Geoffrey Marecek, MD, performs percutaneous osteotomy and lengthening of the distal femur in this 15-minute video. Marecek is an associate professor of Orthopaedics and director of the Limb Reconstruction Program at Cedars-Sinai.
So this, this patient has a, a leg length discrepancy as well as skeletal deformity. And our pre op evaluation demonstrated that the deformity is coming from the distal femur. So what we've chosen to do is to do an osteotomy to correct the deformity. And then we're gonna lengthen through that osteotomy to correct the leg length discrepancy as well. And so we're gonna put this first wire parallel to the knee joint just to give us a constant reminder. So that's roughly parallel to the knee joint. Can I get another Steinman Pin? This is gonna be a reference wire for rotation just that and we're gonna get ready to kind of set our osteotomy. So we're gonna go kind of perpendicular to the shaft here, X ray. OK. So that'll be a good spot to put our reference. We're gonna try to put these perpendicular to the or parallel to the wires that we already have inserted. What? So we want to make sure that this wire sits somewhere that's gonna be out of the way of our instrumentation. X that's generally pretty safe spot to not get into problems X ray. OK. And based on that so kind of use our anticipated location to decide if we're gonna go parapatellar or trans patellar for our incision. And based on this, we'll go trans patellar with this view, we get a little bit of a semi notch, which makes it easier to tell where we are in terms of our start point. So that's a x-ray. Pretty good start point on this view, x-ray right at the apex of Bloomin Soz line, but we need to just double check the other one. So come back to the other view, please. And what we're, what we're trying to do here is to enter at our desired an atomic lateral distal femoral angle. This is the path that nail is gonna take in the distal segment to allow us to correct our deformity. You know, we're shooting for 8182 based on our preoperative templating. So this is pretty close as we put in our drill will adjust just a little bit to get that extra bit of correction. So where, where that is hitting our cortex is a pretty good spot to make our osteotomy. And so we'll kind of mark that out and let's put in our other reference wire as well. So this will help us measure 20 degrees. If we put that along there, then this will be 20 degrees from it. Actually, we want our other wire in the other direction. OK. So that's gonna show us about a 10 degree wedge So go ahead and hit that. So one thing we need to do is we're doing a lengthening is to release the I TB. So that she doesn't a, get a contracture or B get a deformity. So we're gonna release it band as it goes back to the femur here and Cheerly. Mhm. And we're gonna drill for a percutaneous closing wedge osteotomy. OK. So I'm gonna follow the wires that we've set. And basically, as we're drilling, what we're gonna do is we're just perforating a path for our nail or for our osteotomy. And this is the kind of critical part of the surgery because we're trying to make a biologically friendly environment for the regenerate that we need to lengthen the leg. So we're gonna avoid thermal necrosis, X ray like continually cooling x-ray X ray shots and cleaning the drill is a brand new drill. There are lots of options for how we could achieve this deformity correction. We could do a fairly simple osteotomy with X ray with an opening wedge, an X ray, we could do more of a standard open closing wedge could do a dumb osteotomy X ray. But by doing this kind of a percutaneous closing wedge, we hope to avoid some of the issues X ray with delayed healing or kind of poor regenerate formation that can happen when you leave a big gap. Now, let's go ahead and open our um track first. Let me see the guide wire, I'm just gonna pull this back a tiny bit. So the next thing we're gonna do right now, we have our starting point and we have our drill and the drill represents the ultimate nail. So we're gonna do a uh blocking screw, X ray. This screw is gonna help us achieve our rotation, our angular correction X ray. OK. So we're gonna put that there to protect the artery. We also have the leg flexed for that same reason. So here we're gonna start with our Corot X ray and you can sort of feel that we've fallen into it there. X ray. And can I see the mallet, please? So this is just gonna be very gentle correction. Now, we've got a mobile distal femur. So can I see the um Pinder bar clamps in the bar? That looks pretty good. So tighten that down. So let's use the match. So now we're just using some intraoperative fluoroscopy to help us check the mechanical axis and we've got our patella forward. OK. Shot great. OK. And come on distal, please. Tiny bit, tiny bit. We'll, we'll probably get some of that back. But I'm I'm happy with where that is. I'd rather over correct her just a tiny bit then to under correct her. So we templated a 190. OK. So that's about the farthest up we wanna go that's measuring 20. So we should be good. OK. So now we're gonna insert the nail this is a noncannulated nail. So you don't need the guide wire X ray. A more distal, please. X A. OK. Can you roll towards me 20 degrees and then pull back a little bit. So we're trying to look down the medial cortex of the distal femur. Yeah, I feel like I'm probably just in bone. So you're about 65 there. So we'll go 65. It's a little bit of a battle here because we, we don't want to leave screws long on the medial side. But we also really need good bicortical purchase for this. So for the lengthening. So um so our blocking screw, blocking drill bit is blocking the other um screw hole. So let's put in our blocking screw. Yeah. So no shot. This is probably the most important thing if you, you should never ever do a lengthening career without walking through. Let me just check to make sure. Yes. In fact, we are buried. So now we need to put in our proximal interlocks. So we're gonna x A visualize these what we call perfect circles, X ray, X ray, X ray actually shots shots. No. Hold on the X ray. OK. So, pretty good. You happy. Yeah, let's Yeah, let's double check the stitch. And then we're gonna put in our second interlock and we're gonna put in probably uh three more blockers, two more blockers, one A to P in the proximal and then one sagittal plane in the additional segment. So we're gonna put it here so that it can't fall into there. Thanks, sir. Process. Thanks X ray, X ray. So we're gonna put in another blocking group posteriorly here to help X ray, X ray control deformity. Let's see how we get you shot. So, so one of the, I think this is really the most important part of the surgery after making the cuts correctly is X ray making sure that we have sufficient or appropriate blocking screws because they're going to increase the strength of our construct. We only have two proximal and two distal interlocking screws. And they are not multiplanar, but also as we lengthen, we're gonna induce deformity. And so we wanna make sure that this can only go in the direction we want it to go X ray. Let me see the depth gauge, please. Thanks, sir. OK. X ray. Thanks, sir. Uh Can I have a 35 please? That you? Thanks, sir. X-ray. So the last thing we have to do is Mark. Come down here. Mark where the magnet is X ray, X ray, X ray. Excellent. So this is good. She'll have kind of a scar right where she needs to put it. She just put that on there. Yeah. And a millimeter is what I always forget this. It's I know it's seven minutes with the thing. But yeah, so this is uh seven millimeters one minute. So I should be good there. OK. OK. So we confirmed it works. So we're good to go at this point. Um Let's just irrigate and close. Thank you very much.
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