On the first page, the first tibial image that we are provided shows us the location of the very first jig, which is the tibial cutting jig. While the surgeon is operating, he will reference this image to ensure that his tibial jig is in the correct location.

The next image that we are going to look at is the patient’s native slope compared to the slope that we will be making a resection, compared to the slope angle that we will be making our resection at. In this instance, the patient’s native slope is seven degrees and the slope of the tibial cut will be a straight cut, zero degrees.

So what we can expect from that then is to have a higher value or thicker bone cut from the front and as the cut proceeds posteriorly to the back, the cut value will get thinner and thinner. And that is because of the patient’s native seven degrees slope versus a zero degree cut value.

The next image is going to show us the cut values at five, or cut thicknesses at five different reference points along the tibia. After the surgeon makes his cuts, he can take this resected bone to his back table and measure the thicknesses at these five locations to make sure that the amount of bone that has been resected matches the amount of bony resection ConforMIS had recommended.

If there are any discrepancies, the surgeon can make adjustments at this point. One other piece of information we are going to look at on this image is the LL value. LL stands for lowest point on the lateral plateau. If this number is greater than or equal to seven millimeters, it is not uncommon for the surgeon to take two millimeters less bone, meaning a slightly thinner cut.

This will be based on how tight or loose the knee feels. The next image is going to show us the placements of the final tibial implant. This image is important because we want to ensure that the tibial implant is put in at the correct rotation, as well as ensuring that there is no significant under coverage or overhanging of the implant to the bone.

Also in this image, you will be told what the stem drill and keel size is. There are three options. Either 10 millimeters, 12 millimeters or 14 millimeters. In this one, the patients stem drill and keel size is 14 millimeters. Usually, always, if a patient’s keel size is 14 millimeters, then we know this is going to be a very large knee, which tend to be a little more difficult to work with.

We can expect harder bone and spending a little extra time fine tuning our cuts to make sure that they match the values provided by ConforMIS. The last image on the tibial page of the iview is going to show us what the patient’s distal femoral offset value is.

And in this instance, the lateral side of the patient’s distal femur, excuse me, on this particular patient, the patient’s distal femoral offset is going to be 1.6 millimeters. This means that the lateral side of the poly needs to be 1.6 millimeters thicker than the medial side of the poly in order to achieve a neutral mechanical alignment.

In other words, this is the required poly’s thicknesses in order to ensure a straight knee. Each knee will come with four polys on the medial side, it will always be 6.1 millimeters, 8.1 millimeters, 10.1 millimeters and 14.1 millimeters. And the lateral side will be the same thickness as the medial side plus the patient’s distal femoral offset, which again, in this case is 1.6 millimeters. So a 6.1 millimeter medial poly will have a 7.7 millimeter thickness on the lateral side. That’s 6.1 plus 1.6 millimeters.

The next page of the iview will provide valuable information on the femoral side of the procedure. The very first image is going to show us the proper placement of the distal femoral cutting block. The surgeon will frequently reference this image to ensure that the jig is placed in the proper location of the bone. The next image is going to show us the cut values for the distal femoral implant.

After the surgeon makes his resection, he can take the cut bone to his back table and measure the thickness of the cut bone compared to the resection values that ConforMIS provided. If there is any discrepancy between how much bone has been removed compared to how much ConforMIS said should be removed, the surgeon can go back to this jig and make the adjustments necessary in order to ensure a adequate cut value.

The next image is going to show the angle of the distal femoral cut, which is in this instance five degrees, as well as the soon to be made anterior cut, which for this patient is 10 degrees. The next image shows the F4 block otherwise known as the three in one cutting guide.

It is important to know that the medial profile of this cutting block or ijig should match the medial profile of the patient’s medial femoral cut bone, excuse me. It is important to note that the medial side of this F4 cutting jig should match the medial profile of the patient’s femoral bone. This helps ensure proper placement of the jig.

Once the proper position has been found, the jig can be pinned into place and the surgeon can then make his anterior and posterior cuts. After these cuts have been made, the surgeon can take the cut bone to his back table to measure the cut values and compare the amount of bone removed compared to the amount of bone ConforMIS recommended be removed. If the initial cuts did not remove enough bone, the surgeon can go back and make adjustments to ensure that the cut values…

After the surgeon has made his anterior and posterior femoral condylar cuts, the surgeon can then take this resected bone to his back table and measure the cut thicknesses. If the amount of bone that has been resected does not match the amount of bone ConforMIS recommended be resected, then the surgeon can go back to this jig and make the necessary adjustments in order to ensure the proper amount of bone has been removed.

The final set of images on this iview show how the final implant is going to look after the procedure has been completed. The images provided will show the appearance of the knee while the leg is straight from both the front and the back. We will also get a view of the front of the knee while the knee is bent or flexed at 90 degrees. We will also get a view of the side of the knee as it is flexed to 90 degrees.

The first image in the tibial section is going to show us the placements of the first tibial cutting jig, otherwise known as the T1. What we are looking for here is to see if there are any osteophytes that are on the bone that the jig needs to reference in order to ensure proper placements. As the surgeon proceeds with the procedure, once he arrives at this step, he will reference this picture to make sure that the cutting jig is placed and pinned at the correct location.

The next image that the surgeon will take a look at will be the tibial bone resection. Conformis will provide this image and show the surgeon what the resected bone will look like as well as how thick each section of the cut bone will be. After the surgeon makes his cut, he can take this resected bone to his back table and measure the thickness of it and see how that compares to the thicknesses Comformis provided.

If there are any discrepancies, the surgeon can go back to this jig and continue to cut more bone until the proper amounts of bone has been resected.

The next image is going to show us the placements of the final tibial implants. The surgeon will reference this image when placing the final tibial trial to make sure that the implant is placed with the proper rotation, as well as making sure that there is no overhang or under coverage of the final implants.

Since every implants is customized to respect the natural geometry of the patient, there should never be an instance where the knee is malrotated or there is significant overhang or undercoverage. The next image is going to show the patient’s medial and lateral insert offset. For this particular patient the distal femoral offset is 0.8 millimeters.

This means that the lateral side of the patient’s poly inserts are going to be 0.8 millimeters thicker than the medial side of the poly. So if the medial poly is 6.1 millimeters, the lateral poly will be 6.9 millimeters. This offset helps to ensure that we are achieving neutral mechanical alignment.

The next page of the Conformis iView gives us detailed information about the femoral side of the procedure. The first image is going to show us how the distal femoral cutting jig should be seated on the bone. The surgeon will be given multiple reference points to ensure the jig’s proper placement. Once the proper placement has been confirmed, the surgeon can then pin this jig into place and then cut away and then cut the distal femoral bone.

After the bone has been cut, the surgeon can take the resected bone and bring it to his back table and measure the thicknesses. And he can compare this measurement to the measurements that Conformis provided. If there are any discrepancies, the surgeon can then go back to this jig and continue to resect bone until the amount of bone resected matches the values that Conformis provided.

The next image is going to show the 3 in 1 block, otherwise known as the F4. With this jig, it is important that the surgeon ensure that the medial portion of the jig matches the medial portion of the patient’s femur. If these rules are met, the surgeon can then pin the jig in place and then cut his anterior bone followed by his posterior condylar bone.

After this bone has been resected, the surgeon can go to his back table and measure the resection values and compare that to the resection values Conformis provided. If there is a mismatch, the surgeon can go back to this jig and make adjustments as necessary to ensure that the proper amount of bone has been resected.

The final images on the femoral page of the iView are going to show how the final implants will look in the patient’s knee. The images provided will show the implanted knee. The final images provided will show the appearance of the implanted knee as the knee is straight from both the front and the back, as well as how the final implants will look while the knee is bent from both the front and the side.

The first page of the iView provides all of our needed tibial images. The first set of images is going to show us how the tibial cutting jig should sit on the bone. As the surgeon is placing this jig on the bone, he will reference this picture to ensure that the jig is in the proper location. Once the proper location has been confirmed, the jig will be pinned into place and the surgeon can proceed with his cut.

With every piece of bone that the surgeon cuts, Conformis will provide him the thicknesses that each cut should be. So, after the surgeon completes his tibial cut, he can take the resected bone to his back table, measure the cut thicknesses and compare that to the cut values Conformis provided. If there is any mismatch, the surgeon can go back and resect more bone. And so the proper amount of bone has been resected.

When looking at the cut values for the tibia, we will pay special attention to the LL cuts. LL stands for lowest point lateral. If the cut value here is greater than or equal to seven millimeters, the surgeon may consider doing a minus two cut, meaning take two millimeters less bone.

This will help to ensure that we have the opportunity to use the thinnest poly possible…Thereby, maintaining the patient’s native joint line or joint height. The next image shows the tibial tray placement. The surgeon will use this image to make sure that the final implant is placed at the right location.

The next image is the tibial tray placement. The surgeon will use this image to ensure that the implant is placed in the correct location with respect to the proper rotation and avoiding overhang of the implant off the bone or any under coverage. Since every Conformis knee is customized to respect the patient’s geometry, what shape of their bone, there should never be an instance where the tibia is malrotated. And there should also never be an instance where there is any overhang or under coverage of the tibial implant.

The final set of data, that is provided on the iView, will show the surgeon the thickness of the medial and lateral poly, or plastic that will be placed in the patient’s knee. The lateral side will always be slightly thicker than the medial side and Conformis calculates this by… The final piece of data that Conformis will provide on the tibia will be the medial and lateral insert offset.

Conformis will let the surgeon know what the patient’s distal femoral offset is. And will then design polys that respect this offset. So if the medial side of a poly is six millimeters and the offset is 0.5 millimeters, then the lateral thickness of the poly will be 6.5 millimeters. This allows Conformis to achieve a neutral mechanical alignment, which just means that the patient will receive a straight knee without the need for extra soft tissue releases.

The second page of the iView will provide all of the femoral images. The first image is going to show us how the distal femoral cutting block or jig will sit on the patient’s bone. As the surgeon advances to this part of the procedure, they will reference this image to ensure that this jig is in the proper location.

Once the proper location has been confirmed and the jig has been pinned in place, the surgeon will now make his distal femoral cut with his saw blade. Conformis will provide the cut values of the bone. After the surgeon makes his cut, he can now measure the amount of bone he has removed, and if he needs to remove more, he can go back through this jig and cut more bone. And so the proper amount has been removed.

The next image is going to show the three-in-one block, otherwise known as the F4. With this jig, the surgeon will make sure that the medial profile of the F4 matches with the medial profile of the patient’s bone. Once the location has been confirmed, the jig can be pinned into place. And now the surgeon will make his anterior cut and his posterior condylar cut.

After completing these cuts, the surgeon has the option of measuring the resected bone to ensure that the proper amount has been removed. And if not, the surgeon can go back through this jig and resect more bone. The final images, that Conformis will provide on the femoral page of the iView, will be that of the final implant construct as it will appear in the patient’s knee. Conformis will show this from the front and the back with the knee straight. As well as from the front and the side with the knee flexed at 90 degrees.

The iView does consist of two pages with the first page dedicated exclusively to images of the tibia. The second page is dedicated to the femur and the appearance of what the final implants will look like when they are inserted in the patient’s knee.

With regards to the tibia, the first set of images that will be provided will show the surgeon how the Tibial iJig should sit on the patient’s bone. These jigs were designed to reference osteophytes on the patient’s bone to help ensure a “something to grab onto” and make it easier to find the most ideal location.

As the surgeon is doing the procedure and trying to put this jig on the bone, he will look at this image to ensure that the placement of the jig is correct. Once the correct placement has been confirmed, the surgeon will pin this jig in place and will then referenced the iView to see how much bone is supposed to be removed from the tibial cut.

After confirming this amount, the surgeon will make his cut and bring this cut bone to his back table and measure the thicknesses of the resected bone at various points to ensure that enough bone has been removed. If there is a discrepancy, the surgeon will then go back with his saw blade through this jig and cut away more bone until the proper amounts has been resected.

The next image is going to show the surgeon where the final tibial implant should be located or should be placed on the tibia. This information is important to the surgeon because they really want to try to avoid malrotating the implants or giving the patient any excessive overhang of the implant over the bone, or having any under-coverage of the implant on the bone.

Since the Conformis tibia is customized for each patient and respects the shape of the patient’s knee, this helps minimize the risk that the knee can be malrotated or that there would be any overhang or significant under-coverage.

The final bit of information on the tibial page of the iView is going to show the surgeon the difference in the thickness of the polies from the medial side to the lateral side. Since Conformis respects the natural native articular geometry, or shape of the patient’s knee, we have to ensure that the polies or the plastic that’s put in at the end is offset to fill the joint space and not leave anything. Since Conformis knees are customized to respect the patient’s articulating geometry, or in other words, to respect the natural shape of their knee, this leads to the plastic or the polies needing to be offset.

The last set of images on the iView or the last set of, last bit of information on the iView on the tibial page will show the surgeon the difference between the medial and lateral thicknesses of the poly. Each knee will come with four polies and the surgeon will choose the poly that best balances the patient’s soft tissue.

The second and final page of the iView provides information on the femoral side of the procedure. The first image will show the surgeon where the distal femoral cutting jig should be placed on the bone. The surgeon will reference this image while placing the jig onto the bone. The jig will also give the surgeon feedback as to where it should sit on the bone.

Once this proper location has been confirmed, the surgeon will pin the jig in place and will check the iView to see how much bone is supposed to be removed from this cut. Once the cut has been made, the surgeon will take the resected bone, bring it to his back table and measure the cut thicknesses to ensure that the correct amount of bone has been resected. If there are any discrepancies the surgeon at this point can go back through the jig with his saw blade and remove as much bone as needs to be removed to satisfy the requirements laid out by Conformis.

The next image the surgeon will reference will be of the F-4 jig, otherwise known as the 3-in-1 block, the will want to make sure that this jig is placed on the bone so that the medial profile of the jig matches the medial profile of the patient’s bone. Once this location has been confirmed, the surgeon will pin the jig into place and then examine the cut values provided by Conformis and then proceed to make his anterior and posterior cuts.

After the cuts have been completed, the surgeon may take his resected bone to his back table and measure the thicknesses of each piece of the resected bone to make sure it matches with the values provided by Conformis. If there is a mismatch, the surgeon can go back through the jig with the saw blade and continue to resect more bone until the proper amounts has been removed.

The final images on the iView are going to show the surgeon how the final implant will look when it is placed in the bone. The surgeon will get a view of this with the leg in extension or straight from the front and the back. And then the surgeon will also get a view of how this will look with the knee flexed in 90 degrees from the front, as well as from the side.

The first page provides the tibial images. The first set of images on the first page of the eye view is going to show us the precise location that the very first cutting jig, the T1, should be placed upon the patient’s bone.

Preoperatively, the surgeon will look at these images to see if there are any noticeable landmarks that the jig has to reference. Usually, these noticeable landmarks are osteophytes. Intraoperatively, if the surgeon finds that the jig is sitting well in multiple locations, then what he will do is reference this picture to see which location is the best for this patient.

Next, the surgeon will pin this jig into place and prepare to make the tibial resection. The next image will show the surgeon how much bone is supposed to be resected at various points along the tibia. After the surgeon finishes this cut, he will take the resected bone to his back table, get a caliber, and measure the tibial cut at various points to make sure that the values that have been cut, that the amount of bone that has been cut matches with the amount of bone conformance recommended be removed. If there is a mismatch, the surgeon can go back to this jig and fine-tune his cuts to ensure that the numbers match up.

The next image is going to show the placement of the patient’s final implants. The surgeon will reference this image while placing the implant to ensure that the rotation is correct and that the implant is fully seated on the patient’s tibia without overhanging or any significance under coverage.

The final information provided on the tibial page of the eye view is going to show the patient’s medial and lateral offset. Each patient has a unique distal femoral offset. In this instance, the patient’s offset is 3.1 millimeters. What this means is that the lateral portion of the poly that is placed inside of the patient is going to be 3.1 millimeters thicker than the medial side of the poly. This allows us to respect the patient’s neutral mechanical alignments, or in other words, provide the patients a straight knee.

The next page of the eye view is going to show us all of the necessary femoral images as they relate to the procedure being performed. The first image of this page is going to show us the proper placement of the femoral iJig. Just like with the tibial iJig, you want to ensure that the jig is in the proper location. And we do this by placing the jig on the bone and seeing where it wants to sit, and then seeing if that location matches the location that conform is provided in the images.

The next image is going to show how much a bone is going to be resected for the distal femoral cut. After the surgeon has made this cuts, he will take the resected bone to his back table and measure the cut thicknesses and see if that measurement matches up with the amount of bone conformance recommended be removed. If there is a mismatch, the surgeon can go back with his saw blade and fine-tune the cuts to make sure that the correct amount of bone has been resected.

Next, we’re going to look at the F4 or 3-in-one block. What the surgeon will remember while doing this procedure is that the medial profile of this F4 cutting jig should match with the medial profile of the patient’s femur. Once the location has been confirmed and the jig has been pinned at the place, the patient will cut the anterior bone, as well as the posterior femoral cannula bone.

After the resection has been made, the surgeon will take the cut bone to his back table and measure the thicknesses of the cut and see if these thicknesses match with the thicknesses that conformance had recommended. And just as with the previous jig, if there is a mismatch, the surgeon can go back with his saw blade through this jig and continue to cut more bone until the proper amount of bone has been resected.

The final set of images on the eye view is going to show us how the final implant should sit inside the patient’s body. The images provided will show the final implants as it looks from the back of the knee while the leg is straights, as well as the front of the knee while the knee is straight and flexed at 90 degrees. Additionally, conformance will provide one image that shows how the side of the final implant will look with the knee flexed at 90 degrees.

Referencing this picture will give you an idea where the jig should sit based on the shape of the patient’s anatomy. The next image I’m looking at is the patient’s slope. So with this knee, we’re going to be cutting at zero degrees as a straight flat cut.

The patients need a posterior slope is 12 degrees, which means as we make the cut the anterior portion of the bone, it’s going to be a lot thicker than the posterior section. No red flags there, but you just want the surgeon to be aware that way they’re not surprised when they see the variance.

With the next image you’re going to see the cut values for the tibia at five different locations. What we’d like to do with this is after the patient, after the surgeon makes the cuts. We can take this cut bone on the back table and measure it at these five reference points to make sure that the amount that we cut is the same as the amount we should have cut. This way if we did not cut enough bone, we can go back and make the adjustment at that very moment. Instead of having to backtrack later on.

The last thing I want to look at on this image is the LL cut LL stands for lowest points to lateral. If this number is seven millimeters or greater, we’re going to usually recommend that, that the surgeon take a minus two cut on the tibia, meaning they’re going to cut two millimeters less Bone.

The reason we do that is to ensure that we’re using the thinnest possible polys. Also, since this eye view is available weeks before the actual surgery, if the surgeon sees cut values that are really higher than they normally are, he may wish to order additional thicknesses of polys. And because conformance is customized, that is an option that he has.

The next image is showing the placements of the final tibial implant. The surgeon will typically reference this picture when putting the trial on and making the holes for the implant to sit. This just ensures that the rotation is perfect, which usually it will be anyway, because this is a custom made implant and is designed to fit the exact shape of the patient’s knee.

The last image is going to show you the poly thicknesses with each knee, you will receive four, the surgeon will receive four polys. This is the plastic that’s going to fill the gap between the tibia and the femur. Every patient’s medial side is going to meet either 6.1 millimeters, 8.1 millimeters, 10.1 millimeters or 14.1 millimeters.

The lateral side is going to be the thickness of the medial side, plus the patient’s distal femoral offset. So on this one, the patient’s offset is 0.5 millimeters. So that means the lateral side needs to be half of a millimeter thicker than the medial side. So the thinnest poly will be 6.1 medial and 6.6 lateral.

The next page is the femoral side. The very first image is going to show exactly where the distal femoral cutting block should sit. I’m going to look to see how many osteophytes the patient has for the jig to reference. The more osteophytes, the better it just provides more landmarks to make sure we’re putting the jig in the correct Location.

If, we are ever in a situation where you can’t find the exact sweet spot where the jig could sit, should sit. You can reference this image, looking at these outrigger arms over here, ensuring that they’re hugging the correct osteophytes and helping to guarantee correct placements of the jig.

The next image I’m going to look at is the distal femoral cut thickness. Just like with the tibia, we can take this cut after it’s completed to the back table and measure it to make sure that we are where we should be. If there are any mismatches, we can adjust it at that very moment.

Instead of having to backtrack later in the case, which would add substantial more time to the procedure. The next image shows the knee from the side. It shows the angle of the distal femoral cut that we just made. And the angle of the anterior cut.

The fourth image is the placement. What’s called our three in one block. This image is going to show the patient, the surgeon where the jig sit on the bone it is important to note that the medial profile of this jig matches up with the medial profile of the patient’s bone. So if the jig is put on and the profiles don’t match, then the surgeon knows that the jig needs to be adjusted. It’s just an extra reference point and safety check to make sure everything is done accurately.

This jig will also tell you how much bone you are going to be resecting anteriorly. And then at the bottom here, it’s showing you the two posterior cuts, just like all the other ones. After these cuts are made, we can take this cut bone to the back table, measure it to ensure that our cuts are accurate and make any adjustments if they need to be made.

The last images of the eye view are going to show the final implant fitting as the knee is in full extension from the back. Full extension from the front as the knee is flexed at 90 degrees and one image from the side.

So, the surgeon will reference this intraoperatively and preoperatively. Preoperatively what we’re going to look at are the number of osteophytes on the bone. The osteophytes serve as great reference points to help ensure the proper seating of the jig. Intraoperatively we will double check our jig placements on the bone with the image that conformace provided to make sure that they match. Any adjustments that need to be made, can be made in this time.

The next image is a view of the knee from the side. What you’re going to be provided here is the patient’s native slope, which in this instance is seven degrees. And you’re also going to be provided the slope that the cuts is going to be made at which for this knee will be zero degrees.

So, since the patient’s slope is seven degrees and we’re cutting at zero degrees, which is a straight cut. Then what’s going to happen at the anterior or front of the bone, we are going to have a higher cut or a thicker cut than we will posterior section. This is not a concern. It’s just something we want the surgeon to be aware of so that when he makes his cut, he knows that he got what he was supposed to get.

The third image on the eye view is going to show the shape and thickness of the tibial cut conformace will provide five reference points that the surgeon can utilize to measure the actual cut bone versus the cut values that conformace, said they should be at. If the cut bone value is lower than what conformace had recommended, then at this point, the surgeon can go back and make adjustments.

The final bit of data that we want you to look at here is the L L cut value. L L stands for lowest point lateral. If this number is seven millimeters or greater, it is often recommended that the surgeon take two millimeters, less bone in order to help ensure the thinnest possible Poly is implanted into the patient.

The next image on the tibial page of the eye view is going to show us how final implants on the tibia should be positioned. This will help ensure the implant is not malrotated and that there is no overhang of the implant of the bone and no significant under coverage.

The final image is going to show us the patient’s Poly thicknesses, as well as the patient’s unique distal femoral offset. So, with every knee, the medial thickness of the Poly will be 6.1 millimeters, 8.1 millimeters, and 10.1 millimeters as well as a 14.1 millimeter.

And the lateral side is going to be the thickness of the medial side, plus the patient’s distal femoral offset. So in this instance, the patient’s distal femoral offset is 0.7 millimeters thicker than the medial side. So, if the medial side is 6.1 millimeters, then the lateral side will be 6.8 millimeters.

The next page of the eye view is the femoral side. On this patient, what we’re looking at are the locations of the osteophytes, as well as how the jig references those osteophytes in order to ensure optimal placement. The surgeon will look at this image, preoperatively and intraoperatively to make sure that the jig is seated correctly, which will help guarantee that we get the recommended resection values.

The next image is going to show us the placements again of the distal femoral cutting jig, as well as the cut thicknesses of the distal femur. After the surgeon makes his distal femoral cuts, he will take the resected bone to the back table and measure it with a caliber to ensure that the amount of bone that has been removed is the same as the amount of bone that can form this recommended we removed. If there are any discrepancies, it can be fixed at this moment.

The next image is just going to show the surgeon, the angle of his distal femoral cuts that he just made, as well as the angle of the anterior femoral cuts that he’s about to make.

The next image shows the F4 or B1 block. The first thing the surgeon should know about this image is that the medial profile of this jig is going to match perfectly with the medial profile of the patient’s bone. This helps ensure proper placement as well as helps to ensure adequate resection values.

Conformace will provide the thicknesses of the anterior cut as well as the posterior femoral congela cuts. After the surgeon resets the bone, all the cut bone can be taken to the back table and measured to ensure that the cut values are in line with what conformace provided. If there are any discrepancies, the surgeon can address them at this point.

The final set of images of the eye view, are going to show us how the final implants going to look while the knee is straight from both the front and the back, as well as how the knee’s going to look bent from the front and the side.

What we’re looking for are any major landmarks or large osteophytes that the jig is going to reference to help us make sure that we get it in the right place. The next image is going to show us the patient’s native slope, as well as the slope of the actual tibial cuts.

In this image, the patient’s native slope is 10 degrees and we are making a straight zero degree cut. What this means is that the front or anterior portion of the bone is going to be a lot thicker than the back or posterior section of the bone.

That is not a concern. It’s just something that we want the surgeon to be aware of. So after he makes this cut, he knows it looks as it’s supposed to. The next image of the tibial iView is going to give the surgeon the actual cut values of the resected bone.

So after the surgeon makes his cuts, he’s going to take this resected bone to his back table and measure the thicknesses and ensure that it matches with the resection values that Conformis provided. If there are any discrepancies, the surgeon can go back at this stage and make adjustments to his cuts as needed. The next image is going to show the tibial tray placement.

This is to help make sure that the final tibial implant is put in the best location for the patients without any malrotation. Also, avoiding any overhang or under coverage of the implants. Since the tibial implant is customized to fit the shape of the placement’s knee, the risk of a mal-rotated or poorly covered tibia is significantly reduced.

The final image on the tibial page of the iView is going to give us both our poly thicknesses, as well as the patient’s native distal femoral offset. The four polys that are given with each knee are going to measure on the medial side, 6.1 millimeters 8.1 millimeters 10.1 millimeters or 14.1 millimeters. On the lateral side, thickness will be the thickness of the medial side plus the patient’s distal femoral offset.

So in this instance, the patient’s offset is 1.9 millimeters. So if the medial side is 6.1 millimeters, then the lateral side will be eight millimeters. This offset poly helps us to achieve a neutral mechanical alignment, meaning the knee is straight.

The second page of the Conformis iView shows us the femoral images. The very first image on this page is going to show us the proper location for the distal femoral cutting block. The surgeon will take notes of any osteophytes that Conformis has outlined in order to ensure the proper placements of the jig. The next image is going to show, again, the placements of the distal femoral cutting block, as well as the section values for the distal femoral cut.

After the surgeon makes his cut, he will take the resected bone to his back table and measure it to assure that the cut values match the numbers that Conformis has provided. If is a mismatch, then the surgeon can make adjustments at this very moment without having to back track later on in the procedure.

The next image is going to provide the cut angles for both the distal femoral cut, as well as the anterior cut. The fourth image on the femoral side is going to show us the 3-in-1 block, otherwise known as the F4. The one thing to note here is that medial profile of the F4 block should match up perfectly with the medial profile of the patient’s femoral bone.

Once the surgeon has found the proper placement or has confirmed the proper placement of this jig, he will pin it in place and make his resections. Conformis provides the resection values for the anterior and posterior cuts. The surgeon can take these resections to his back table and measure it to confirm that the amount of bone resected matches the amount of bone Conformis recommended.

If there are any mismatches, the surgeon can go back to this jig and make his adjustments to assure that correct values are obtained. The final set of images on the femoral page of the iView is going to show us how the final implant will sit. We’ll get an image of how the final implant sits with the knee bent and with the knee straight, both from the front and the back, as well as an image from the side.

The first page of the iView shows us all of the necessary tibial images that we need to ensure a smooth procedure. The first sets of tibial images are going to show us the proper location of the tibial cutting jig.

While the surgeon is doing this procedure and placing the jig, he’s going to reference this image to ensure that the cutting jig is seated at the correct location. Once the correct location has been verified, the jig will be pinned into place and now the surgeon can make his proximal tibial resection.

The next image the surgeon will look at will show how much bone is going to be removed as a result of the cut through the T1 jig. Once the surgeon has finished this resection, he will take the cut bone to his back table and measure the cut thicknesses at various locations to make sure that it matches with the cut values that Conformis has provided. If it turns out that enough bone has not been removed, the surgeon can go back to his jig and continue to cut more bone until the proper amount of bone has been resected.

One specific cut value the surgeon will pay extra attention to is the LL cuts of the tibia. LL stands for lowest point lateral. If this cut value is greater than or equal to seven millimeters, the surgeon may decide to do a minus two cut, meaning they will take two millimeters less bone in order to preserve as much bone as possible and to help ensure that we use the thinnest polys possible at the end of the procedure, therefore creating the least amount of variance in the patient’s native joint line.

The next image is the location of the tibial tray. The tibial tray is the final implant that will stay inside the patient. The surgeon will use this image to ensure that the implant is placed at the proper location without any malrotation, also assuring maximum of the tibia with no overhang and no under coverage.

Since each tibia is customized for each patient, the fit of the implants on the bone should be precise. The final data provided on the tibial page of the iView will give us the thicknesses of the medial and lateral polys. The medial polys will always be 6.1 millimeters, 8.1 millimeters, 10.1 millimeters and 14.1 millimeters.

The lateral side of the poly will be the same as the medial side plus the patient’s distal femoral offset. This is different for every patient. And in this instance, the patient’s distal femoral offset is 0.5 millimeters. So in a 6.1 millimeter medial poly, the lateral side will be 6.6 millimeters. This offset allows us to achieve a neutral mechanical alignment, or in other words, allows us to give the patient back a straight knee.

The next page of the iView is going to show us all of the femoral images that are necessary in sharing a smooth procedure. The first image is going to show us the placements of the distal femoral cutting block. The surgeon will place the jig on the bone, and then will confirm with the image on the iView that the jig is seated in the right location.

The jig will reference as many osteophytes as possible to ensure that the location is proper. Once the correct location has been established, the jig will be pinned into place and then the surgeon can continue with his saw blade and make the distal femoral resection.

Once the bone has been cut, the resection can be taken to the back table and the surgeon can measure the cut bone and see if the thicknesses that have been cut matches the thicknesses that Conformis had recommended. If there is any variation, the surgeon can go back to this jig and continue to cut more bone until the proper amount of bone has been resected.

Next, the surgeon will look at the F4 jig, otherwise known as the 3-in-1 block. To ensure the proper placement of this jig, the surgeon will confirm that the medial of the jig matches the medial profile of the patient’s own. Once this location has been confirmed, the jig can be pinned into place and the surgeon can continue with his resections.

He will now cut the anterior portion of the femur, as well as the two posterior condyles. After the bone has been resected, the surgeon can take the resected bone to his back table and measure the thicknesses of the bone. If there is a mismatch between the amount of bone that has been resected and the amount of bone Conformis has recommended to be resected, the surgeon can go back to his jig and cut more bone until the proper amount has been removed.

The final set of images on the iView are going to show us how the final implants will look when it is placed on the patient’s bone. You will get an image of this from the front and the back with the knee straight and flexed at 90 degrees.

Daily activities such as driving, writing, typing, playing sports, gripping, etc require proper functioning of both the hand and wrist. Wrist pain, therefore, may have a significant impact on our everyday activities.

The wrist joint is made of a number of small joints connecting the forearm with the hand. There are 8 bones in each wrist connecting with bones of lower forearm and hand. Besides bones, there are tendons and ligaments forming an essential part of the wrist joint. Various structures such as nerves and blood vessels pass across the wrist joint in a small space.

The tendon is a tough connective tissue that connects the muscle to the bone. Similarly, ligaments are a tough tissue that connects one bone with another. The small bones with their articular cartilage form a joint with one another. The small joints in the wrist work in unison for smooth movements of the wrist.

Causes

Hand and wrist pain is commonly associated with injury but a number of other causes may lead to wrist hand.

• Trauma or injury to the bones, ligaments, or tendons of the wrist may cause sudden pain in the wrist. Injury may result in sprains, strains, or fractures. Scaphoid bone fractures in the wrist require special attention. The scaphoid fractures are not evident until a few days on X-ray.
• Triangular fibrocartilage complex (TFCC) is a small tissue that provides a cushion to the small bones on the pinky side. Tears of TFCC may cause chronic pain and instability.
• Cysts are small fluid-filled sacs that may cause pain and swelling. Ganglion cysts are usually located on the opposite side of the palm. It is a result of swelling of the covering of the tendons passing over and under the wrist. The fluid is similar to the fluid inside the joints.
• Overuse and repetitive motions may result in inflammation and swelling of the tissues around the wrist. Certain activities such as writing, typing, knitting, racquet sports, cutting hair involve repeated wrist motion which may cause inflammation.
• Carpal tunnel syndrome occurs due to compression of the median nerve as it passes through a small canal in the wrist.Overuse and repetitive activities such as typing may result in swelling of the tendons around the nerve. The median nerve gets entrapped and compressed within the small space.
• Kienbock disease is the avascular necrosis of the lunate bone in the wrist. The blood supply of the bone gets disrupted which results in bone death. The lunate plays an important role in the smooth movements of other bones. The disease usually affects young adults.
• Osteoarthritis is a wear and tear disease of the cartilage and surrounding structures. The condition mostly affects the older age group of patients. Other joints may be involved as well. Although the causes are multifactorial, the disease may run in some families.
• Rheumatoid arthritis is an autoimmune disease where the body’s own cells destroy tissues. Multiple joints are involved and commonly both the wrist joints may get involved.
• Psoriatic arthritis is another disease of the immune system associated with the skin disease psoriasis.
  Gout is a condition resulting from excess uric acid deposition in joints. Other joints are involved as well. High protein-rich foods, water pills (diuretic), alcohol consumption, and chemotherapy are risk factors.
• Tendonitis is the inflammation of tendons. Diabetics and pregnant women are more prone to develop tendonitis of the wrist with subsequent carpal tunnel syndrome.
• De Quervain’s disease affects the side of the wrist near the thumb. There is inflammation and fluid accumulation in the covering of the tendons.

Symptoms

The symptoms of wrist pain are wide-ranging depending upon the cause of the condition.

• Pain is the most common symptom. The pain resulting from wrist injuries may be sharp in character. The part of the injured wrist is usually tender to pressure. The pain from osteoarthritis may be dull in character.
• The swelling of the wrist in addition to pain is present in injuries and inflammatory conditions.
• Stiffness of the wrist joint may result from a chronic condition. The patient is unable to move the wrist in the normal range of motion.
• Pins and needles usually result from carpal tunnel syndrome. Additionally, the patients may complain of numbness of the pinky, ring, part of the middle finger and the thumb. Numbness and tingling sensation may accompany pain, especially at night.
• Loss of function in the form of gripping, writing, driving may result from pain, swelling, stiffness, or numbness.

Diagnosis

A physician visit is required for the diagnosis and management of wrist pain. A thorough history regarding the onset of wrist pain is obtained. The physician will then examine the wrist to look for tender points and swelling. The range of motion, deformity, and the strength of the hand and forearm muscles are assessed with special tests.

Radiological examination is generally undertaken. An X-ray helps to locate any fractures and signs of arthritis. A CT scan is helpful to look for fractures not visible on an X-ray. MRI helps to look for inflammation and swellings of the wrist as well as the nerve entrapments.

Ultrasound examination is done to look for superficial swellings, cysts, and tendons. The physician may also request nerve conduction studies to look for nerve entrapment. Additionally, blood examination may be done to rule out systemic illness.

Nonsurgical Management

The treatment options of wrist pain depend upon the cause of wrist pain. Simple muscle strains and sprains can be effectively managed at home.

• Rest to the wrist is important to reduce further damage to the joint.
• Activity adjustment or completely stopping the activity causing wrist pain is necessary to stop further progression.
• Icing is used for sudden injuries to reduce swelling and pain. Heat therapy may be used in chronic conditions to reduce pain and promote healing.
• Splints and casts are sometimes used to provide rest to the injured part while it heals.
• Therapy is helpful to strengthen and stretch the muscles around the wrist. Physical therapy also aids in increasing the range of motion of the wrist.
• Medications such as anti-inflammatory drugs are used to reduce pain and inflammation of the wrist. Conditions such as rheumatoid arthritis may require the use of drugs known as disease-modifying anti-rheumatic drugs (DMARDs).

Surgical Management

Certain conditions require surgical management, these surgeries can be done via an open incision or an arthroscope. Wrist fractures that cannot be managed with a cast or splint are operated upon. They may require fixation with hardware fixed to the bone.

An arthroscope is a special instrument consisting of a minute camera. The camera is inserted inside the wrist to look for possible causes of wrist pain. The camera images are displayed via a live feed on a large display. Arthroscopy is the gold standard for diagnosing wrist conditions.

The added advantage of arthroscopy is using miniature instruments to fix any encountered injury or disease. Various conditions such as carpal tunnel syndrome can be surgically fixed with an arthroscope. Consider visiting an orthopedic surgeon specialized in sports injuries if you have wrist pain for proper diagnosis or treatment.