We are looking for surgeons to join our established orthopedic practice in Manhattan and Long Island. We are looking in all sub specialties including Sports Medicine, Spine, Foot & Ankle, Shoulder & Elbow, Total Joint, Upper Extremity, Lower Extremity, Hand, Foot & Ankle. We are also looking for a physician interested in working with us in an outpatient orthopedic setting.

We offer a highly attractive financial package. The incoming physician will have a very congenial, supportive environment with physician extenders. Visa sponsorship can be done for the right candidate.

If you are interested, please reply to this email with an updated CV and a phone number and time to reach you. You can also email us at office@cortho.org

We are looking forward to hearing from you!

The vertebral canal is present between the front and the back of the vertebrae. It has all the nerves that are brought from the brain and supply all the body. The spinal cord in the vertebral canal sends out local, at each level, it supplies the nerves to the arm and the respective parts of the body.

The cervical spine is supplied by blood from the vertebral arteries on each side of the vertebral body. The cervical spine is wrapped around with muscles in the front as well as in the back. These muscles provide stability to the cervical spine, as well as lead to movement of the cervical spine. The food pipe and the wind pipe are present in the front of the cervical spine.

And patients who have instability may complain of loosening of the shoulder or the shoulder popping out. Patients also have nighttime discomfort and pain. Occasionally, patient may present with pain along the back of the shoulder blade or tingling and numbness and pain radiating down their extremity.

Transcription:

Larry Mikorenda: Hi. I’m Larry Mikorenda and welcome to Excelsior Forum, and with me today is Vedant Vaksha. He is a spinal surgeon and if we have heard that terminology, “Oh, my aching back,” and hopefully he’s going to tell us a little bit about what’s going on with that aching back.

Larry Mikorenda: If you would just tell the audience a little bit about your background and how you got to become a spinal surgeon.

Dr. Vaksha: Hi. I’m orthopedic surgeon and I did fellowships in spine surgery. I did two fellowships. Rochester, New York, and Cleveland Clinic, Ohio. And spine has always been my passion. So, with the background of fellowships, I have been practicing spine for the last few years now. Taking care of patients surgically, non-surgically, of their back, of their neck, and the lower back.

Larry Mikorenda: Now, how exactly is the back put together? We always hear disc and hernias and all these other things, and we’ll get into those later, but how is the back basically put together?

Dr. Vaksha: So, back is made up of vertebrae, which are multiple bones stacked over each other. Now, there are seven vertebrae which make up the cervical spine or the neck. There are 12 vertebrae which make up the thoracic spine, or the upper back, and there are five lumbar spine vertebrae, or the lower back.

Dr. Vaksha: Then, there are five sacral vertebrae, which are all fused together to make one bone called sacrum, and there are three to five coccyxial segments which fuse to become a coccyx. So, essentially there are three segments of the spine. The neck, or the cervical spine, the upper back, or the thoracic spine, and the lower back, which is lumbar, sacrum, and coccyx.

Dr. Vaksha: These are all stacked over each other to give a structure which holds the body together, helps in transmitting the weight of the upper body onto the lower body and the legs. At the same time, they protect all the nerves within the spinal canal, which go down the body to supply the muscles as well as bring the sensations back onto the brain.

Larry Mikorenda: Now, that was a mouthful. But the disc. We hear a lot of times, slipped disc, and everything. Where exactly are the discs in the back? Are they between the bones?

Dr. Vaksha: So, between each of these segments. These segments are mobile onto each other. So, there has to be something between the vertebrae to help them with the mobility. Essentially, every vertebrae with each other makes three joints. Two are the facet joints, which are the back, and the one is the intervertebral joint, which is essentially the disc. So the disc is a cartilaginous structure between two vertebral segments. It is made up of a fibrocartilaginous outer ring, and gelatinous inside, which is called a nucleus pulposus.

Dr. Vaksha: This disc is hydrated when we are born, and it gradually, as the aging process, loses some of this hydration, loses its water content, and that’s what happens when we call degenerative disc.

Larry Mikorenda: Now, you hear slipped disc a lot. “I slipped a disc in my back.” How does that occur? What’s happening with the body when you slip a disc?

Dr. Vaksha: So, essentially, when we talk about slipped disc, what it means is that there possibly is an annular tear in the disc or some of the material from inside what we call the nucleus pulposus, comes out from the disk pushes behind the disc, and maybe compress one of the nerve roots. This is essentially what is slipped disk, and this is closely related to what is called the degenerative disc disease, because with loss of hydration as we discussed the disc is prone to injury prone to tears, and this is gelatinous structure comes out pushing the nerves.

Larry Mikorenda: So if you have a slip disc, even if you fix it. It’s a good chance that you could re-injure it very easily.

Dr. Vaksha: Yes, as the disc is already in the aging process. So, the injury that has happened cause the slip disc or the disc herniation can again happen, can happen on the other side, can happen on the same side, but it is unusual. Though, not impossible to have the same thing at the same level on the same side.

Larry Mikorenda: Now we talked also about, we have pinched nerves or sciatica. So let’s take pinched nerves first of all. What happens with pinched nerves, is the disc is eroded… nerve gets in there? I really don’t know.

Dr. Vaksha: Yeah. So, as you know, the nerves are present in the spinal canal which is protected by the vertebrae itself. The nerves at each level, get out of the spinal canal from every vertebrae. Now this is the place where the nerve route is surrounded by multiple structures, which is facet joint on the back, bones on the side and front but also a disc in the front. Now this disc if herniated it can push this nerve root and decrease the space for the nerve.

Dr. Vaksha: When the space for the nerve decreases, it gets irritated, its blood supply gets decreased, it gets inflamed and that’s when it becomes painful. It presents with pain in the area that’s going to supply and it may be associated with other symptoms like tingling, numbness, really weakness. There are nerve routes which supply the bowel and bladder function. If those are involved, then they may involve the bowel and bladder function and patient may have retention, or incontinence.

Larry Mikorenda: So you can actually from having something wrong with your back, it can actually affect your internal organs also.

Dr. Vaksha: Yes, essentially, the internal organs that usually get affected if there is a problem in the back and nerves getting compressed, or bowel and bladder. The other internal organs of the belly and all they are essentially supplied by the other nerves which are not contributory from the back.

Larry Mikorenda: Right so that whole lower back area that we will call it the lumbar?

Dr. Vaksha: Lumber sacral spine.

Larry Mikorenda: Sorry if I can’t pronounce.

Larry Mikorenda: But also, we talked about sciatica we hear that word is so much, and so many back injuries. What exactly is sciatica?

Dr. Vaksha: Sciatica word comes from the inflammation or pain along the sciatic nerve, the sciatic nerve is formed by multiple nerve roots that come up out of the spine and fuse to become a thick nerve called the sciatic nerve. This nerve travels from the back of the head into the back of the thigh to the back of the knee, making small branches and supplies, all the way along. When the nerve roots usually l five and s one are compressed because these are the most mobile segments of the lumbar spine patient starts having pain which goes along the back of the thigh and the leg or on the outer aspect of the thigh and the leg. And this pain, which goes from the back towards the toes is essentially described as sciatica.

Larry Mikorenda: Now, also can that sciatic nerve give you pain in your hip?

Dr. Vaksha: Yes, very good question. So, the sciatic nerve can occasionally present with pain in the hip. Now, it’s not usually because of the nerve itself, but the because of the pathology that is causing the sciatica because it is compressing the sciatic nerve at the same time, there is some pathology going on, which may present with a hip pain, also.

Larry Mikorenda: Now, the way to diagnostic all right there’s so many areas of the spine, the neck, like you were saying, how do you go about diagnosing some of these diseases?

Dr. Vaksha: So, first of all, as a clinician, a history and physical examination is of paramount importance for these patients. The physician by the history itself, supported by the examination can make a clinical diagnosis, as to what’s going on. Then we need relevant investigations to support our diagnosis, especially when we are trying to do something actively for the patient to relieve the patient of the pain.

Dr. Vaksha: So we do x rays and just to see if there is no fracture, no subluxation, dislocation as to the amount of arthritis that’s going on, or any other relevant finding. Then, if needed we do advanced imaging, like the MRI.

Dr. Vaksha: MRI helps very much in detailing all the soft tissue in the spine, it gives us how the disc is how the capsules, how the facet joint, if there is any cyst, fluid filled cyst, if there is any ligament which is buckling causing compression of the nerve roots, a lot of information that we get from the MRI.

Larry Mikorenda: Now, do they ever use like sonograms for the back or anything like that?

Dr. Vaksha: Sonogram is not usually used for the back, but we can still use investigations like CAT scan, we can use investigations like putting dye into the spinal canal and taking a CAT scan after that called the CT myelogram, and this is essentially done in patients who cannot undergo MRI, and this is a population who have MRI non compatible pacemakers usually some patients with individual clips or certain implants, which cannot undergo an MRI. They are helped by a CT myelogram.

Larry Mikorenda: Now we’ve, we’ve mentioned and spoke before about osteoporosis on this program and one of the things is, is that these back injuries are not just limited to people who are over 50 or over 45, you also deal a lot with athletes and sports medicine, because it gets to the rigorous bending and jumping and everything else that they do.

Larry Mikorenda: How do you go about treating patients who are younger was going to have the spinal problems because they may lead to much worse problems later on in life?

Dr. Vaksha: Yes, younger population is prone to spine problems, more often like disc herniation, rather than the older population who are more prone to conditions like spinal stenosis, younger patients are a tricky population, because we don’t want to do too much because they have a lot of life in front but at the same time we don’t want to leave them in pain, which will make their life, very difficult to go on. Spine surgery as almost any other orthopedic surgery or today’s medicine is more about quality of life. So we try to do optimum, so that they can regain their quality of life, and live better.

Larry Mikorenda: And a lot of times, and I know from the other doctors who founded the program. They don’t want to be pill doctors they don’t want to keep filling people with painkillers and stuff like that, of course, you know there are some cases that may be different, but the majority is to treat and to get out get rid of this this problem not to just keep throwing drugs and stuff like that. So you will also specialize in certain therapies also for the back?

Dr. Vaksha: As a surgeon. I do prefer that I keep the patient, off especially the narcotic medications, but I need to give them, I will give them, but I try to keep them off that so I try to do the therapies, or surgeries so that they get better off all the problems that they’re having, and they get off the medication soon, as soon as possible for them.

Larry Mikorenda: Now we were talking about athletes before spondylitis, I believe it is, and the spinal stenosis, what are they?

Dr. Vaksha: So spondylitis is another technical term for degenerative disc disease and this actually starts early in the age, 30 or 40 years age but usually it’s asymptomatic and patients do not present in the age of 50, 60, depending on their symptoms.

Dr. Vaksha: Now in patients who are athletes, who are sportsman, they may have had rough reason they’re back in the past, which can accelerate the process of spondylitis, and they may present early. These are the patients who represent with disc degeneration, disc herniation, and they made a treatment for that. Contrary to that older population presents with more of spinal stenosis, in this, they may have disc herniation but they may also have bottling or calcification of the ligament which is on the back of the spinal canal called the ligament inflame and multiple disc bulges and they usually present at multiple levels.

Dr. Vaksha: These are the patients who contrary to the disc herniation patient who presented with a regular pain, or the sciatica. These will present with pain or nagging sensation in both their calves, both their legs, after walking a certain distance, and they will tell you, I walk a block, and then I cannot walk, I want to sit down, I need to bend forwards. These patients when they go to a grocery store, they will take a grocery cart and lean on it, and then they go to shopping. If they don’t have a grocery cart, they won’t be able to shop, because they’re not able to lean. So these are the patients who are spinal stenosis.

Larry Mikorenda: Now, we hear the term subluxation used a lot. Now, subluxation sounds like a some sort of building block or something like that. Can you tell us really what that is?

Dr. Vaksha: Yes, subluxation is what it means is partial dislocation.

Dr. Vaksha: That means that bodies, the vertebral bodies are in contact with each other, but they have not, they have separated slightly, or slightly more but not completely. In spine the word that we use is spodnylosis for the same thing. That means that the patient has a movement of upper body. Over the lower body, and these spondylosis are divided into grades. Grade one, two three, four and even five depending on how far it has gone. Most of the patients and these patients usually have a degenerative disc disease, present with a grade one spondylosis. And these patients, again, do not need treatment, till they have symptoms, which may be just back pain or which may be already clipping going down the legs. They may also have tingling, numbness, weakness, gait problems, walking problems because of the weakness in their muscles. Very rarely they will have a bowel or bladder problems.

Larry Mikorenda: Now, sometimes people think it’s restless leg syndrome. When it can actually be the back and the, I believe you said the lumbar part of the spine, because the spine is broken up into three sections right?

Dr. Vaksha: Yes.

Larry Mikorenda: Now, we also hear the word spinal tap a lot, which is scary to hear the word of it but basically what is that procedure that the spine fills up with fluid, it has to be drained or?

Dr. Vaksha: Spinal tap essentially it’s a procedure in which we put a needle into the spinal canal to pull the fluid out, and this is more often, a diagnostic procedure in which this fluid is taken out and sent to the lab for some testing and these are done if we’re suspecting a patient to have some brain infection on some spinal cord problem, which may be causing inflammation and.

Larry Mikorenda: So, when is it the time to see a doctor? When you are having, you know these problems in the back. I mean, should you just say oh I’m going to take a pill or you know ibuprofen or something like that and I’ll be okay in a day or two. When is the time to come and see you or see a doctor?

Dr. Vaksha: 80% of human population will suffer back pain, once in their life. That does not mean that all 80% have to see a doctor. Most of these back pain are self controlled, self restraining. So this treating of just treating them with a short period of rest, taking some medications, over the counter, using some ice, maybe heat. It can help elevate the pain and that’s it, but if the pain is not getting better with all these podalities in three to five days, then they should try to see their primary care to know as to what’s going on, and they may actually start some physical therapy for them or educate them how to use their back more efficiently.

Dr. Vaksha: But there are times when you start, especially when you start having been going down your legs, which again does not get relieved with the usual medication, then you may have to see a spine surgeon. Pain physician, someone who specializes in taking care of back pain, which is associated with radiculopathy or sciatica. And this is the time when you see us.

Larry Mikorenda: Now, also the term has been used spinal fusion. Now that’s something that sounds scary too but basically, can you tell us a little bit about what that is in case maybe somebody out there who’s going to have this procedure done?

Dr. Vaksha: Yes, so most of the times that procedure that we try to do is like a pain we are doing a procedure is decreasing the pressure from the spinal roots and this can be done in the form of this discectomy or laminectomy. Occasionally patient may have what we discuss about like sublimation or instability of the spine. These patients, if they just undergo a laminectomy or discectomy will further aggravate the instability and have problems. So these patients usually need to undergo a fusion surgeries. Also, if patients have more of back pain, then the leg pain, then fusion surgery is a better surgery for them to take care of everything which has been going on and elevate all the symptoms.

Larry Mikorenda: Now can some of these spinal problems also cause like twitching in the legs pain that constantly comes and goes? Recurrent pain? Some of the other things are like, total numbness I know some people like what the pains is it back but they can’t feel anything in the bottom of their feet, is that well because of the sciatic nerve or is it something else going on?

Dr. Vaksha: Yes. So, so there are certain patients who may have really severe form of this disease, and they need to, people need to understand when there is an urgency to go to see maybe a doctor, maybe urgent care, maybe emergency room. These are the patients who start developing worsening tingling, numbness pain, weakness of muscles, they start slapping their foot on the ground when they’re walking, which is called a foot drop. Patients may have numbness around their genitalia patient, may lose control of their bowel, bladder. And these are emergency conditions. They should seek urgent care. So as the process, which is causing this may be diagnosed and stop as soon as possible.

Dr. Vaksha: The diagnosis word that we use for here is accorded Aquinas syndrome, which is an emergent diagnosis and need, usually need surgical treatment to take care of it.

Larry Mikorenda: Now you had just mentioned before about a discectomy and I think it’s lumbar domain..

Dr. Vaksha: Laminectomy, yes.

Larry Mikorenda: What are those two procedures?

Dr. Vaksha: So these procedures are done in patients who have compression of the nerve roots, because of a disc herniation, then what we do is we go inside through a small incision minimally invasive surgeries. We use microscopes, we use tools, we use visual enhances, and we go in clean little amount of bone, go on to the disc. The disc which is causing the pressure on the nerve, results are great these patients do really well. This is a very small surgery minimally invasive surgery and this surgery do not contribute to the instability of the spine for the future and patient gets relieved. Laminectomy are usually done if the patients have symptoms on both sides, or in patients who we discussed as spinal stenosis because there is more of stenosis in the center, there’s a thickened ligament in which we talked about, maybe calcified, we need to remove that and then laminectomy is done. Again, a very successful surgery, very good results.

Larry Mikorenda: Now, with the way surgery is gone now you’ve been around for a while, and how would you say that the way modern medicine, just during the past six years in your field has changed? It’s pretty incredible isn’t it?

Dr. Vaksha: Yes, the best things that we have got our visual enhancers, the optics, the microscopes, the loops that we use, the lights that we get, apart from instrumentation. Also we have developed very new surgical techniques, over the last, I would say 10 years, 15 years. And these surgical techniques and enhance in plant material has specially helped us in developing the fusion surgeries, initially fusion surgery was only done from the back. Now, we can do the fusion surgery is from the back from the front from the sides and is done in the right patient can give great results.

Larry Mikorenda: Now, another thing I heard about which is really blew my mind is these synthetic disc, where surgeons can actually go in there, remove the deteriorated disc, slide in this synthetic disc which is probably even better than the regular disc that it’s replacing because of the content and cushion and everything else is made of. Now, what exactly is involved with that?

Dr. Vaksha: So there are very small percentage, but there are patients who can be a great candidate for a disc replacement surgery. In this, these patients usually present with low back pain, and they have when we do an investigation find a very degenerative dark disc. Usually a single level disc and for this we have to go from the front from the belly we go in clean up the disc and put this artificial disc.

Dr. Vaksha: What’s advantage of artificial disc? Well, we are able to keep the movement of the disc level intact because rocking a movement causes increased stresses on the segments above and below, causing them to degenerate. So keeping this movement intact, we are not bio mechanically harming the spine. So we are not doing fusion, these are non fusion surgeries and patient do great with.

Larry Mikorenda: And the synthetic material gets along fine with the body where there’s no major rejection and all these other problems that you get with these other things because it is the spinal column right?

Dr. Vaksha: Yes, good question. So again, this is very unlikely that the patient will have any rejection on these, these implants are very biocompatible, they have been tested, have been researched on and have been used in a number of patients before even get an FDA approval. So these things are researched very well on it.

Larry Mikorenda: And just before we get ready to wrap up here. I had a couple other questions for you. As far as the surgeries are concerned. Now, someone goes in for, you know, back repair lumber ectomy I can go on and on about some of the ones. Now, a lot of these people think that because they had back surgery… I’m going to be out of it for two or three months, I’m going to be you know a half a year and that’s no longer the case for these surgeries is it?

Dr. Vaksha: We try that our patients get out of bed, the same day or the next day, so that they are mobile. Definitely the fusion surgery or bigger surgeries, they are a little more painful, we control pain for the patient we keep them in the hospital for a few days and then send them out. But these patients are mobile right from the day one, and we keep them active, so that they can get back to their normal life as soon as possible.

Larry Mikorenda: So compared to like to say, even six or seven years ago, the turnaround time with the spinal surgeries has decreased majorly compared to where they used to be five or six years ago so people who maybe need the surgeries, they should not have to worry about recovery time?

Dr. Vaksha: I think we have come a long distance over the, I would say, last two decades, with all the improvements in the surgeries in the way we do it the approach we do it, and how we treat them, even after the surgery. We have a team, which works with the patient, the physical therapists, the hospital and everything to make them keep them mobile to make them out of bed, as soon as possible to keep the complications down, and to keep their quality of life high.

Larry Mikorenda: Well, we’re basically at a time here but if you stay tuned for part two, you’ll catch part Two on this program, later Vident W.on this week and we’ll have more. This time we’ll be talking about the neck. Until next time, I’m Larry Mikorenda. I’ll see you right here on this channel

Dr. Vaksha: I’m Vedant Vaksha, I work with complete orthopedics. We have offices in Stony Brook, in Little Neck, and in Babylon, and I can be reached through our website, cortho.org, or through our phone number, 631 9812663.

These patients usually present with pain in the shoulder joint, which is worsened with overhead activities. They may also complained of nighttime pain and discomfort. The diagnosis of rotator cuff tendinitis is usually made by a history and physical examination. An MRI may be needed to rule out rotator cuff tear in such patients.

The treatment of rotator cuff tendinitis is essentially nonsurgical.

It involves medication, physical therapy, and if needed, cortisone injection. These patients recover very well from the inflammation and are back to their normal life in about three to six weeks. Occasionally, in patients of rotator cuff tendonitis, surgery may be needed especially in those who have a bone spur or the acromial osteophyte, which is digging onto the rotator cuff tendons and causing the inflammation.

Workers’ compensation covers all medical treatment for your work related accident. One must never pay out of pocket for any medical bills involving work injuries. The Workers’ Compensation system pays for all hospital and medical expenses that are necessary for treating your injury.

Types of workplace injuries

There are many types of workplace injuries. Some common injuries include:

• Sprains / strains
• Cuts and lacerations
• Burns
• Breaks and fractures
• Amputations
• Back herniations / sprains
• Neck herniations / slipped disc
• Concussion/ Head Injuries and Traumatic Brain Injury

What to Do When you are Injured at work?

As soon as you are injured at work, make sure to give notice to a supervisor. The Board rule says you have 30 days to give notice to the employer by writing or orally. While the Board says you have these 30 days, you should not wait. An employer will do an investigation once they have notice of an accident. If too much time goes by without telling a supervisor, they may raise doubts and deny your case.

The next thing to do is to seek treatment. You should go to a reputable doctor such as Complete Orthopedics. The right doctor can make or break a Workers’ Compensation case. The goal is to treat early so that all of your injuries could be documented. If one of your injuries is not claimed immediately, there is a chance that the Board will deny the injury.

After you give notice and have treated, you need to file the prescribed Board form to start your case. The form is called a C-3 and it is available at the Board’s website. Here is a link to the form.
It is also important to consult the right lawyer. Representation in Workers’ Compensation is free and there is no obligation. There is no fee unless the lawyer obtains a cash award for you.

Does Workers’ Compensation Cover accidents and Illnesses Occurring Over Time?

A direct injury such as a fall off of a ladder or a motor vehicle accident is covered by Workers’ Compensation. Many injuries, however, occur over time and cannot be easily seen. For a person that types a lot all day they may develop carpal tunnel syndrome. For a factory worker, constant lifting or bending at an assembly line can cause herniations and slipped discs.

Many workers therefore receive compensation for injuries that are caused by overuse over a long period of time. Examples of this type of injury are tendinitis or gradual tears to the knee or shoulder. So it is not just accidents.

Besides direct and repetitive injuries, you may also make a claim for industrial exposure injuries. These conditions could be the result of your work conditions. For example asbestos workers can make a claim for lung disease by being constantly exposed to asbestos dust as they strip paint. Transit workers can make a claim for hearing loss if they are constantly battered by loud noise on tracks and tunnels. You may also be eligible for compensation for some illnesses and diseases not limited to include heart conditions, lung disease, and COVID.

Can I Be Treated By My Own Doctor?

In New York, you are entitled to choose your own workers’ comp doctor to treat a work-related injury, as long as the doctor has been authorized by the New York State Workers’ Compensation Board. A doctor such as Complete Orthopedics, can diagnose your condition and give you the treatment you need.
Are All Employees Covered By Workers’ Compensation?

Many businesses in New York State are obligated to provide workers’ compensation coverage for their employees. The rule may include part-time employees and family members employed by the company. Note certain jobs however do not offer Workers’ Compensation coverage or benefits. Most full time NYPD police officers, Most Department of Sanitation workers, Most NYC School teachers are not covered by Workers’ Compensation. There are exceptions though, so contact a Workers’ Compensation attorney to see if you are eligible.

Author Bio:
Sam Hechtman, Esq. is a lawyer with Ugalde and Rzonca, LLP. He has been with the firm since 2005 and practices exclusively Worker’s Compensation and Social Security Disability. The law firm focuses on all Workers’ Compensation accidents such as slip trips and falls, construction accidents and occupational accidents.

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.