitutional on or whatever else, then this is the best that your instruments will do. So you can see in the bottom right corner, we've gone from uh 9, 227 degrees, eight various, uh 20 various just by putting the instruments in, in that particular weight. Okay. And we can sort of size up the instruments on each of these screens, we can anteriorizing, we can post arise, we can rotate, we can flex, we can extend. So you think that's all really great that, that looks like a really good knee replacement. And then this is your stress range of motion. So essentially um on this graph, the zero line is sort of zero laxity and the gap above the zero line is any laxity that you want to dial in. So what you can see in this particular case is that this patient is actually very tight, very tight all the way through the oranges, medial side, the purple is lateral side. So you sort of go back and think, oh shit, you know, how am I gonna make this? Sorry, my legislative um uh You know how, how am I, how am I gonna sort this out? Cause it seems that if I put this knee in, in this way that everything's going to be a bit tight. And is that going to be one of these patient's one of the so called 15% wherever um that are going to be unhappy. So what you do is go back to that screen where you can change your implants around and you see what you can do to change the gap. So these are your gaps and you guys will be used to dealing probably with rectangular gaps at zero and 90 degrees. Well, what we're looking at here, we are looking at 0 90 to some extent, but we're also looking at medial and lateral. So what you can see there is the only one really that's approaching zero is the lateral side in extension. So, can anyone think of a way that we might, uh can you think of a way that we might try and get those gaps looking a bit better if we want to raise everything up? I'm not too sure. No. So the sort of thing. So this is where this, this is where it becomes hard. This is the hardest thing about doing this type of surgery and I'm still learning as well. But essentially you're looking at this and you're, you're just hoping maybe that the rep for someone might say behind you, why don't you do this? Um But the sorts of things you might want to do here. So if you, if you could take, you could take more tibia, so you could immediately take a bit more tibia. So that's going to release both of those gaps. It's still going to be a bit uneven, but you can do that. And if we go on, I've done a few other things as well. So what, what I've done here is I've managed to make the flexion gap okay, extension. Still a bit of an issue. And if you look at what I've done with the femur, I've put it in one degree of various and I've also put the tibia in one degree of various. And that's essentially to almost decompress the medial compartment. Okay. So you put them back into a little bit of the deformity that they came in. It's still quite topical at the moment. And if you look here what your pre op was eight degrees of various, actually, you're putting them back in about two degrees of various. So that's what you can do just by twiddling around with the implants. But what you mustn't do in this situation is go tumbling down a rabbit hole, chasing the, chasing the numbers on the screen because you've got to remember and this is good for instruments as well. Um But it was actually robotic surgery that, that made me think about this is that you're going to release a lot of stuff just by doing the operation. So, you know, you cut a tibia, you recess a PCL, you take off your pasta. Rasta fights, you know, you do your releases, etcetera, etcetera, just by doing the operation, you're going to loosen stuff off. So in this situation, I'm quite happy to leave that uh that extension gap as it, as it was knowing that hopefully by doing the operation, it's gonna all come good. So basically what you do is in this situation. So the robotic part is basically the device that used to cut the bone. So in my opinion, you know, all the companies say isn't this great, but to me, it doesn't really matter what you used to cut the bone. Actually, it's more about the previous stuff that we just talked about. Um So you can cut your tibia femur and then also record things at the end and this is what it looks like at the end, this is what it looked like in this case. So actually your gaps are pretty even there's a bit of play, each of those increments is one mil. So there's about two mills worth of play throughout your range of motion. And at the very end, you get this really nice kind of summary screen which basically tells you the orientation of your implants. Um how much you've resected on both sides, uh what your gaps were like in the planned section and what they're actually like in your soft tissue tension at the end of the operation. And if you look up here, you can see that your alignment. So what you've changed their alignment from and to, and also your flexion range. So you're obviously they're fixed flexion this one. Um And you've corrected that and given them a little bit more flexion as well. So I think you can probably see from that, that it's, um you can see the attraction of doing it this way. It's nice. You can, I mean, if you, we've not worked it quite to do, but if you wanted to, you could take a picture of this and upload it onto your uh notes or whatever else. Um So you walk away from the table knowing basically exactly what you've done. Now, I suppose the question is what will that have any tangible difference? Um That in itself is hard to know. I think what we are on at the moment is sort of robotics 1.0. Um I've chosen to kind of get on the train and go with it. I think that there'll be a lot of innovation. Um and a lot of development of the technology to make things better. But remember as is in this situation at the end of the day, we're still banging in a genesis to Christian retaining me. So which probably was developed about 30 years ago. So there is still, you know, an issue about, well, that's great if all the technology is increasing to put the knee in. But at the end of the day, you are still putting in the same implant. So that's a big consideration. I'm actually gonna move on. I've got, how long, how long have I got to about quarter to tend to something like that. Um I'm gonna, so this is just what I was saying at the start, you know, you can, you can say basically, okay. Well, I'm going to use it to make all the intrinsic things in the hospital better. Um That is just as it is with any business case. I mean, we said all the usual things that you'll see. Um This is a bit actually, which is quite interesting and we, we've done loads of stuff, then loads of education. Uh We're working on with a company to look at things like marker list, navigation, laser cutting, all these sorts of things. And actually, the reason that we've done that is the reason that we've got that is because we started doing robotics. We've um we're about to start to uh be one site of to robotic are CTS. Uh We've just opened up an Institute of Robotic Surgery, Anglia Ruskin Uni with a million quids and from the trust that's pretty good. Um And then, yeah, you look at things like what other stuff can you add to the robotics. So we're looking at digital operating rooms, all that sort of stuff and then future proofing, attracting staff for the future. And probably at the moment, that's probably the biggest one that robotics marketing because most of the robots are in private hospitals as I'm sure, you know. Uh, yeah, we just said we do more you knees. Um, and that your knees are really good. We do more complex cases, avoid things like vision airs, avoid endo prostheses, complex cases to follow, um, that we could get better efficiencies in theater and then all those other things that we mentioned, they're so I'm going to stop that one there and I think if we just do any questions at the very end, so we can get on to the, the good stuff. Uh Right. So do I discard that now, Eggy and put the, yeah, this garden and neck. Let me take a couple of questions while I'm loading the other ones if we want. Hi. Hi, Mister Barret Salman here. Hi, I'm it. Hi. I'm just uh just been thinking about the difference between their protic and the P S I patient specific instrument. I presume the, the only thing is that the robotic can allow you to put implants in, in a cinematic alignment uh where PCI is uh force you. The only one option is mechanical. I presume I can't think of any difference between them apart from that. Um Well, there's a few other differences but that is probably the crux of it. So essentially what PS I will allow you to do well, until recently. So what happens is when you, when you become a consultant, uh the company says puts you in touch with one of their technicians and they say, well, how do you like to put a knee in and you say zero degrees and they say fine and they just set up all your parameters. So every time you get a P S I, they set it up like that. So you put it in mechanical, mechanical alignment. Um, actually recently, certainly with Smith and nephew who we work with, they can give us PS I jigs for other types of alignment. But one of the problems about that is it's hard to categorize patient's, I think preoperatively, you know, whether they've got constitution of areas or not. I mean, one of the nice things about using the robotics systems is that, yeah, again, like I said, whether it's accurate or not or super accurate, but one of the things that you can take into account is your soft tissue laxity as well. Whereas obviously that's being dictated to you, if you've got P S I jig's, in fact, what you can do with robotics, I mean, myself and Mr Alum almost use two different philosophies. Um I tend to try and do all my deformity stuff and balancing the knee through the bony cuts. Um And then I'll add in some soft tissue stuff if I need to. Whereas he does the opposite, he actually releases the soft tissues and sees what sort of outcomes that gives him on the machine. Okay. So, uh let's go through this. Uh I'm going to assume that I've got about 15, 20 minutes. Um, so let's go through, I've got quite a few cases. We don't have to go through them all. Um, so case one, you can read it yourself. 54 years old just had a previous DVT. That's all he's had a previous ACL. Um, yeah, almost 20 years ago with now severe medial sided knee pain. He'd had an arthroscopy by the referring consultant, which suggested that he had pretty bad medial. Oh A. Um So who's right? Nikki, you're right in front of me. Yes, this is the easiest one. This is the easiest one. Okay. So here's your X rays. Yeah. So what do you think? So A P S and Natural of the Bright me? Um They demonstrate he's got stable fixation to screw consistent with previous ACL. Um Yeah, he's got a bit of patella baja maybe. Yeah, joint space narrowing on the medial aspect of the joint with some subchondral sclerosis. Not too much in the way of osteophytes. Um Yeah, good, good. So, on all of these cases, guys, I'm going to just, we're just going to assume the history and examination part, you know, but for your exams obviously talk about the history and um and examination. So do you know what type of A C O reconstruction that is? No, so it's a transtibial. So this thing's, this is arthrex, these things called a trans fix. Uh Basically that pin in the femur, uh, kind of suspends the graft on it. Uh And then you've got your sort of standard interference screw in the tibia. And you've also put a staple on here as well. So, okay. So what do you want to do with them? You've seen them in the clinic? You've done the history examination? Um, and I, he's got pain. Yeah. Um, well, an examination wise raft is intact and there's no a suggestion that there is a soft tissue, new soft tissue injury or anything like that. That would be, yeah, it seems to be pretty, it seems to be pretty solid, but you'd maybe like to know for sure. Um, so I'd examine him. Yeah. And then do, uh, um, and then possibly get, get some more imaging. Yeah. So what you want to do and it's probably an MRI. Yeah. So we did that as well. I do a long legs as well. Try and do long leg for most complex patient's uh MRI scan. So basically it should, we had not much cartilage on his medial side and this doesn't project well at all. But I think that's his graft going. Can you see my point on the screen? Okay. Well, I think it's basically his graph was intact on the MRI scan. So, what do you want to do with him now? Is desperate to have something done about it. Um, so, and does the MRI show that he's got try compatible disease? Or is it just, just the medial medial? So, well, Luke's just presented a very nice uh set for evidence on the arguments for and against the treatments for media. A so I suppose his options are high tibial osteotomy or, you know, economy replacement, but given that he's had a previous ACL reconstruction, I'm not sure whether HDL is going to be appropriate. So probably you're looking at a unicorn baby replacement for him. Yeah, I think that's fair enough and I think, but I think it's fair enough to bring the H T O argument into it. Absolutely. I mean, one of the things um that you can do nowadays is an H T O and an ACL at the same time. Um, but I suppose the problem would be that you would have to take out his tibial fixation screw. And although in theory, it should probably be obsolete now, then you might worry that that might prejudice the reconstruction. I think so. Yeah, I think uh medial uni is fair enough. So, if you were going to do that, what sort of considerations would you have? Because, you know, if it's coming up for the surgical surgical day and you're thinking, well, am I gonna, what am I gonna, what I'm gonna need? Um So I would be so examination was I want to make sure that he's definitely like an appropriate candidate for immune constantly replacement. So, yeah, he doesn't have fixed flexion, you know, a significant fixed flexion deformity and that he's a good surgical candidate in that he's someone that's going to rehab well, and doesn't smoke and isn't. Yeah, all that's a given. So, and then on the day these, I suppose you're gonna, you want, you're gonna want to plan him. Um, well, because potentially if you run into inter operative complications such as fracture, etcetera and you've got the interference screw there, you might have to take that out. You might want to have things like bone, bone dowels may be on standby if, if, if the worst happens and you get a condo, a fracture and um you, you need to abandon ship, so to speak. So you might want to think about that and don't let everyone into our secret of what happened this week. How's it going to mention it? I was just thinking, yeah, that's tibial plateau fracture in the uni this week. Um Oh yeah, what I'm getting at is I think you're right. You hinted that if you think if you look at his tibia and think about where tibial tray for a uni needs to sit, you know, and how much bone you need to cut, then you're going to be worried about that screw, aren't you? So what, what would you do if you came into contact with it? Can I take it out? Yeah, that was my plan. I was just, I was, I was just, you got two options. Really? I mean, one is two, you can back it back out a bit. It's quite deep so you could back it out a bit. Um, just to give you some room to get your tibia in. Um, and sometimes in these sorts of cases, I mean, in the worst case scenario it's not ideal but you can actually just get on my dis wrecks and remove any metal that, that is there. But obviously you end up with quite a lot of metal in the joint or you could just take it out completely and hope for the best. I mean, he's got a staple there. So um it's probably gonna be okay. So, um and that's pretty much what we did and that was actually a robotic one as well and, and, and the, the beauty of the robotic side and that was I could choose a tibial reception depth. So, uh and then I could balance out any imbalance through the, through the femur. Whereas when you're doing an instrumented, you know, you're kind of bound to um essentially four typical resections and two types of, of femoral resection. Good. Um Does anyone want to volunteer for the next one? Yeah. Sure. Okay. So a month. Thank you. Uh So six years old, fracture, lateral condyle, severe osteoporosis. Okay. Um Picked up by a colleague. That's your original X ray. Um and there's your original CT scan. So it's basically a mess, isn't it? Uh You know, she's got a condo, a fracture. She's gotta kinda, um, hoffa type element to it as well. And it's very communicated. Yeah. And so she was taken off and had this fixation done. So, basically what they tried to do is to fix it all from a sort of anterolateral type plate. So, she comes back to clinic and she's not doing well at all. She's got very little movement in the knee, um, maybe 30 to 60 degrees. Um, you can see here that the caught this part of the condo hasn't healed at all and this is actually blocking flexion. Yeah. And then can you see the other problem that she has? Oh, yes, I can. Yeah. Patellas way off her patellas off the site. Okay. So, yeah. How long after surgery is this now? So this is about four or five months or so. So, basically you've got this woman who can't walk. She's got currently subluxed patella. She's got a very poor range of motion and her legs and quite extreme valgus. Mhm. What do you reckon? What, what your options? So, so obviously there'll be non operative, inoperative options. Non operative consuming she's fit and healthy. I would probably opt against. Yeah, she's desperate to have something done about it. Yeah. So operative options. I think the, the only option she has really is a total knee replacement and you will have to uh plan for a complex, I suppose this would be a complex primary uh it's not. Yeah. Uh So, um, she's collapsed into valgus because of the fracture. Um Patella is uh I'm al tracking and it's, I would assume it's chronically maltreat act and it's probably been stuck there. Absolutely. I see on the CT. So this, so that, so this is sort of a, so she will, I would plan for the highest constraint possible she would need, uh, she'd likely need a rotating hinge prosthesis with stems. Um, she would possibly need augments or well, her feet, the motor fixation, she's zone one is gone. Zone to maybe she might, she might have some bone stock on the medial aspect or they're looking at the CT scan, the bone stock looks pretty poor. Um So there are, there is, there are concerns about whether I'll get a secure fixation in zone two. Uh So, uh bulk of my, uh bulk of my fixation is going to be in the diagnosis. Um There's also a higher risk that, uh, you know, uh extensive mechanism, uh maybe ruptured as a result of this surgery because they'll be already quite a lot of strain on the tibial tuberosity because of a, the current state of uh extensive mechanism. So, so sounds fair enough. So you probably just say, right, let's, we might not get the greatest result, but let's go for a highly constrained needed, basically. Correct. And you said the right reasons for that because actually her, her valgus was so bad. That the MCO was pretty much incompetent. But also this patella was stuck. I was actually stuck to the to the side of the femur essentially had to be completely um release and big sign of ectomy and everything else. So, um that's actually is what we did. Um And yes, she was happy with it actually. Yeah. So once you did a big sign of ectomy, a big release uh brought the patella back, which came back nicely. Thankfully, um a bit kind of squeaky bum time about the osteoporosis because her bones were like ghost basically. And as you can see on the image on the on the left, she actually had an intraoperative fracture and, and it literally it was pushing the implant and it just crunched down. Um But if you look at the image on the right that healed over time and it's not the ideal situation to be put in a hinged knee in a, in a 60 year old. But I think, you know, you're right, you went through the things and it's what, how do you get a weight bearing? How did you get her moving it? And she's pretty low demand and she understood everything rather than trying to go back and somehow couple couple things back together. So I think you consider cemented implant for this, for this patient or I do sometimes consider cemented hinges for those patient's with that are osteoporotic. Yeah, I do. Yeah. OK. Um To do. I think we'll miss this one out and go on to the next one just very quick that, so that was her X rays. She's, she's had a G C T curated out before and she comes with quite severe um knee arthritis, basically. Um And she was sort of told the last time she was seen it Stanmore. Look, next time we see you, it'll be a distal femoral replacement. So, um actually, and again, this is where the robotic devices are useful was able to do a Corey knee and her, that was her pre op tracing and then you balance up her gaps and that was her POSTOP X ray. So some of that is actually cemented into cement but it seemed to work okay. Um Okay. Um and I'm gonna also skip through this one because I want to get to the good ones who's coming up for their exams. So these are quite collects rays. So you had previous tibial mail unions, a tibial and female male unions. Uh seniority wise will be uh pretty myself. Ok. Crazy and may as well. Hello? Sorry. I'm trying to use the hospital accommodation, internet. So I'm sorry if it keeps cutting out. Okay. Uh So you've got this one, here's 84 year old man, progressive pain and decreased function in his left knee. He had a left total knee 12 years ago. Yeah. So here's his X rays. Um What do you think? Okay. So what I can see is an ap and lateral radiograph, um, of a left total knee replacement. Um, it looks like, so it's not an implant that I'm necessarily familiar with. I don't think looking at that, it's called the natural knee and it was made similar, it's not made any more fine. Okay. Um, but it looks like, um, looking at it, it looks like there's a little bit of licence going on underneath the tibial uh portion of the implant in particular. Um And it looks like I'm sorry, I'm just trying to zoom in on my phone as well to see if I can see anything else. No, no, it's just, it's quite a lot of license you probably. Yeah. So, so basically, particularly around the tibia, there is also some license around the femoral component, but the majority of it that I can see on my phone anyway, seems to be around the tibial component in particular. Um So that seems to be the main abnormality that I can see. Yeah, brilliant. So what you want to do, first of all, so obviously, first want to take a good history and examination patient. I'd want to do some blood tests, look for any signs of infection. Um So obviously a CRP white cell count, et cetera. Um And I would then also want to get some further imaging for this patient. Um So I could request to get a uh either nuclear medicine white scan based um imaging so that I can look for any signs of infection around the implant, or I could even look at getting a CT scan to assess the bone stock a little bit better around the implant as well. Um So those things would help me then decide on kind of my next course of Axion. Okay. Uh So looking at this, you can see that there is significant loss of bone stock around the implant, significant license. Um and therefore the implant itself. Um You would imagine a that you're going to struggle because you don't have much bone stock to work with for any revision procedures. Um But also um have we ruled out infection? Sorry if we said that we've ruled out infection? Yeah, that was on your blood. Yeah. Okay, perfect. So um yeah, so now that we know that we're not dealing with an infection here, we need to discuss with him the pros and cons of obviously revising this knee looking at him as a suitable operative candidate. Um And I'm guessing I might have missed. You said he was 84. Is that right? Is 84? But he's okay dated for fine, you know, he's normally mobile, but this is the thing that's holding him back. So yeah, I think we can assume that we want to revise this. Yeah. So given the fact that we know that we're not dealing with an infection, we're hoping to just do a revision in one sitting for him. So a single stage revision in this case, um but we need to decide exactly what kind of implant we're going to use given the fact that we do have particularly poor bone stock around the tibial component. Um I'm actually hoping that the components will probably come out quite easily given that. Um So that shouldn't be too much of an issue. Um But then it is, I'm, in this case, we're going to have to look for something that stemmed to increase the constraint, given the fact that we can't really rely on that kind of uh proximal bone stock that we have. Um So I'm just trying to think what, what could be a suitable something stemmed like a either a stemmed implant or even. Well, I think it is still normal is a bit extreme for this because the femur itself looks reasonable. So I'm not, I'm not really sure what else we could consider. Given the implant. That's okay. So let's, so it's good to have a number of plans when you're, I think the femur we can assume is fine, you know, because it looks fine forward revision. Yeah, in terms of the tibial side. So your first up you want to, yeah, like you said, you take that tibia out and then yes, something stemmed. Absolutely. Um What else might you want to do on the tibia as well as have a stem going down it? So you may also need bone graft. Um you know, some sort of to help supplement your implant. Uh what else could be consider. So, bone graft stemmed implant, um something that uh what else trying to think you could do to sort of augment your fixation. So obviously, if you're going to put a stem down, either it will be a cement lis stem that fits fixes this delay or will be a cemented one. That's so I would probably use a cemented stem in this case. Um just given the bone stock in particular, but also his age, et cetera. So uh probably a long cemented stem with kind of the augmentation of bone graft. Okay. Anything else you can use to augment it other than cement and bone graft? Because you're asking a lot if you put a long cemented stem down and you get that area of about five centimeters below the joint line, which is basically almost avoid of bone. Is there anything else that you can put in that area? That zone? Um Yeah, so I think you can get, oh, I forgot what they're called now, but I think you can get kind of implant, augments as well. So kind of something that is I I've forgotten the name of them now, but they're obvious like a metal implant or am or I can't remember what they're made of now, but in terms of an augment that will actually fill that void or that defects you're not relying solely on the graft. Yeah, it's just to try and give it because obviously hopefully you're going to have a flat surface for your prosthesis to sit on and hopefully you're going to have some sort of fixation distantly whether that's cement or, or not. Uh, and then you've got that area in between what would be really nice just to augment it and, and bone graft it. So, um, yeah, I mean, you can, there are a whole number of things, but generally speaking, sleeves and cones are the things that we kind of we talked about. So I think, yeah, so um you can see here that essentially um we've put this sleeve in there. This is made by link and it's called a trabecular. Actually, it's called a Colon Tribeca lint cone. And it's kind of it just covered with like hydroxy like like is it like an integrative? Yeah, it's like great blasted. Um And essentially what you do with these is you can um sort of uh squeeze them, squeeze, squeeze them to make them a little bit smaller, fit them into the top of the canal and then release it and then it expands slightly. Okay. So, um and then yeah, like you said, I went for cement with him because he's I went old and frail and um you know, you worry about sort of blasting open the rest of his tibia during a revision and you can see it a bit of a blow out at the back here. Um, but actually watched him over time and that, yeah, I think that kind of started to reconstitute basically. Um, so, yeah, that's, that's quite tricky when that implant. We get a few of them around where we are because some of the surgeons used to use them and it always tends to be around about a 12 year mark. If they feel like that, it tends to be around the 12 year mark and a lot of them bad license. Do you think there is an argument? Sorry, then for these particular plants to watch them a bit more closely because I know often now arthroplasty surgeons discharge their patient say at the one year mark. So do you think that with particular implants where we know that there is a higher risk of Austral icis or particularly the younger patient that we maybe should be watching them, kind of at the five or 10 year mark to look for these in advance, you're not left with this kind of case where you've got kind of extreme Austral Icis and then you're dealing with adjuncts and augments to try and revise these knees. Um I mean, I think in an ideal world that would be good, but we just got too many patient's, don't we? So I think if there's an implant that you've got concerns about, then it's probably worthwhile. I mean, if I see these guys and they've got any problems. I do tend to keep an eye on them because the license for whatever reason from that particular implant is just so profound. Yeah. So, yeah, do to turn to keep an eye on them, right. We got a few. Thanks. Thanks. Have you got a few minutes for the last one? Because it's um g I think you said you're coming up for your exam. Uh Yeah. Well, we've got, yeah, who else have we got? We've got Rachel as well. Okay, Rachel. If not, I'm more than, do you want to do it, Rachel? Yes, I think if my, my one will work. Yeah. Okay. So we've got this guy 76 years old, previous knee replacement, 14 years ago, progressive pain and decreased function otherwise. Well, he's an ex royal marine. So he's pretty hard. And, um, but he's struggling basically. And these are his X rays. Um, directors ap and lateral radiographs of a, right and demonstrate a rectal knee replacement in situ, um, suspended. Um, there is a bit of license possibly under that medial tibial plateau, but actually, overall it doesn't look too bad. Um, to be, uh, he said he's struggling quite a lot. So I'd be wanting to just find out a little bit more about him from in terms of how he's struggling, what problems he's having, want to find out a little bit. But when the operation was done, if he had any problems with wound healing and whether we're looking at any sort of infection I'm with him. Uh, and then we wanted to get some more imaging. Yeah, that's good. Um, so, otherwise, yeah, he's pretty, he's pretty healthy, um, blood to normal. Um, so, yeah, what sort of imaging would you want to do? I think pretty went through all really nicely, sort of ct looking at your bone stuff. But you could look at sort of nuclear medicine imaging to see whether there's anything particularly that's lighting it. Um Yeah. Yeah. Yeah. So those ones I don't tend to see to everybody, I think, you know, in the ones which is so obvious and I'm thinking about the operation, then CT is useful, but his is a bit more subtle, isn't it? So you can see on this, it does light up especially immediately on the tibia a little bit laterally as well. So, um he's pretty keen for you to do something about it. So what, what, what could you offer him? Uh uh I could offer him a revision. So if, if it, his bloods are normal, um I'd probably still have quite a low threshold to aspirate this in theater just to make sure that we're not dealing with any underlying infection in this at the 14 years down the line, acceptably also very reasonable. Uh in terms of revising it, it's uh hopefully not gonna be quite so complex as the last one. Uh We wanted to have options there. Well, yeah, because you never really know. You're absolutely right. Yeah. Absolutely. Right. And actually I was thinking, um, that we didn't used to say it when I did my exam, but when you guys are doing your exam, probably what a really good thing is just to add in a, discuss them in the M D T meeting because you get Bernie points for that, I guess so. I think, yeah, you're absolutely right. Bloods are normal. You've done a bone scan, you've evaluated him clinically. Um, you've discussed them in the M D T meeting and, um, yeah, you can aspirate it if you want. Absolutely. There's nothing wrong with that. Um, so you can aspirated it. Um, and then you're going to do a single stage revision. Yeah. Yeah. Okay. So he has a single stage revision. Here we go. Looks all right, I think. Um, but it comes back a year later or so and he's pretty miserable. This guy, he's never, just never really done that. Well, his leg's always, his knees always been swollen. It's not been red or hot and then it's just always been swollen. Um, he's always kind of complained of pain and he just has a real troubling time with this. Um, can you see anything on that? Just say if you can't because I didn't, um, my eyes kind of drawn to that media, femoral condyle, but I can't really. Yeah. Yeah. Absolutely. Well, that's, that's a really good spot. No, no, there's something, there's something that we're going to the next one. So, six months later, anything definitely looks like there's something almost looks like there's a bit of, sort of license around the medial condo, doesn't there? What about the stem and the femur if we go back to the original? Mm. So, that's the original. Yeah. Well, so it's moved position slightly, isn't it? It's gone into a bit of flexion. Well, it's, if you look on the AP view, it's just tilting in a bit, isn't it towards the medial cortex? Okay. What about this? Yeah. And then you can see more clearly there. It's definitely upsetting video cortex, isn't it? Yeah. And even you've got periosteal reaction developing on the, on the periosteal surface. So um so basically this guy's in this situation is blood's have CRP of about 30 odd and an esr of raised as well. So what do you want to do with him now? So I want to uh I want to ask about his name. So if we can um culture anything um be liaising with a bone infection MDT, make sure they've got the appropriate people involved in this as well, but be considering a revision then to a longer stemmed implant, um accepting that that might then further re revision might involve having to use a hinge system rather than just this sort of stem system. Um And obviously antibiotics appropriate if we weren't able to um culture anything on an aspirin and we want to treat this as a two stage revisions taking over the night. Okay. So you, you do the aspiration. Um It comes back as staff epidermal, this sensitive staph epidermis dis um he's discussed in the infection in G T meeting and the, the microbiologist thinks it might be a contaminant. So, what would you do next? Um I think if the microbiologist feels that it is a contaminant, then I would be treating this as a, as a two stage revision rather than a single stage revision. Um Anything simple that you could do to try and be sure or two separate. All right. What's what? Hello? Not sure you could. Well, you could um I mean, the classic kind of teaching is you can repeat the aspiration, but actually what I think most units do now and certainly what we did was go and do an arthroscopy basically and get loads of samples. Um So in this case anyway, he did, we did do that and he had six samples of Synovium and a fluid sample funnily enough. The fluid sample was the only one that grew the staph epidermis this again. Um So yeah, so you got a sensitive low virulence organism. Um And you're discussing it in the M D T. What kind of revision do you think you'd want to do? Um So I think the Staph Epidermidis ones can be put difficult to treat because they form that really thick biofilm and, and so I probably even still be considering treating this as a two stage revision in him rather than a single stage. Yeah. Okay. Um, I wish I had as well. Uh, we decided to a single stage but what would be the problems about doing a two stage in this situation? So, doing a attestation that, I mean, obviously he's got significant sort of stemmed implants in. There's, there's already a revision knee and you're looking at quite a lot of bone loss and having a suitable space or something to put in there, then everything contracting up afterwards and score ing up and the, then going in for the second stage is pretty miserable. Yeah. What, what would you put in temporarily? Um I'd probably consider putting in a loosely cemented knee replacement possibly. Uh So that's, that's mm, not sure. Discuss it in my M D D. It's a really tricky one because, and that was one of the factors towards going towards single stage because the problem here is that really, as you say, once you knock out that tibia, you can have quite a lot of bone loss and you've already got quite a big gap if you think if you look at the x rays and think about what, what a big gap you've got once you remove the implants. So really, you're looking at either using another implant as a spacer in which case you're probably going to have to go again to another revision implants are still an awful lot of metal and I do use um normal implants for spacers, but um using so much metal and not, not necessarily so sure about the other option. Actually, that is becoming a bit more common is to use a fusion nail as a spacer. Um You know, that can obviously uh traverse quite a big gap that rest is soft tissues and, you know, you, you sort of wrap it in cement and it was a stimulant in or whatever and treat him with his antibiotics. So, but anyway, we chose to do a single stage and managed to get everything out. And his um tibia basically turned into like a Schatz care 50. And uh but we managed to reconstruct and actually get his, treat him for six weeks of anti politics. Good as CRP down. And I thought I'd cracked it. I thought I've done it, but he comes back not long after his antibiotics have stopped and uh his, his infections record. So he ended up with an epiphany out with an amputation, um which is just a bit of a bummer, but that's, you know, the ultimate kind of endpoint often of um of infected revision knee surgery. So I think I've probably gone on long enough. Is that all right questions? Yes. Can I, can I just ask a question about my case? The one with the chronically dislocated Patella. Yes. Yes. How did the extensive mechanism behave during the case? And did you, did you, I can't remember if you reserved research. I think it did resurface it. Yeah. Um, please ignore all the banging in the background. I'm home alone and 11 month old Springer spaniels going absolutely nuts next door. I think it's going to wreck the house. Um, so, uh, yeah. No, I think what we have to do is if you know, when you do a revision and basically you do a full on sign of ectomy and you take out everything and you release everything and a really big lateral release. Um And then actually, you know, if you get your implants in the right place, then we managed to get there the tele back over and resurfaced it. So, so that was, yeah, it was, it was fine. Maybe lucky. I don't know, but she did. All right. Yeah, Mr Parrot, can I just ask quickly? So, yeah, if you've already done a single stage revision, was it that there wasn't enough bone stock to then do another two stage after or was it that the patient was a bit fed up or was it more your recommendation as to further revision surgery versus they, uh you know, amputation that he's had? So, yeah. No, absolutely. Really good question. And, and actually one that just highlights um that all of these things are multifactorial. That's why, you know, in your exams, you have to do that whole rigmarole of or there are patient factors and implant factors, whatever else. Um He, you speak to your patient's and, you know, he was keen, he was happy to give it one more go. But I was under no illusion that if he, if it failed that he wanted an amputation, you know, he, he felt that he'd sort of wasted enough time in his life with this problem um in terms of the technicalities. Yeah, I mean, we have a knee infection MDT that we run across Cortisone Ipswich. And yeah, microbiologist was saying we could, we tend to take it from the mic. Uh is he dropped off for anyone else or is that just a week? It might be me. Um And so we, we just went for that and actually what I had was um both distal femoral replacement and proximal tibial replacements on standby just in case we have to go really big. Um But yeah, we weren't keen on, I wasn't keen on being in the situation of having a completely shattered tibia and then trying to, you know, temporarily um span the joint with, with something I just, I don't, I don't think it would have been achievable to be honest. Yeah, just no worries. Uh Sorry, Christie, that was the other thing for that other case of yours was um to have a proximal tibial replacement on standby. So, uh just, you know, it's good to you know, know how to do end up prosthetic replacement or, or at least have someone in the department that can, sorry, boss. One more question for a couple of questions for this last case. I mean, from, from a learning perspective for someone who comes in with a painful knee, um you know, and you know, with the initial x rays that uh the initial X ray that H will have to look at it, didn't look like much, maybe a bit of license. Um The medial tibial plateau area. Uh would you, would you just consider just going straight for an arthroscopy and get rather than just relying on the, on the, on the aspiration alone? And would you also? Yeah. Yeah. Well, we've, we've actually decided to make that standard uh standard practice in our department. Yeah. And also would you consider getting a pet CT because you can look at it's a type of scan that I assume you can look at the structure of the, of the knee and any bone loss as well as any increased sort of white cell activity going on as well. Um Yeah, I mean, we were increasingly using spect um but I think it's more in those cases where you're just not sure. Um And in this particular case, it's just, it was as simple as he's got a septic loosening and sometimes it's obvious and other times you're, you know, you're a bit concerned about whether it's infected or not or, you know, so, you know, something with a patient but, um, I think if it's cut and dried, uh, then you don't need to go crazy on the imaging. I mean, I think probably what I mean, I could fairly low. It has to, you have to bear in mind that a lot of revision needs are not happy, you know. Um, and definitely, uh, if it's someone like him, um, I probably try and get you all them on a bit, you know, trying to just keep them, keep them on with that with that knee and keep an eye on it. Um Yeah, yeah, you, you learn to experience. Yeah, thank you very much. Okay. No other questions in the messages. Um Just a quick one on Sino for sure for the, this whole European. So uh we talk a lot about this whole European joint infection criteria that's just come out for the F R C s. But then does it actually help with its including sign of a show and polymorph um differentiation differentiation? I can never say that differentials. Um Look, I think the thing with C novasure or alpha defenses or whatever else um is that it's not the sort of holy grail, you know, it's not, it's not, they'd still need to find a better test if that makes sense. Um I, I, I think the best answer to that is that if you're, if you're worried about infection, then get a bug basically, you know, do the scopes do this. I know, uh, that synovial biopsies, you know, trying your hardest to get to get a bug. Um, and often in cases where you maybe don't get a bug but your clinical suspicion is that it's infected. Um, do the two stage basically. Um, I actually don't use sign of Absher really ever because I just, I'm just not, I think some guys like to use it to show that it's negative if that makes sense. Um But I guess the counter to that is, well, if you're planning, if you're doing a single state revision, you do assign overtired and it's positive. But you know what, what do you do because, you know, do you just then do a single state, do you do a single stage or do you do your first stage? And the problem about actually almost both of them is that you don't know what buck you're dealing with. So, yeah, I think it's a decent, um it's a decent addition to what you've got. But just the key thing is always actually to try and get a bug and get the right advice. Micro biologically. I was actually reading that. I think maybe polymorphonuclear nuclear sites, whatever they are possibly better and cheaper. Thank you very much. And remember also that now there are other ways of culturing you. We have broth cultures and we send samples away for, you know, bacterial D N a PCR and all these sorts of things as well. So it's sort of, uh, sort of in the best position ever has been in towards actually getting a bug and you do sometimes get some weird and wonderful ones. Okay, thank you. Okay. No further. Sorry, I've gone on quite a bit but I'll come back on later, later on to, um, to listen to Frank's talks. If anyone's got any questions, um, that I think of, you know about any of this stuff then, uh Yeah, I'll be back on then and um, as some of you might know we do, right. Uh Can you hear me? Yeah. Yeah. Yeah, we run a complex clinic and culture stuff for knees every two months. So, especially if you're coming up to your exams. Just give us a, uh, just get in touch and you're more than welcome to come. Great. Actually, uh Mr Frank Foley is on the line. Mr Foley. Are you able to share your slides and C test the I T side? And we can, in the meantime, we can, it says it's viewer only Frank you? Okay?