Name: A Five Chapter Approach to: Opening Wedge Osteotomy Utilizing the Arthrex iBalance® HTO System
Uploaded: 2011-06-15T00:00:00Z
Channel: Arthrex

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VID1-01056-EN | A | A Five Chapter Approach to: Opening Wedge Osteotomy Utilizing the Arthrex iBalance® HTO System

Thomas Hackett

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A Five Chapter Approach to: Opening Wedge Osteotomy Utilizing the Arthrex iBalance® HTO System

Hi, my name is Tom Hackett. I'm at the Steadman Clinic in Vail, Colorado, and this video today will discuss the use of the iBalance system for the procedure of a high tibial osteotomy. High tibial osteotomies more recently have really come into favor again, primarily for two groups of patients. One being those patients with various osteoarthritis with varus alignment. And then the second group of patients are those patients who are undergoing additional procedures, such as an osteochondral allograft and OATS procedure, a microfracture, or perhaps a revision ligament surgery that is being done in conjunction with somebody that has underlying malalignment. We've learned over the years that alignment is really critical to the success of those other procedures, and the iBalance is really a very nice way to maintain and preserve alignment in the face of those other surgeries. In general, the iBalance is really a very safe device and the instrumentation is very precise, very reproducible, and you're essentially milling the proximal tibia while preserving as much bone as possible. And so there is a really a significant safety envelope here that is very satisfying for the surgeon. So without further ado, we'll go on to the video and the technical aspects of the surgery, as well as the rehabilitation and indications for the surgery. This is a five chapter approach to the opening wedge osteotomy utilizing the Arthrex iBalance tow system. Initially, we'll discuss preoperative measurements using a full length standing AP radiograph. A line is drawn from the center of the femoral head to the center of the tibiotalar joint. This demonstrates the patient's mechanical axis. Another line is drawn from the center of the femoral head to a point midway in the lateral knee joint. A final line is then drawn from the center of the tibiotalar joint to the same point in the lateral knee joint. This angle, formed by the intersection of these two lines, determines the degree of correction required to return the patient's mechanical access to the point of point of intersection on the lateral side. The approach is typically halfway between the tibial spine and the posterior aspect of the tibia, and this can be done with or without a tourniquet. Soft tissue dissection is taken down to the pars, anserine and sartorius fascia, which can then be reflected off of the medial aspect of the tibia. This is done as a complete sleeve directly down to bone, and includes typically transecting a small portion of the medial collateral ligament, which will then be repaired at the end of the case. The patellar tendon also needs to be elevated. This shows the approach using electrocautery. The sartorius fascia and the patella tendon here is being elevated, and entire sleeve is being taken all the way back to the far posterior aspect of the tibia. It's important to take this all the way to the edge of the posterior tibia, and it does include a partial resection of the collateral ligament, which will be repaired later on. A posterior retractor here is used to elevate the popliteus muscle off of the posterior aspect of the tibia. And this is a very important step to be taken directly over as far as the proximal tib fib joint posteriorly. A finger should be able to get back into that area. The iBalance Steele rule is then utilized for measurement both anteriorly and posteriorly. And the two readings are then averaged to obtain the size of the implant. This shows the posterior retractor reflecting the posterior aspect of the soft tissue envelope. This allows and ensures that the neurovascular shield will go at a 15 degree obliquity all the way back to the proximal tib fib joint, to protect the neurovascular structures of the posterior aspect of the knee. This demonstrates it here. Live with the shield easily going behind the knee, and it's confirmed under fluoroscopy. By planar alignment. This is done with a radiolucent triangle and a lateral of the knee done with fluoroscopy. A perfect lateral is conducted at the proximal tibial plateau, utilizing the posterior aspect of the tibial cortex. The base is then placed through the incision, with the patella tendon guide being placed behind the patella tendon, as is seen here. This is a critical aspect of this portion of the procedure. The periosteal sleeve is then lifted to allow the base to be placed along the posterior medial aspect of the tibial plateau. There is an anterior and medial tab that must be placed against bone. Here you can see the alignment bars are being moved one plane at a time, and they are superimposed upon one another to perfectly match the tibial slope. This is what allows for the slope to be reproduced with the implant later on. Once this is confirmed, the anterior guide pin is placed and this anchors the base. Then the hinge pin hole Pinhole is adjusted appropriately and the second pin will be placed again. It's very important that the anterior and the medial tabs are placed directly against bone at this portion of the procedure. Here's the anterior pin being placed. And now we go into full extension looking with an AP view directly down the pipe of the hinge pinhole. This is like a perfect circle type technique to get a perfect circle of the hinge pin hole. This must be 25% greater distance below the tibial plateau than it is from the lateral cortex. And by doing this, the hole is placed in the appropriate location. This circle provides stress relaxation, thus preventing osteotomy propagation into the lateral cortex. And once this is confirmed, the second pin can be placed. Now we place the 4.5mm hinge pin. This is placed here. A tissue sleeve is placed through the collet. A 2 to 3 millimeter incision is created through the skin, and the tissue sleeve can be bluntly placed down onto the cortical bone. Anteriorly. The collet nut can then be secured, and under lateral fluoroscopy, the drill can be placed both to and through the lateral cortex, and then the actual collet nut can be removed and the real hinge pin is placed. The hinge pin has a slot so it goes in with the flat portion aimed medially. The pin is going into place here. The outrigger with the alignment guides is removed and the collet pin is down to secure this in place. So now we'll illustrate drilling the key holes and cutting the osteotomy within the safety envelope. The keyhole reamer is utilized posteriorly first and then a provisional pin is placed. You can then move to the anterior keyhole And this is reamed as well. Collecting the bone debris will allow for the use of autograft. Once the device is placed here, the reamer is removed. You can see the keyhole reamer being placed posteriorly provisional pin, and then anteriorly and again. All of this bone debris should be preserved for later use. Once the keyhole has been reamed posteriorly and anteriorly, the cutting guide is placed. The cutting guide fits flush on the outrigger, and a hex driver can then secure it into place. With the cutting guide in position, the neurovascular shield is then placed posteriorly. This. All the preparatory work done previously allows this to go in smoothly and again the hex head secures this to the cutting guide. It's critical that this be a very tight fit as seen in this position here. Now the osteotomy can be created. You're doing this within the safety envelope and hitting metal both posteriorly and anteriorly. And the patella tendon is protected as well. Here a hand osteotomy is utilized to manually complete the posterior lateral aspect of the osteotomy, and then is confirmed with a tactile sensation. Here you can see the saw coming in. It's hitting the hinge pin and then the neurovascular shield. This can be done both from an anterior and a lateral approach. Here's the hand osteotomy manually completing and feeling for the metal throughout the safety envelope. This small portion of the posterior lateral aspect of the osteotomy often needs to be completed by hand. The conformation of the osteotomy is done by placing a valgus stress on the knee and evaluating opening of the osteotomy site. Once this has been confirmed, the handle can be placed on the neurovascular shield, which subsequently can be removed. The cutting guide is then removed and here you can see the handle going on to the neurovascular shield being secured into place, and then gently removing the neurovascular shield from the posterior aspect of the tibia. The cutting guide is then removed again with the hex head. The pins are then removed, which can be done either with a pin removal or with the multi-tool. The collet is removed and subsequently the hinge pin is then also removed with the multi-tool. So now we'll be discussing and illustrating the opening of the osteotomy and the actual fixation of the Of the iBalance implant into the dough construct. Here the osteotomy has been completed. The jack is placed and this jack is size specific for the osteotomy site. A provisional pin is placed to keep the jack in its appropriate location, and then the angular correction can be confirmed off of the correction guide. This shows the jack going into place. It is placed through the incision and into the osteotomy site and then very slowly opened. The correction guide can then be placed in based upon your preoperative templating. The appropriate angular correction is obtained. This can be over corrected to allow for application of bone graft in these austerian plugs. These oliverian plugs allow for bone Ingrowth, are soaked in ACP ahead of time and actually assist in early weight bearing in that they are able to resist a compressive load. This is demineralized bone matrix StimuBlast, which can be mixed with the patient's own autograft that has been collected during the keyhole reaming and drilling process as a slurry. This can then be packed into the more lateral aspect of the osteotomy site, prior to the actual implantation of the implant itself. Here's the implant now going into place and is held with a finger or thumb. The implant has been placed and the jack is being removed. This is a two part jack and it is actually disarticulated and taken off of the osteotomy site. One limb at a time. This is the superior limb being removed. A finger or thumb will keep the implant in place and then the inferior limb is removed. Two cancellous screws are placed proximally to. Cortical screws are placed distally, and these screws are really not providing significant compressive force, but rather are acting as anchors just to keep the peak implant in the osteotomy site. This shows these cancellous screws being placed proximally. The two distal screws are actually cortical screws. It's important to drill through the posterior cortex of the tibia. Tapping is then done in the usual way, and the in the proximal and distal cortex are tapped. The screws are placed. The head of the screw actually have some tabs and indentations that match the peak implant. This gives a tactile sense when the screw is actually seated properly. After the final construct is confirmed under fluoroscopy, the soft tissue envelope is repaired. This is an anatomic repair of the medial collateral ligament as well as of the pes and the periosteum. We've noted a significant reduction in soft tissue irritation with this final repair. This video has illustrated the surgical technique that has allowed us to conduct a high tibial osteotomy now with the iBalance implant, and typically well under an hour's worth of time. The following slides represent some of the post-operative rehab protocols. We've noticed with this device that there are shorter hospital stays, less pain, and decreased narcotic usage, as well as the ability to integrate earlier weight bearing into the standard protocols.

A Five Chapter Approach to: Opening Wedge Osteotomy Utilizing the Arthrex iBalance® HTO System

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