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A-1179 Wide awake surgery in PIP and MCP total joint arthroplasty
Mike Hayton, Wrightington, UK
Friday, June 15, 2018 · 3 p.m. · 14m 12s
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00:00:00
okay so uh thanks very much for uh for inviting me to speak um
00:00:05
so wide awake low class easy hon surgery um i've been championed by down home then as you know is that quite
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a few uh presentations of the last few days and is really sort of champion this and many of us
00:00:17
would you answered your take it on board and the certain operations which really lend itself to this type
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of procedure things where you need biofeedback from patients so you need to assess range of movement
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each assessed ability each of s. s. f. fixations issues tend and a flex a tendon
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will probably reconstructions all these types of things are really great for wide awake considering
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uh and not more so than a p. i. p. your replacement i can't remember
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the last time i put a p. i. p. joint replacement to sleep
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for a a an an offer plastic gears don's book and
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also the web side both which a non profit and
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i'm a commodities and uh all the money goes back into a into a
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a the a leading green american society so it's a good thing
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to do and i think you should uh i will have a look at this book and silly will help you with your wider techniques
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so what is wide awake concert rely like um when i'm explaining it to searches you pass never done it
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before i say it's like walking your dog across a field in the summer or in the winter
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so in the summer you both walk across pretty quickly you get that to the other side you have a good time and you don't have a
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good time when you do in the winter is a bit wetter it's a bit it's low g. uh you don't have a great time
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and you don't have quite as good a time so that's kind of how why or how i summarise wide awake
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city so p. i. p. doesn't make any difference whatsoever is just a ring locked if you didn't you patrols
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uh uh skin grafting all that kinda stuff it does that it probably about twenty twenty five percent want you surgical time
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so i'm a p. r. p. don't replace when you know the speaks of told
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before patient expectations a really important thing that you need to get across
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we can predictably get that painter very tolerable level or range of
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movement may be unpredictable and the writing team data from
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all or implants we probably should on suggests that the range of movement that you take into the operating theatre
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is likely to be a two year range of movement so we generally speaking don't tell operations when it
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increase your range movement you gonna maintain it but hopefully your pain is gonna be somewhat less
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having said that with silicone you know you can be a little tiny bit more aggressive we get caught so
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you may increase your range movement but our research is tell us that we don't improve or injured man
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the good thing about than on the local on saturday as you can tell you patient low looking a finger this
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is your range of movement now this is the stability deepen the two piece implanted in these be them stable
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in certain positions you can say don't take it down to this level
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so this is enormous patient biofeedback yeah you can get with patients
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so it's all about adrenaline and uh really in the for the p. i. p. don't i still use a digital tony
00:03:04
kaye so don't think that i'm doing this just a a on the local ascetic of course you can do
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i think it's only case of no pain whatsoever it's the patient and it just gives you a slightly uh the
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less bloody failed so if the n. c. p. replacements i don't use it all the cable come out a
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lot so adrenalin we know it causes phaser constrict she's been using dentures for a long time selling when i
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was at med school it was absolutely uh no no in the finger digital screen here and the crosses
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but we now know that he's relatively safe and there's lots of publications out there saying it is safe
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uh hoff live less than the cops clinical times no mostly the digit
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but also you should have some fence how many available if you feel a bit
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moot nerves again the procedure and you wanna raise a reverse the adrenaline
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this was a flex it probably a reconstruction i showed yesterday
00:03:53
when we do a local aesthetic a wide awake no
00:03:56
twenty k. surgery you put a little tiny wall to mail blob of local an ascetic in the paul
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go away for five ten minutes get that skin them and then put a little bit more in
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what you weigh down the thing over the next five to ten minutes that's if you have time you hounds i'm busy y'all
00:04:14
busy in generally speaking i just go up all the way down the finger and i get it over and done with
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so that's how i do uh i think the block which is very straightforward you will be able to do this for p. i. p. joint
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i'll tell usually how to do m. c. p. jointly slightly different so
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there's nothing special about people if they're i think a block
00:04:32
for p. i. p. job we do know that uh actually reduces the
00:04:36
toxicity of local aesthetic but also it keeps in the finger for
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a lot longer and uh it doesn't get washed away so your arms that is gonna last a lot longer which is great
00:04:47
the advantages the paper patient is there's no jen wanna setting
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hangover no nausea there's no significant formal up around twenty
00:04:54
k. pain they can go home straight away but the main advantage is you can say come on but we
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had over the green have a look at what we've gone look at the range of movement this is more
00:05:04
we're not gonna get any more when you leave here so this is as good as it's gonna be
00:05:10
that helps them get in the mine because sometimes when the doing therapy you know that that pushing pushing pushing against the brick wall they
00:05:16
know what the maximum range of movement is is when they are in the or with you and we call it pretty hard
00:05:22
so we have often far piece coming to fit with this to tell a patient what
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budget is gonna be over the next six to eight weeks as a rehab
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you can also do surgery for much longer than you could under twenty k. so
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probably ten reconstructions like the tandem reconstructions you're not worried about twenty k. time
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so writing to express with p. i. p. joints with kind of put them all my formal it over
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the is very large series and all of them and i've cannibal myself down to silas stick
00:05:52
over twenty years experience now with this implants or writing ten and that's kinda might go to i use a flexible hinge
00:05:58
and searches the new flexes you on those didn't uh removed i'm not going to
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strike a and that's kinda my will course implant for the majority of people
00:06:07
but i do put the the p. i. p. yeah are we from all
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of the way in which the module affiliate shows you the two alternatives
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i think that's early has significant advantages over a a a more block ascension uh
00:06:18
type prostheses so these modular prostheses i tend to prefer that preserve those four
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the uh younger patient without significant but only defect uh all body
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of the mouth people i've still got significant pain function limitation
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so there are uh the the c. d.'s the two types of implant on the right is
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the the metal so in trails that implant on the right is the new flex
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so the p. i. p. joint replacement as i say it's just a simple ring
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block under a plus or minus um actually k. i think is in
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important feature relies that it makes no difference to you technically what do you do this
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on the local or the jen wants that i don't think you patients asleep
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it's gonna be any easy is just the fingerboard the patients gonna be that but they don't have to tell you
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don't swear when things go wrong when you you fractures something obviously that's not the ideal but you patient
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will be away we'll give you this feedback so it's the last choice which you want but
00:07:15
approaches i've tried the mold a historically we did the dorsal sham
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a approach we got really bad extend so lax and i
00:07:21
think that's what can only be two in his door so we don't do we've not done that for the ten years
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let's approach my colleagues even trial he lives a lot to approach i don't really like it
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the vocal approach like i don't really like it when i do is i do exactly
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what felipe is to show here is this central splitting approach which is super easy
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grey exposure really sick actually humans of using a flexible hinge
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um and um you don't need to reattach the central slip and i'll show you the video about that shortly
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so here is is just an incision right down the middle of the boat and you just open that central slip like about
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there's no accents alike in our experience with this i think that was with
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the shah may as a set with the central slips letting not re
00:08:05
attaching the central slip close like a boat there is no accents like is
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it a video of it just speeded up to operate this quick
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in trial those
00:08:21
the thing is with just a it just last about a minute and a half this
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the seal okay yeah so you get a knife goes right down to bone
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down the midline
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just stop short of the d. i. p. joint and then you just elevate one
00:08:42
side of the bach on one side that's essential slip be lifted off
00:08:49
sometimes uh some sound advice in the back is solely with the bribing not remember
00:08:54
swelling of these joints from some devices post optically can inhibit range of movement
00:08:58
so i do deprive designer might is and then you just simply release the other
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side of the uh the uh the uh um tendon off the bone
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once you get around to the mid axial portion you that able to flex the finger forward
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and then start to realise the clutter ligaments
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we go with the flex that fall it's
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i think this page is actually sleep one of them this was we've got a long time ago this video in say a
00:09:38
knife inside the joint and then just realise that collateral ligament on one side and then release on the other side
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the little play release and then you can gonna make some really nice a bone calls on the the side and just just zoom for
00:09:52
both uh it's got a nice box i really like to take out all the bone
00:09:58
i have a feeling side that to make sure there's no like topic bone
00:10:01
no classification the clutch roles which can tell c. five and then in case the
00:10:05
bone i didn't prepare the canals in the routine wage you all know
00:10:11
and then and um for the implanted and then this is how why yeah how i suture the uh the central
00:10:19
split as my implanted it especially was awake now we would be do
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range of movement just assessed on table stability such to proclaim multi
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i've put one see joe in the central slip across light doesn't
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reattached countable look how far away from the boat it
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would be far we attach that back down i would cause a lot of problems a lot of problems with flexion
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and all we do is just simply run a locking suture along the line of the finger
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such is that okay
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easy easiest approach you'll ever do
00:10:58
so um we discussed about the the hinges i don't wanna go over the
00:11:02
others because um i it says tends to be my go to implant
00:11:05
this particular good with hyper traffic osteoarthritis you wanna excise all all the uh all the bone
00:11:12
is a patient after five months um right range of movement another one here five years
00:11:21
indexing is it five years
00:11:25
no accents alike
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so again was say in this room much ah just to say is it more difficult
00:11:36
to do with two peas or one p. c. on the local ascetic there's actually
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no difference whether it's ga or local as i think the both just is a
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is equal this is a two piece component or the uh the metal though
00:11:47
pick up a little thing i just had a previous the i. p. future again not to ninety degrees here out
00:11:54
so that's p. i. p. joy that's pretty straightforward and c. p. is slightly different
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what i suggest you do with this is put in intro articulate injection
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i don't image guidance or if you can feel the joint line
00:12:06
drop it one mail into the joint as was along the line of your incision
00:12:10
and turn the handover i just put some local ascetic around a one probably region
00:12:16
and here's a case against silas stick implants
00:12:20
long table you can at least the trial implanted and uh
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just assess what the range of movement is on table isn't is never gonna be as good as that so
00:12:30
and you show the patient watch arrangement and then you just simply switch the two tendons online each other
00:12:36
so double bubble is one patient came in to show that you can this was local on the
00:12:39
say why the way you can uh look at the range of movement doing two joints
00:12:44
and then from i. p. joint a replacement this was in the news it a magician
00:12:50
and he needed thumb i. p. joe inflections to do is card tricks and he got a traumatic
00:12:55
uh injury choose p. i. p. join us spontaneously fused so he wanted this i'm replacing
00:13:02
so we thought well have a bit of a challenge in this case i did do a show my approach 'cause i didn't feel so i could um
00:13:08
successfully do a set your uh a long too dull splits we do this show on a
00:13:13
the advances sham age you can lengthen if you need to with the v. why i cut to a bone block
00:13:20
but the implants in situ the up a long table we were then able to assess is range of movement on table
00:13:28
we could show in this is your range of movement now
00:13:31
but a bleeding and here is up to six months not brilliant movement
00:13:36
maybe with hindsight could take a little bit more bone out
00:13:39
but he was enough for him to flip the card so he was a happy uh it was a happy bunny
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so in summary i think you should always considered in uh your p. i. p. choice on the local an ascetic and
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even with the digital topic i i always use a digital tony kaye just makes it just a bit easier
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um to m. c. p. joints obviously company twenty k. on and you could just fill the joints what we determined and there's no
00:14:00
difficulty with the now and again no difficulty to look on a
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A-1179 Wide awake surgery in PIP and MCP total joint arthroplasty
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