Name: iBalance® HTO Using Patient-Specific Osteotomy Instrumentation
Uploaded: 2026-10-02T00:00:00Z
Channel: Arthrex
Description: Aaron J. Krych, MD (Rochester, MN), demonstrates how to use a 3D-printed, patient-specific instrumentation (PSI) osteotomy guide with the iBalance® HTO system.

Knee

<p>Aaron J. Krych, MD (Rochester, MN), demonstrates how to use a 3D-printed, patient-specific instrumentation (PSI) osteotomy guide with the iBalance® HTO system.</p>

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VID1-010217-en-US | A | iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

Aaron J. Krych

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

Speaker  My name is Aaron Critch from Rochester, Minnesota, and I'm very excited today to demonstrate the Arthrex iBalance HTO patient specific instrumentation. So to demonstrate, we're going to first look at this three dimensional printed anatomic model. So this is a left knee. So here you can see our tibial tubercle. We're on the medial side of the knee. You can see the articular cartilage of the medial plateau and the medial side of this tibia. So we're going to first show you the guide in terms of how do we link the patient's anatomy to the HTO iBalance system. So this is custom printed from the patient's anatomy. And it contours extremely well. We want to find first that anatomic positioning where it locks in. So a couple landmarks here you can see on the tibial tubercle how it locks right in underneath. And you find the one and only stable spot where this guide is intended for this patient's anatomy. Once we have that spot, then we will convert and we'll use the iBalance HTO system for a completely instrumented osteotomy. So you can see we have our custom printed patient guide. And now we've coupled this to our iBalance HTO standard instrumentation. So we first find the stable position on the patient's anatomy, where we've customized this plan to our corrected plan for the osteotomy correction. So once this is in a secure location, we'll now fix it to the bone with these babies which do a really nice job of locking in this guide. Speaker  So it's completely stable. So we have two proximal fixation points and two distal. So once that's complete again this is completely stable On our osseous anatomy. So once we have the patient's guide connected securely to the bone. Now we're going to connect the standard iBalance HTO metal instrumentation guide. So we'll place a pin anteriorly in the front as we normally do. And then we'll place our second pin medially as we would normally do for the iBalance HTO instrumentation. So now that the hinge pin guide is in place, this was set to a medium to accommodate the patient's anatomy, per our preoperative plan. The. One of the advantages of this system is that Intraoperatively. We can change to a larger implant size if needed. So we'll take our hinge pin guide, and we can look to make sure that we have this closer to the lateral cortex than to the lateral plateau. We want this ratio to be at least 1.25 to 1. If you so desire, you could also take an X-ray, An AP X-ray straight down this guide to see exactly where this lines up. If for some reason you were not as close to the lateral cortex as you wanted, if you weren't at that 1.25 ratio. Now you can simply change this to a large size before we start drilling anything further. Speaker  So again, flexibility in the system to make some intraoperative adjustments per the patient's anatomy if needed. In this case, we like the medium. So we're going to lock that in. We're going to place our hinge pin guide down. And we're going to lock down that guide. And then we have our drill for our hinge pin. And we want to make sure that this is bicortical but that we're not going beyond the posterior cortex. So we'll first go through the anterior cortex. And then once we're through, we'll feel the cancellous bone, feel our posterior cortex, and then just pop through, taking care to protect the neurovascular structures behind. And notice the hinge pin here is completely from anterior to posterior. We want a nice lateral hinge. We don't want to create a posterolateral hinge and change our slope in the system. That's another advantage of this guide. So once we've drilled for hinge pin now we're going to place our hinge pin guide to maintain our hinge pin throughout the rest of the case. So this has a slot on it that will lock in for rotation. Once we have that we can then take our alignment mount off, and we'll replace our locking nut for the guide for the hinge pin. And then at this point we can uncouple the patient's custom guide. So we'll remove this portion and we'll remove our two proximal and our two distal BB-Tak. Speaker  And at this point, we are completely aligned from the patient's anatomy to the iBalance HTO system. Once we remove the patient guide completely, one important double check on this system is to make sure that this tab is right up against our Posteromedial tibia. And then you'll see this tab right in here also needs to be right up against bone. That ensures the bone that we remove for the peek implant will sit nice and flush inside of our cortical window that we make for the osteotomy. Once we've confirmed we're in the correct position, then we'll go ahead and ream our two pegs. So I like to ream anteriorly first, and then we can replace that with a peg to make sure nothing moves in the system. So then we can ream for our Posterior peg. And again, this is a positive stop. So we make sure we're all the way flush. And that will set us up for our next step, which is to place the cutting guide into the bone. So we'll use the screwdriver to remove this locking screw. And then we're going to place our cutting guide. At this point, you could save any autograft bone that you wanted to and use it as bone graft later in the procedure. So once we have our pegs reamed, we're now going to place our small medium cutting guide. Speaker  So that slips directly on and we're going to secure that with our screw up here. And then once we have our cutting guide in place, we're then going to place our neurovascular shield. So once our cutting guide is completely secure, then we'll take our neurovascular shield. Protector. This is the small medium. So we'll hug the back of the tibia. And you can kind of give this a little bit of a roll, and then we'll secure this neurovascular shield in place, which helps protect everything right behind our tibia. Once that's done, I will remove this handle to get it out of our way. And then now what we've done is we've completed our safety envelope. So you can see we have our hinge pin goes from front to back. So that's protecting our lateral hinge. We have our neurovascular shield going in the back to protect our neurovascular structures. And then this guide right here is to protect our patellar tendon. So when we use our saw blade, we have a complete envelope of safety when we perform this osteotomy. Okay. Now that we have our safety envelope completely assembled, now it's time to perform our osteotomy. And with this guide, we want to get all the way from anterior to posterior. We want to get all the way from medial to posterolateral and then all the way lateral. So we'll go ahead and complete the osteotomy. Speaker  Once we've completed the osteotomy with the saw. Then we can use our osteotomy. You know you really want to feel are we hitting metal again with our safety envelope really is a good indicator that our osteotomy is complete. So once our osteotomy is complete, we can then take our neurovascular shield and remove it. So we'll put the handle back on for our neurovascular shield. And then we'll take this neurovascular shield completely off. Usually when you have the soft tissues, it might require you just to wiggle it around to remove it. And then at this point we can remove our cutting guide. So we can take our cutting guide completely off. And then at this point, we can decide sometimes what I will do is I'll take my osteotomy, and I'll just double check before I remove everything that we have mobility in our osteotomy. And you can see here, this is exactly what I would want to see. It's nice and springy. We have a lateral hinge. This is going to be great for our opening wedge osteotomy correction. Once we've confirmed movement, then we'll remove the rest of the guide at this point so we can remove our hinge pin. And we can also remove our other two pins. And we're going to take everything off from our tibia and get ready for our next step. So at this point we will begin correcting and opening our osteotomy. Speaker  So this is our jack opener. We have it set to medium and it's lined up with the hinge pin. So one pearl to help line this jack opening guide up is we can actually use our peg to make sure that everything fits perfect. These flanges want to be right flush with the bone. And then we can just start gently opening it until our peg is loose. At this point, we'll use our angel wing. So we'll bring that in to measure. For this patient. We wanted a medium seven degree correction. So you can see the degrees here. Right now we're just at two degrees. And I'll open the osteotomy slowly a few degrees every 30s or so you can take your time. Opening the bone just depends a little bit on how easy it's opening. In this case, everything's opening very easily and we're preserving again that lateral hinge. So here again we're going to take this to our preoperative template, which for this patient again we wanted seven degree correction. So we're there. So at this point we can just take a look at everything clinically to make sure that we're happy with our preoperative plan. So here one pearl is that we can just open our osteotomy just a degree or two beyond our correction, and we slide our peak implant for iBalance osteotomy into place. Speaker  And at this point we want to remove the jack opener. So in this case I'll actually disassemble it. And you want to make sure that that plate stays in as you're taking this jack opener out. So you can either remove it in 1 or 2 pieces. And the key with this implant is that you want it flush with the bone, or even maybe a half a millimeter off the bone, but you never want to insert this implant. What's nice about this completely instrumented system is this will fit right exactly where we want it to, to get cortical support for the patient as they're beginning weight bearing rehabilitation. So we lightly tapped our implant into place. And you don't want to over insert it because you want the cortical bone support one pearl as I leave this about a half millimeter off the cortical edge, and our screws will actually bring it in flush. I like to place our proximal cancellous screws first. And the nice thing is we have a custom plan. So I already know that this posterior proximal is going to be 32mm. And the proximal anterior will be 24mm. So our guide has our numbers and we can read our depth right off of our guide. So we'll drill right to our line at 32. So now we'll place our two distal screws. And these are cortical these are bicortical screws. Speaker  So again from the preoperative template. I know that this one is going to be 34mm, so I just confirm that depth with my guide. And then the difference between our proximal cancellous screws is this one we will need to tap. And you want to make sure you tap to that second cortex and through that second cortex. So these peek screws can fit in nicely. So I feel that second cortex I get through it and then we'll place our bicortical screw. So now we've placed all four of our screws, our two proximal cancellous our two distal bicortical screws. The most important part when we're finished is we want this posteromedial part of the implant to be completely flush on that cortical bone. So in this specimen, this looks perfect. That means we've lined up our guide perfectly to mill for the implant that replaced the bone that we opened. In real life, we would place bone graft at this point in our osteotomy. So we would place some AlloSync Pure bone graft. And then you can see with our perfectly lateral from front to back, anterior to posterior hinge pin. This is a completely stable osteotomy. And you've got our nice peak implant that won't be painful. That won't be prominent for the patient. We've got a lot of tibial real estate to do combined procedures, ACL, PCL, root repair, etc. so overall an excellent system which was customized for this patient.

iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

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