Die Arthrex iBalance-Produktfamilie bietet hervorragende Lösungen für die patellofemorale, mediale tibiofemorale und die laterale tibiofemorale Arthrose. Forschungen zeigen, dass bei nahezu der Hälfte aller Patienten mit Knieschmerzen röntgenologisch eine unikompartimentelle Arthrose vorliegt.1 Dies zeigt, dass konservativere Endoprothetiklösungen wie jene im iBalance-System für Patienten mit Veränderungen an einem Kompartiment eine Alternative zu Totalendoprothesen sein könnten.
Referenz
1. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow MM. The radiologic prevalence of patellofemoral osteoarthritis. Clin Orthop Relat Res. 2002;(402):206-212. doi:10.1097/00003086-200209000-00020

Arthroplasty Knee

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Das iBalance PFJ-System ist eine endoprothetische Komplettlösung für Patienten mit isolierter patellofemoraler Arthrose, posttraumatischer Arthrose oder anderen degenerativen Veränderungen. Das anatomisch geformte Low Profile-Trochleaimplantat des Systems, das in 4 verschiedenen Größen erhältlich ist, artikuliert mit einer runden Dom-Patella mit 3 Verankerungszapfen. Bei der iBalance PFJ-Instrumentenplattform wurde besonders Wert auf Einfachheit und Effizienz gelegt. Die Verwendung eines einzigen Instrumentensiebs senkt die Durchlaufzeiten sowie die Kosten für die Sterilisation und trägt dazu bei, die Positionier- und Reproduzierbarkeit der patellofemoralen Endoprothese sicherzustellen. Eine anteriore femorale Resektionslehre und Setzvorrichtung ermöglicht die präzise Präparation der Trochlea, sodass die Form mit der Unterseite des Implantats übereinstimmt.

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iBalance® Patellofemoral Joint Arthroplasty

The Arthrex iBalance FJ system is designed for the treatment of localized or diffuse arthritic changes in the patellofemoral compartment of the knee. The completely instrumented technique focuses on creating key reproducible transition zones, reliable rotational alignment, and suitable femoral resection every time. Patellar preparation may occur prior to or after femoral preparation, depending on surgical preference. A caliper is available to measure the thickness prior to and after resection. The size of patellar component is assessed, and lug holes are drilled to accommodate pegs on the domed patellar component. Soft tissues are elevated slightly using the blunt end of an extramedullary guide as it is inserted, ensuring it rests on the interior surface. A five millimeter Intramedullary hole is drilled, matching native flexion. The entry point should be at least 20mm posterior to the deepest aspect of the trochlea. The guide is removed. The side specific base is inserted into the intramedullary hole. Rotational alignment is established and a pin is placed medially. The cutting guide is attached. The level of resection is established by a single stylus representing the thickness of all size components, which minimizes the risk of overstuffing first at the depth of the trochlea, followed by the anterior aspect of the lateral condyle. This captured guide may be pinned into place and the resection is performed. The cutting guide and all alignment instrumentation is removed. Proper component size is established through size specific finishing guides. A proximal position stylus rests on the articular cartilage, defining proper proximal distal position. Proper size ensures the component will not overhang at the anterior lateral aspect of the component, as represented by the shape of the finishing guide. Headed pins secure the block into place. The stylus is removed. An optional pin may be placed posteriorly for added fixation. Reamers are used to create the radius of the trochlear component both distally and proximally. The radii created by the reamers are then extended using a series of guided osteotomy. Osteotomies are first used distally. They are then used proximally. A final osteotomy is used to create a clean up punch in the middle. These single use osteotomies are custom shaped and hollow ground, maximizing precision on both the medial and lateral sides of the trochlea. The finishing block is removed. Ephemeral trial is used to test establish proper transition zones. Transition. The trial is pinned laterally. A lug guide is positioned, then pinned medially, ensuring proper fixation. Three lug holes are drilled. Removal of the trial and lug guide may take place. An optional trial may be used or one can proceed with standard cementation.

Ned Amendola, MD, (Iowa City, IA) discusses and demonstrates the surgical technique for the iBalance® Patellofemoral Joint (PFJ) Arthroplasty System on a cadaveric specimen. The Arthrex® iBalance PFJ Arthroplasty System is a complete arthroplasty solution for patients with isolated patellofemoral joint osteoarthritis, post-traumatic arthrosis or other degenerative changes.

iBalance® PFJ with Arthrex 600 Power System

So I'm just using a, just a slightly medial longitudinal incision, as you can see here. So we just prepared this already just so leave a cuff on the patella so you can close this. It's a little bit more extensile than you would need in a regular situation, just so that we have a clear view for the surgery, but generally go up to the, the vastus and the just the medial edge of the patellar tendon just distally. And then you can obviously flex and extend the knee. And to work on the patella, you can extend the knee a little bit and invert the patella. And here we already usually do that. First you don't have to do it first. You can do the trochlea first. It's the same same idea. So this patella measured 23. And we use the same calipers. Made the cut in the patella and removed about nine millimeters. Made sure it was smooth. And we sized it to a 34 which is nine millimeters thick. It's the same sizes as the total knee implants. So they have four sizes of patella. So this restores back to the 2220 three millimeters. So you're not overstuffing the joint I think that's very important. I think if you want you can take an extra millimeter or so. But often you have a very eburnated patella, as you saw in some of those pictures that I showed. So you do have a very thin patella. And so in those cases, you obviously don't want to take too much patella and restore the anatomy. All right. So we're just going to put some retractors in here. We were mentioning these tend to be lateral subluxations. Are you adjusting your where you put the patella medial or lateral. No, I think I think in these cases, no, I think if they don't have gross instability or gross malalignment in terms of a Q angle, I tend to depend on, on just performing an anatomic reconstruction. And if you look at this implant, the Patellofemoral trochlear implant, it's it's got a rise of seven millimeters on the lateral side. And so that it protects against that subluxation. And then if I think that there's a little bit of excess lateral subluxation, I'll do a medial vastus medialis plication or advancement. I've been doing this for over 12 or 13 years, and I've never done an mpfl reconstruction with these these procedures. All right. So this is an intramedullary guide that we're using. So this just sits on top of the femur. And it's basically just to to give you some orientation where you need to put this intramedullary drill hole. And again this is it's a very important step. And if you can see here it's just above the the notch. It's about, you know, probably about a centimeter above the notch. But I just like to make this hole a little bit bigger than usual because you don't want to obviously extend and flex that. You want to get a the guide sitting flat where you want to make that anterior cut. So so this is the guide for the anterior cut. And you can use a number of of measures here. You know in terms of I usually just look at it directly where it's sitting, but it's it's supposed to be sitting on the epicondyle or line. And you know, you're basically looking where, where you want that to sit. And you can see that there's a little bit of play and rotation, but you know, it looks looks pretty good. So we're going to put the the pin in place here. [00:03:50] Let's go ahead Alex. I'm basically just looking from the front and making sure that this looks like it's sitting properly. And, you know, it's obviously going across the Piccadilly line. You can look at the condyles posteriorly and make sure that you're sitting in the right spot. So he's using the epicondyle or axis there. That internal external rotation is really you're focusing on where the patella is tracking. That's what that's going to set that. So so in terms of determining how much you're going to take off the front, obviously you don't want to you don't want to notch and you want to just take off the articular surface on the front. That makes it flush with the anterior femur. And here you can see the just this is a guide to to make the cut. You can see it's got the trochlear groove and then the lateral condyle. And this is what I had mentioned in my presentation about dysplastic trochlea. Sometimes you can't use the trochlear groove as a measure. So if you use this in the in the trochlear groove and you adjust this so that it's sitting flush with the trochlear groove, that takes about three millimeters of bone. 3.5mm of bone. And so if you have a normal trochlea and you have normal anatomy, that's how much you're going to take. If you have abnormal anatomy, you know, you might want to use a lateral condyle because the lateral condyle measure takes off seven millimeters of bone. So if you put that in here and you like both of those measures to match. So you can see here that the lateral one is touching the top of the lateral condyle. And the trochlear one is touching the, the the deepest part of the trochlea. So you like that to match. And obviously you want to take off just the, the amount of bone required to replace that. Now here's another measure. This is the angel wing. And I'm just going to hold that in place. So this kind of gives you an idea of where you're going to end up on the top of the femur. And you can see we're almost at the top and just looking at this. It just seems to me like we could be another millimeter lower. Okay. So we're just holding that in place. So that looks pretty good to me there. See there. So we have all those measures to help us decide how much we're going to take off the front. And, you know, this is really the most important part of the surgery is this anterior cut. And you obviously don't want to take too much. And but you want to take it just enough. For the sales guys in the room that stylus is designed to fit the implant. So it's unlikely that every single person's anatomy is going to fit the trochlear groove and the lateral condyle that's set up so that it fits the implant. So don't be surprised if you if in a in a case where the anatomy is abnormal that that doesn't fit. It's not because the stylus is broken. Yeah. I have a I just have a coworker. All right. Knife. All right, so there's. You see, our anterior cut. We haven't notched it at all, and it's flush with the femur. Okay. There's really just just the right amount of bone has been removed. So now we're going to obviously determine the the sizing. And this is just the same as the total knee implants. You saw the that anterior cutting block that was put on the total knee implant. So this is a size three. And you see here they have this trochlear guide in the middle. You want to sit in the middle. And so obviously we're sitting this on top, putting the trochlear guide down the trochlea. You can see that. Can you see that through the middle hole there. There's the trochlear guide. So again you want to try and restore anatomy. And it's sitting nicely in the middle. I don't have any concerns in terms of where it's rotating in terms of the size. I think this looks looks pretty good. So we're going to put a couple pins in. And I think you're all set from here on. So that was really the I think that's the the most difficult part of the surgery is to make sure that anterior cut, you're taking off the right amount of bone and everything is dependent on that. So we're just putting a lower pin in here. [00:09:07] Keep the drill. Pretty quick. So this is the reamer. So for the trochlea. So we're going from distal. And then from proximal. That's a new reamer it looks like there. Ned. Yeah. So this is. The old hole. Saw is changed out to match the total knee. Almost. It's probably getting dull. [00:09:50] You should just push down. It'll give it more pressure. This week. Okay. So this is the you know, this is a little device to kind of lock in for the osteotomies kind of these finishing cuts with the osteotomies you see there. So this just fits in in one direction. And then the Osteotomies you can see here have a matching line. You just kind of match up with the with the cut. Ned, can you talk a little bit about just your experience with competitors? Trochlea. I mean, they're not fully instrumented. Some of them are inlay there. I mean, what what separates this? Well, I think this is a very straightforward way to do it. And here's the osteotomy for the top. So the, you know, as you, as you outline the, like the Zimmer implant, it's basically just a reaming device. And it's a very similar implant, similar setup. But I think you get into the same problems in terms of sitting the implant correctly, where it's supposed to sit, and how much you ream off the bone. You know, they have little pegs to kind of sit the reamer the right depth. And so if you have any type of dysplasia with these other implants, it's very difficult to kind of set up the the reamer to cut the right amount of bone. These guys are too quick for me. So here you see the the area that we created. There is this really a minimal amount of bone that you're resecting here, and it's really just the patellofemoral joint and the trochlea. So this really kind of minimizes how much you're taking off. It leaves the condyles alone. It doesn't extend down into the condyles at all. So I think it's a it's a good implant for isolated patellofemoral disease. You know, just it's really just the basics that you want. And I think it's it can be used for, for lesser disease and more significant disease. And it just kind of covers the whole thing. So here's the trial. So I think with the with the soft bone, as you can see here, the you know, we've taken a little bit more on the sides. It's not fitting. Exactly. I think that's part to do with the soft bone. I think when you have harder bone it fits well. Now it's fitting well down here. And again, I think the position of the implant is the most important thing. And I think it's reproducing the trochlea it's reproducing where the patella is riding. And so I'm happy where that's sitting right now. So we're just going to put the two pins in here. So I think you should put one pin in pin in first. As you can see here, the lateral pin. Then put the cutting guide for the lugs. Like that. And then put the other pin in. That's it. It's going to ream the three lug holes. So this is cemented implants. So if you have if you think you've taken a little bit too much bone and you think that the implant is too extended you know, this is you just hold the implant where you think is the right position, and you can use the cement to build up a millimeter or two if necessary. Perhaps the most impressive thing, I think, with this design is not the number of cases it's going to be done. But this was something that Arthrex believed in and wanted to provide a solution. And this started from scratch. And these are the the engineers here are tremendous. And it's really their project. And if you like it, me, Dave Caban here and Ned did a lot of work on it. If you don't like it, it's really their fault. So All right. Here's the implant. So, you know, I think the important thing is, is you can see the trochlea here. It's reproducing the trochlea. There's no step there. And it's basically repositioning and reconstructing the trochlea as it was before. And it's sitting nicely on the top of the femur up here. So these two little edges right here, I don't think that that's of any concern right there. And I think that's probably due because of the soft bone in the cadaver here. We got the patella. So you know at this point you know just do a trial run. And you know, flexion extension. And you can usually see if there's if there's any catching or problems with that. This is where I get a good feel for the stability of the patella. You can see I'm not I'm not holding and I'm not holding the patella over anything like that. If it's subluxation, you have to hold the patella over. Then I just kind of reef the medial side and just bring the just coker. Ned, you mentioned it quickly, but there was a question basically. Do you do you Roger that. If you do see that on that lateral side or, or do you think the patella is going to track in the, in the central portion of that implant? It's not going to affect it. No. I think if you have something that's really prominent here, you can take a little bit, you know, with the roger. But I usually don't find this necessary because the patella is tracking in the middle. I think it's the most important is here, you know, at the at the bottom end, make sure that it's sitting smoothly. And so again, if, if I feel that there's any instability, I just do a VMO advancement and just bring that over more distally on the patella to hold it over medially. But as you can see in this one, there's really no instability at all. And it's working very well even without anything on the joint. So here I would just close up the medial side and that's it. In terms of cementing, I cement both implants at the same time with the same small batch of cement. So basically put the patella in with the cement and there's a clamp for the patella. And you can just clamp the patella just like a total knee. You can see the clamp here. So basically put the put the cement in the patellofemoral implant. You know, just kind of put that and then go ahead and cement the trochlea and hold the trochlea in place. Once you get the cement in. So it's I think it's a very simple procedure for somebody like me that doesn't do total knee replacements. I do Eunice and Patellofemoral Eunice. And so I think for the sports medicine surgeon or any surgeon, I think this is a very straightforward surgery to do.

Orthobiologics

Jack Farr II, MD, (Indianapolis, IN) and Brian Cole, MD, MBA, (Chicago, IL) review the various treatment options related to large articular cartilage lesions. Discussions include the role of malalignment in regards to management of large lesions (iBalance HTO), new surgical options available such as the BioUni OATS Instrumentation, as well as iBalance UKA and PFJ.

Treatment Options for Large Articular Cartilage Lesions

Cory Edgar, MD, PhD, (Farmington, CT) discusses complex patellofemoral pathology and solutions using tubercle osteotomy and the iBalance® PFJ system.

Treatment Considerations for Patellofemoral Arthroplasty

Welcome. My name is Doctor Cory Edgar. I'm from the University of Connecticut. Today I'd like to talk a little bit about treatment considerations for patellofemoral arthroplasty. One thing I'd like to talk about is the more complex patient. They can do very well with patellofemoral arthroplasty and allows us to do very beneficial things for these patients. Oftentimes they have significant dysplasia within the distal femur and the trochlea. And these patellofemoral arthroplasty is especially the only ones allow us to really change the morphology. So remember these patients have risk factors for their chronic instability that have now led to patellofemoral, arthrosis like dysplasia, malalignment, hyper laxity of the soft tissues, and certainly patella Alta. This is a prime example of a patient that has chronic patellofemoral instability. As a young girl, she has progressed into her late 30s. These are X-rays. Now at 41, she has severe patellofemoral arthritis, lateralized patella tracking, increased tibial tubercle angle. On this left MRI image you can see their TG distance is 22.6. You can even see our patellar tendon rubbing against the whole lateral side of her trochlea. You can see the progressive wear and tilt pattern for patellofemoral joint on the right MRI image. I think these patients do very well if you treat them like patellofemoral patients. Just doing an isolated patellofemoral replacement might help with some of their anterior knee pain arthritic symptoms, but the instability may lead to sort of long term issues in terms of their their native anatomy. Malalignment. So I do think treating these patients. This is an example of mine that had a tibial tubercle osteotomy allows you great access to the patellofemoral compartment. And then you can adjust their patellofemoral tracking with this. Additionally, it's important to make sure you take enough bone. Soft tissue balance is important as well as, in my opinion, making sure that the patella button is as large as possible centric or even slightly lateral. Again, all we're talking about is this lateral force vector, which is what the quadriceps angle is, which is what we're quantifying with tibial tubercle trochlear groove distance off of images. Now this can be measured and it's within a well range. And remember that just because people have lateral tilt, that doesn't beget tightness. It could just mean that there's some malalignment issues. So we have to think about this with our approach with these patellofemoral patients, and realize that some of their pathology may be a little bit more than just simple patellofemoral arthritis. Trochlear dysplasia is typically based on lateral x rays. That's why I usually get them. But I think with patellofemoral dysplasia specifically with the inlay systems you cannot adjust this. So even though you might have a lower de jour, meaning a less dysplastic patient, you often have moderates which could do well with a en laye type of system, but certainly in the person that has a much more severe patellofemoral dysplasia, the ability that we have to manipulate the anatomy of the trochlea with a onlays system is much better and allows us much more opportunity to adjust their native morphology. Again, this is an example of a patient that has severe patellofemoral dysplasia. The younger patient doesn't necessarily have arthrosis, but it highlights the highlights the point of the anatomy of a dysplastic patient in the distal trochlea. You can see how small the surface area is. So simple inlay system does not adjust this. It doesn't affect the length. It doesn't affect the depth. Adjusting this with an inlay system allows us to manipulate their native morphology much better. Regarding the medial approach, sometimes we forget that there are various force vectors on the medial side. Oftentimes we talk about mpfl reconstruction for the non arthritic patient with lateral instability. However, there are various variable force angles that are looked at here with the anatomic studies. So over tensioning this medial side can affect your patellofemoral compression forces with the medial arthrotomy approach. Quantification of their malalignment typically is done with this concept of axial relationship between the tibial tubercle and the trochlear groove. Typically, with instability patients, we think a normal range in males and females are slightly different, but anywhere from 9 to 13 is well within the normal range. Things above 15, and certainly greater than 20, are considered highly abnormal and may need to need to be considered as something you have to address when dealing with malalignment and a patellofemoral arthritic patient. Addressing this malalignment is actually not that difficult. Tibial tubercle osteotomies are implemented for a variety of reasons, and even patients with pre significant arthritis with lateral cited pain osteotomy can even be done. The goal of the osteotomy is obviously to correct the functional q angle and adjust the patella tracking. Variable cuts can be made. In my opinion, a reasonable oblique angle of about 30 degrees provides enough surface area two screws, and this for my patient population does not slow down by any means the amount of postoperative rehab I allow them weight bear fully. They can initiate range of motion as soon as they tolerate, usually by two weeks. They're walking without a brace after patellofemoral replacement with a tibial osteotomy. Again, the tibial tubercle osteotomy can also address the angle at which the patella engages. So obviously we have patella Alta. A high riding patella just takes longer of knee flexion until the patella is captured within the trochlea. So by either adjusting the patellofemoral implant, creating a longer trochlea, you're adjusting that earlier capture, or by doing a tibial osteotomy where it helps that balance of a high riding patella, Alta. Lastly, I want to talk about the complex dysplastic patient with chronic instability. So this is a particular case example. A patient of mine who's had chronic patella lateral instability with multiple dislocations from a very early age. She's got bad morphology, bad patellofemoral tracking now in her late 30s, early 40s, she's severely limited, can no longer even work as a nurse, as you see on her lateral x ray. She's got a tracking patella with not a true lateral x ray, but she does have patellofemoral dysplasia. This is her merchant view, and you can see what looks to be like a good relatively patella captured in a lateral compartment. However, if you look at this through a wider range, she actually has a preserved trochlear groove. She has completely worn away her lateral trochlear ridge with a severely malaligned patella from a compartment she had native trochlea dysplasia. Now, with lateralized, tracking has literally worn into her lateral facet, now with more significant patellofemoral arthritis and instability. Her complaints now are instability and patellofemoral pain secondary to arthritis. Tibial tubercle, trochlear groove distance, as you would expect, is fairly high and I would say in a pathologic range of 25 for her. She also needs a tibial tubercle osteotomy because of her soft tissue, which was hyper lax. She did have a medial repair through a lateral approach of the arthrotomy that allows me to do a primary repair on the medial side. Some cases I've even done a medial patellofemoral ligament reconstruction. Obviously, we do a tibial tubercle osteotomy to get her alignment back into a much more normal range. And certainly an onlay patellofemoral prosthesis allows us to adjust her patellofemoral morphology, which was part of her problem in the beginning. As you can see with this on her contralateral side, which was less symptomatic but still has the same anatomic issues you can see on her patellofemoral replacement or realignment size that she has much better patellofemoral tracking. She has full capture of a distal femur. She's quite happy in both her patellofemoral instability symptoms and pain. Symptoms are gone, and she's been progressing well and actually returned back to work as a nurse. As a patellofemoral surgeon. There are many ways you can approach this from an arthrotomy standpoint. The classic way. As we're all taught, doing total knees is through a medial side. I think there is real benefit in doing a lateral approach, especially for people with more complex patellofemoral problems that we're trying to treat with an patellofemoral arthroplasty. First of all, it allows us an ability to titrate through our lateral approach by doing a step cut lengthening. So when we do our arthrotomy closure, we can actually titrate our closure. So we can actually create a patellofemoral lengthening on the lateral side that gives us soft tissue balance. Certainly that helps after we've made sure that we've adjusted our patellofemoral implant so it sits central or even lateral. Our Patellofemoral button has to be placed either central or potentially even lateral. This is difficult because it's difficult to cut the patella in particular with these patients, because oftentimes they have significant lateral cited where oftentimes when we do our cuts we're trying to trying to maximize the amount of patella bone that's left. Oftentimes with these patients, you even have to build up the lateral side with cement to make sure the button is placed perfect. So the cut underneath the patella is important. I believe from the lateral side it's much easier to approach this problem. Additionally, from the lateral side, in my opinion, I think it's much easier to visualize the femur the distal femur. We're making our cuts, so that way we can adjust the rotation and the position on the distal femur that we're putting our onlay arthroplasty. So an example of this is a patient that had bilateral patellofemoral replacements. No significant malalignment but classic lateralized patella tracking with adhesions within the lateral retinaculum. The left knee was done through a medial approach. Right knee was done through a lateral approach. You can see there are slight differences in where the button is placed, slight differences where the implant is placed. More importantly, there's a much bigger difference in the titration and the tracking of the patella. Same flexion angle on the x ray. Done. Bilateral merchant view.

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iBalance® PFJ Patellofemoral Joint Arthroplasty

iBalance® PFJ System

Child (D)

Das iBalance UKA-System ist ein komplettes, minimal-invasives Instrumenten- und Implantatsystem zur Behandlung von lokalen unikondylären Knorpeldegenerationen in Folge von Arthrose oder posttraumatischer Arthrose des medialen oder lateralen Knie-Kompartiments. Anatomisch geformte Implantate für den Oberflächenersatz der femoralen und tibialen Gelenkfläche sowie eine neue und innovative Instrumentenplattform ermöglichen eine präzise, effiziente und reproduzierbare Operationstechnik. Die koronale und die sagittale Geometrie der Femurimplantate passen sich der Biegung des normalen Knies an und haben einen konischen vorderen Teil, der dazu beiträgt, den Patelladruck zu reduzieren. Das Instrumentensystem ist minimalistisch und elegant konstruiert, sodass die Handhabung für den Operateur und das OP-Personal leicht erlernbar ist. Das iBalance UKA-System sorgt für ein planbares, ausgewogenes Ergebnis und eine nahezu natürliche Kinematik des operierten Kompartiments.

This animation demonstrates unicondylar knee resurfacing using the iBalance® UKA system, which helps improve operative efficiency due to the expanded flexibility provided by the new adjustable spacer block.

iBalance® UKA Technique

Mark D. Campbell, MD (Phoenix, AZ), demonstrates how to use the iBalance® UKA disposable tibial cutting guide. This innovative guide provides the patient-specific slope and tibial bone resection level, helping to ensure a more reproducible tibial resection. It further simplifies the iBalance UKA technique by minimizing variability in tibial resection.

iBalance® UKA Disposable Tibial Cutting Guide

My name is Mark Campbell. I'm an orthopedic surgeon from Phoenix, Arizona. Today we are going to perform a Arthrex iBalance medial unicompartmental arthroplasty. We are going to be demonstrating a new tibial cutting guide. It's very unique. It's a disposable guide that uses patient specific slope and depth of resection, and really simplifies this procedure to give a reproducible flexion extension space. And now if you look we have very nice exposure of our joint. We now take the disposable tibial cutting guide. And it's a two part guide. We've got the guide itself as well as the stylus that will help set our depth of resection as well as our slope, and match that to the patient's specific anatomy. So I will place it in the joint line and advance it between the tibia and femur. And once I can feel it go right past the tibia, at that point I rotate it 90 degrees. I pull forward and it catches on the posterior condyle of the tibia. So now, in order to determine our various valgus positioning, and I drop a drop rod through the cutting guide, and then I'm trying to line this up and make it parallel with my marks I made on my anterior tibial crest. The last thing I need to do with the guide is just set my medial lateral position and rotation, and I use this ruler that's in the set. There's also a Angel wing that can work as well. I'm going to put this in the vertical cutting slot. And then from that determine my rotation and position. Now one thing I do is I utilize the lateral aspect of the medial femoral condyle is where I'm going to be aiming. It's a patient specific cutting guide so to speak. I use an osteotomy first just right on the bone just to make sure soft tissue attachments are released a bit so it doesn't tether my saw blade during the saw cut. So that opens up a little area. Now that I can take my ruler, I can actually set it in the vertical capture and set this right up against the lateral aspect of the condyle. So it's sitting right up against the condyle right there. I know that's going to be my rotation and my position. So at this point depth of resection and slope has been determined by my pen. My varus valgus has been determined by my drop rod and my rotation and medial lateral position by my ruler. So everything is set. Now we will place in pins in order to hold it. Now I will put a single pin in to start with. The pins themselves are actually above the level of resection, so it stabilizes that piece. And we'll show you that there's a way you can actually get it out as well. So I'm also going to a hinge pin in. Now the hinge pin is very nice. And that helps protect your saw blade. And there is actually a third pin. Now in order to get that one in. We're going to take our stylus. We actually bend it straight up. So what that does is it gets out of our way for our last pin and for our saw cut, but at the same time helps maintain fantastic stability of this cutting guide. So I'm going to put the last guide pin in. So now we are set for our saw cuts. We're going to start with our vertical saw cut. And again because we line this up so well this saw blade fits right up against the lateral aspect of the medial condyle and fits right down into my slotted size. So you can see I've cut down very nice positioning. And my pin right here is protected me from undercutting that. So once that's done, we can switch to our horizontal saw cut. One thing I will point out that even though it's captured, we do want to have a retractor protecting the MCL because the blade can go past there. And we certainly don't want that. We are protected from the lateral side by this hinge pin. Now I am done with this tibial guide. I can remove that. And actually if I remove it all together, depending on soft tissue attachments it may actually bring my bone out with it. And if you look there's my cut very nice slope depth of resection. There's a very nice cut. All came out in one. You see how that did that. The pins were in the bone itself. And again my stylus was holding right in the back of the tibia and was able to pull it all out. Once we've made our tibial CoolCut. We have now developed a space. We need to know what that space is and make sure it is adequate. We have a adjustable spacer guide here and this will help us measure that. Simply place the end into the space and we have a laminar spreader that will help tension this to the correct side. Now I will tell you this again is a measuring device, not a device meant to GAP open the space. So we will manually lift open the space, and then we gently will elevate it until it measures the correct space. And you'll hear a click. And every click is analogous to one millimeter of space. It's now tensioned in that spot. And in this space it's nine millimeters. We want a minimum of eight millimeter space here. And a nine clearly is right where we would like to to be at. So once we have measured our flexion space we take out the tensioner and we will extend the knee, and we will now measure our resultant extension space. We again place the the adjustable spacer block in laminar spreader will place it. And again we tension it to the same tension that you tension it to in flexion. And when I do so it has the same three clicks. Again it happens to measure nine in this instance. Now it's important to know they do not need to be the same. And they often are not the same. But this gives us our extension space at this point. So I'm going to put a distal femoral cutting guide in. And it slides right over the spacer block. And once that's into place I can place a couple of pins to help stabilize it. One thing you may notice is we want to make sure we're not extending or hyperextending the knee. We can look in the notch to clearly see there's no impingement. And so that's a good position for that cutting block. Once that's completed, I can take out my spacer and my cutting guide. Once the guides are out, you have better visualization. There may be a little bit of bone that needs to be continued to be cut, and that can easily be done with this exposure. We will flex the knee back up in order to get back to our flexion space. So I'm going to use a posterior femoral cutting guide. This again slides over the slots in the in the spacer block. And it sits down right on the flat distal femoral cut you made. Now it's important that this fit flush to it in the way that it will fit. Flush is a variance of flexion and extension. So I will flex and extend this until it sits flush on the distal femoral cut that we had made. And you can see through this window in the guide that it is flush down on to the bone. And once it's in the correct spot, then we pin it into place. It is a slotted cutting guide and it is captured on the lateral side. The medial side you have a retractor protecting the MCO. So now we can remove our guide. And again if we have to do some freshen up cut we certainly can if we need to. And so now a very nice visualization. The cuts almost completed. There's just a little lateral bridge of bone that I will finish with the saw. Here's an 18 millimeter static spacer block. And I'm going to fit it in. And it fits absolutely perfectly with perfect tension. So our flexion space has been set. We will check our extension GAP. And in this case the block fits in perfectly. Now I will say I no longer do this step. The reason I don't do the step is because it is so reproducible. Reducible. If you have a fixed space and you cut a fixed amount, it is going to be that total amount every time. Now it's just a matter of preparing and placing the femoral and tibial component. I am going to place on a five to start with and do so. It just fits right in now. I can see it fit right there. One thing I want to do is one I want to feel into my notch. It's right perfectly centered on my condyle. Then I'm going to take my army Navy and look up top because what I want to do, and it's hard on the video to see this, but I do have a couple millimeters of cut bone anterior to this, this guy. Now that's very important. You don't want oversize. You want a little bit of bone to be remaining. So this five actually looks really good. Two things this guide will require one. You need a drill for your lug holes. The other you will use a saw blade to cut your chamfer cuts. Always drill your lug holes first. And the reason for that is, once you've made your chamfer cut, that piece of bone is missing in the in the guide will not be as stable. So this is the most stable it can be. It's got a positive stop. You drill those two. Now you go to your chamfer cut. Chamfer cut is captured. The only area that it's open is on the medial side. And again a retractor will help protect that. It is captured and blocked on the lateral side. And the other side of the guide keeps the blade from going in the tibia. So it's very, very safe and well protected. We can remove our pins and our femoral preparation is now complete. Once that has been completed, we can go on to our tibia. We can look at sizing our tibial side. Now that ruler will do the same thing on the tibia that it did on the femur. And again the sizing. So as you'll see, as I capture the back and pull out, in this case, it measured approximately a four. And again this is an anterior posterior measurement. What's very important you don't want to overhang medially, but thankfully you can see that visually quite easily. So we'll now select our tibial preparation guide to correspond to the size that we measured. In this case it was a four. And we're going to see how that fits in there. I set it right up against the vertical wall. And so it's sitting right on the anterior cortex. When I do that there's two spikes that sit down into that tibial bone. I then take a freer elevator because I can feel around the side, and I can both visually see and I can feel that we are absolutely flush with the cortex there. So this is a perfect size. It's perfect. Around the tibia there's a single pin that goes in. Now I hold this with the handle while it's pinning into place. So our stability now is compromised. Those two tines on the bottom of the guide. And this pin as well as I hold it with my handle as well. Once I've done that, I am going to punch for the fourth keel punch. This has laser lines that tell you when you're deep. I stabilize this with my hand and set it in. I then tap this down and the video won't show up, but I can see those laser lines disappearing in the guide, so that is set down. Now, while that keel punch is in, we have the ultimate stability of this guide, so I keep it in there for the next step. I take my lug drill and I sit it in the more medial slot and I drill it down. It's not 90 degrees down. It's got a little of an angle to it and it's sitting nicely in that. So I know that is my angle. At this point I pull my keel punch out, and that will allow me to see my other lug hole, which is exactly the same angle. So I strictly bring this straight out, put it straight in the other one, put it straight down without any tension on the guides. So once our tibia and femur have been prepared, we're going to go on to cementing. When I cement, I place just enough cement on the bone itself to fill the lug holes and the keel punch. I then place a light amount of cement on the undersurface of the tibia component, covering the cement pockets. If you'll notice, I put a put a light amount on posteriorly, but the way this goes in with you see the posture oriented lugs and the keel. And using our initial impactor, it actually catches the back and pushes the back down first. In doing so, any cement is forced forward to the front of the knee, making removal of the extra cement very simple. So we will set this in. And I set the keel hole right in place and the lugs will fall right down in place. Now it's up in front, but I'm going to set this again until that captures the posterior aspect of the rim of the tibial component. And once it's on there, I'll gently tap it. And what that does is that put the poster back. Then I walk it forward a little more and you can probably see look at the front as it closes down as I come forward. What that also does will allow any cement to come out the front for easy removal. So our tibial component is now in place. I cement the femoral component very similar technique as I did with the tibia. I start by placing cement into the lug holes on the femoral bone itself. I then coat the back side of the femoral component, covering the cement pockets. I leave the lugs free for visualization. The technique is such that the first thing you need to do is get the posterior lug lined up with your posterior lug hole. Once it's in that position, I gently extend the knee while the while the assistant is pulling the patella laterally. Once the patella is pulled out of the way, you can rotate the femoral component over and into place, and then you can flex it back down because the patella is no longer in the way. We have a impacta that sits in line with the lug holes. We just gently impact it in. I generally will do a gentle anterior impact or and posture as well. In this case it's going to be very easy with different levels of flexion extension to get your extra cement out. At this point we'll put a trial polyethylene in. I find that it's easy to gently tap this down from the anterior medial aspect until it sits right in. Once the polyethylene is in place, I can check my flexion extension. One thing you'll notice is very nice alignment between the components and the knee flexion extension is very smooth. I get fully straight and then I'm going to check my tension in my medial compartment. I want a couple millimeters of play. If I feel it's a more play than I'd like, I can always put a bigger polyethylene in. This one here feels perfect just with the eight millimeter poly. So once the cement is hardened and you want to put the real polyethylene in the trial, polyethylene is removed very easily using this device. It fits into the hole on the trial polyethylene. You just flex up pull straight out nicely pulling that out. Once this is done, you put in your real polyethylene. Once the real polyethylene is in, we use a pulse lavage to copiously irrigate the area. We close the retinacular opening, my choice being oh vicryl we use three zero subcuticular monocryl under the skin, I use staples. Some people will use skin glue. Either one is fine.

This animation demonstrates unicondylar knee resurfacing using the iBalance® UKA system, which helps improve operative efficiency due to the expanded flexibility and reproducibility provided by the new adjustable spacer block and the disposable tibial cutting guide.

iBalance® UKA Technique With Disposable Cutting Guide

Steve D. Lucey, MD, (Greensboro, NC) discusses with Alex Bautsch (Arthrex Group Product Manager, Knee Arthroplasty) his experience adopting the iBalance® UKA system for knee arthroplasty procedures.

Knieteilgelenkersatz

iBalance^® PFJ System

iBalance^® UKA System

Knieteilgelenkersatz

iBalance® PFJ System

iBalance® UKA System

iBalance^® PFJ System

iBalance^® UKA System