Dr. Adam Rothenberg performs live surgery using RI.HIP NAVIGATION through a direct anterior (DA) approach. POLAR 3 total hip solution with Smith+Nephew’s proprietary OXINIUM (Oxidized Zirconium) is featured.
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www.real-intelligence.com. unique to this situation with our right hip placement. You have to place the general ray on the thigh. That's painless. And so we abduct the legs positioning on the table and then prep the leg circumferential. E including the media and post your thigh. That sterile Koven and plate can be applied prior to application of the grapes. We are with the leg abducted. We placed a sterile drape and to prevent any contamination. I'm able to put the yeah stds and leave them in place. But my circulators prepped circumferential. E you didn't wrap a sterile carbon around the distal thigh to provide some a stable base for the plate. I usually position a little bit medial so that the patella doesn't make it ride. It makes it more stable. Just really want this to be secure so that you have the leg length and the the offset measurements accurately. So we use a standard shower curtain drape, well impervious drapes underneath it. Ah I've expanded my field to include the pelvis here so that we can have access for the pens. This patient has right hip osteoarthritis. He's 73 year old male. Um It's fairly routine. Uh I template in pre operatively and saw that he was six short on this operative side. Um It's pretty imperceptible for him that shortness but discuss that in the pre op area in the clinic. Um Generally to see if we want to link to them by a certain number of millimeters based on if they're symptomatic or not. I believe it's an 8° posterior tilt to the pelvis. Okay so we cut through and then we have a sterile drape here, you know the stereo base plate. So now we'll place the I don't know if it's I have not, I'm not certain if this is important, but I always keep the orientation the same for consistency with the tea, the bottom part of the T facing the foot. And then online this array, make sure it's well secured and the balls are tight here for pelvic pin fixation. We use a 40 pelvic pen um we'll know right away if that's not gonna work for this patient. There is a minimum distance between the two points that's well secured, its rotational is stable, it's not going anywhere here. And then that enhances visibility for the camera system. Have this tea there, we measure the distance from the Lester on the trauma cat and then we let's double check it here, market out. Okay, so now we're gonna um place this retractor over the tensor. Oh, so that's going around the trophy, then we'll internally rotate the hip and so here we can see the fastest here, here's the femoral neck. Here's capsule here, poster capsule abductors are behind me tensors here, so we want to get as far lateral as we can to place this checkpoint to be accurate. And so does that feel about maximal internal for you. Okay. And so there's usually a bear area here. So I'm I'm going behind in front of the media's here and then I just kind of push the tensor down and we'll get that far right here. And I like to tag it just so we know especially people with a lot of fat or muscle where to go. So now we'll put the arrays back on a little bit of artistry here from taylor, trying to work around the retractors, want the leg to be in a neutral position, and now we've got a blue and all the pelvis ephemeral and appoint pro Berets. So click that button before it on the screen, mm hmm for the corkscrew and the thermal head and neck, and then Go ahead and come out with this one Taylor. So we want to map the articular cartilage. This patient doesn't have a tremendous amount of Austin fights in some situations where there's lots of austin fight build up or uh you might want to remove those as part of the technique, but the goal is to get a good uh cone our sphere, I guess from the articular surface here. So now I'm gonna depress the the button here, and then I'm gonna take points around the periphery, just like the image shows. So I'm just trying to map this existing as tabular a portion. It's that quick. Now we're going to come down and mapped the media wall here. So again, I click that, and then I want to make this kind of circles to get a foundation and a base of how far medial we are so we can get our numbers on offset and there it went, it went through I think I template to 54. I usually shoot for four over the native asked tabular size. And so This is saying 51. So we're definitely in the ballpark here. This is a 51. Remember this traditional raining here. Get the hospital fights. Get a sense for size to make sure everything is what we wanted to be. Before we get our final rumor in. It looks like and go a little deeper here. Mm hmm. I'll remove one under. For most cases I would say 2/3 or three quarters of cases. But for a good solid bone, a lot of resistance. I'll go line to line here. The hip. Seven software is right. The monitor's right in front of me so I can see my template. So this is our offset insert. Er there's a offset and a straight insert er option with the arrays here. I like the offset for my approach. I generally place the opening for the liner for removal tool here at the corner of this insert. Er so they're in line That way my screw positions are in the right orientation and then enhances visualization of the uh of the liner. If I need to remove it during the case during any future date. So now it's visualizing the pelvis. We have eight degree post your tilt and then I'm gonna bring the cup in here. Yeah, I made for a second 1st. I'm just clearing out some soft tissue and then I try to put it where I I think I want it based on anatomy and positioning and where I'm used to seeing in relationship to the thigh. And then I then come to the screen here. We've got this patient two numbers. The left is the essentially the anterior pelvic plain, which is kind of our standard reference point and then the right is the functional plane which is a corrected number based on his posterior pelvic tilt. Um And so Here we've got an inclination of 46 and 47. You can see there's a difference in the and a version based on pelvic tilts, it doesn't affect inclination nearly as much. So I shoot for 40 20 overall. And when they have large post here tilts ah I think we don't we're not 100% certain whether we should be correcting tilt, either spinal tilts. And so there's a little bit yet to be decided upon. But here I've got a confident that I'm in a safe zone because I'm at between 40 and 42 on my inclination and uh Unsorrected 13 and 19. Got it. So I just want to double check this because it's it's always it's been accurate in my hands. But I just want to make sure am I an inverted enough under an inverted. Just always good to go back to the foundation of how you train and just check that out. This Ashtabula is covered here. It's pretty in line with the T A. L. And I'm at 38 and 18. So with the post your pelvic tilt, I choose to generally picked the functional pelvic playing for these patients. And so I'm going to yeah, just give it a little bit more. Okay, I typically my workflow, I'll put a screw in now and then we'll just get a C arm shots are just confirmed depth and final positioning here. I have a depth gauge this time. 35 I think for you know, I use Crm to confirm cup positioning. I would have taken multiple shots here today to get a perfect view to get my inclination and version where I want it. And I've skipped that step here because I trusted that this these numbers have been reproducible for me. Okay, so g we'll get a shot here. Please predict the airplane out. Yeah, you can come back towards you a little bit a little bit more towards you. Okay, you see where we're at. So here we said we were 40 and 20 on the functional plane 41 and 50, you know, 13 or if there's something like that in 39-13 on the an atomic plane. I think, you know, I you could we could tweak this image to get a perfect reproduction of his pre operative standing view. But this is pretty darn close in my mind, this is enough information to move on, screw placement is good. Depth is good. Cup height is good. It looks like my template. And so I'm gonna go ahead and put a neutral liner here. One question I get asked a lot is can you eliminate c arm? I think you I think there's a the comfort level you're gonna have to get to in a combination with what you see anatomically and then what numbers you're getting with the system. I do like making sure that I don't have any surprises. The whole point of the technology that we use is to eliminate outliers. And uh for this, I just I like to make sure my depth is good is right where I want it to be. And I like to check my screws. So ah based on placing that cup in alignment with where you were screws easily placed here. And then we have our liner removal tool right visible. So if you ever have to top it off, exchange to a collateralized liner. If you're, you know, coming back in that unfortunate situation, it's easy to access. I'm gonna start my approach. So I I used the double offset instruments for polar. It's been nice for I think kind of a game changer for access for me. Um Roger please. Yeah. Uh really easy. We've got this space over here. That's not in our way even you could even for those of you that want to use us single offset or straight. Um I don't know why you're, you know, doing that. But you know, if you if you like to do that, ah you can do that with this system since that arrays movable. We had a five. Yeah. Mhm. Uh huh. You go 345. I see the saw please. Mm hmm. It's going to get a little bit lateral here. Mhm. Did we get him? No, hopefully not? Okay, sorry, dr Newman, I like that for looks good, occasionally stable. Right where we want it right on our neck cut. So we'll see where we're at was the standard zero or minus one of them. I didn't minus, I can't remember minus. Yeah, so we temple did a five standard stem And a 54 cup. You come up nelson, I just put a four standard in and felt that that was stable uh when go ahead. So uh obviously I'll undersize if I think I'm between sizes, Nelson is doing a stability test. So he'll take the leg to 60° of external rotation and drop the leg. You wanna do that one more time nelson. And here she's he's stable all the way to the bottom there and then I'll usually test stability and neutral. I'd say I've got a little bit more Black City. I'd probably go back to a zero on based on the field. So we're right, basically on template. The Four standard with the -3 head was what we did. The five standard for templates. So now we'll take the point probe. Um I think one of the feasibility checks you want to do is you want the leg to be back in the same position as when you started, which is what we have here. So uh just making sure that the all the system has been stable throughout. Just double check. Everything here is rotational is stable, this is rotational is stable. And do the numbers make sense to you and I would say, yeah, I felt like there was maybe a little bit chuck but maybe I was just a little short so now we can dial in the implant positioning to try to adjust for length and offset. We'll see how this looks. It went, the stem went right back to where it was before. Check stability again, it feels good. Check attention. I like that. And then point probe please. Zero and zero. I think I'm going to do plus four final. Yeah, I think that's nice. That'll be two and 2. He started out six. Maybe, you know, give a little bit more attention. Keep that Vegas there and it's got really good bones. So let's do that. That's what the numbers are dictating and we have the option. So let's do it. Mhm. Yeah. Plus four to me. That's that right where I wanted it. I've got the H. A. Coding right at the right at the level of the Asiata me right above it. It might have sat down a millimeter or two. I like the 00. If I get the two plus two plus two, I'm happy. Yeah. Okay. We'll reduce Stability one more time. Good there that point probe. Oh got it. There we go. So it sat up just a touch. And I, you know, we We started we were six shorter. You can see that there is some play. If you move this around a little bit, you might get a millimeter here and there. Uh But I tried to put it right back where I started. I think that's I mean I'm I'm happy about that. Mm hmm. Mhm. And so we will remove the checkpoint at this point that's out cerebellum. So now we'll just check bleeding and get the wound closed.