Smith & Nephew Technologies: VISIONAIRE™ Patient Matched Instruments and LEGION™ Total Knee System Intermountain Health Care Hospital Park City, UT May 10, 2011 Good evening. My name is Jim Bresch, and on behalf of Smith & Nephew I’d like to welcome everybody to here Intermountain Health Care’s Hospital for Joint Replacement, an LDS hospital in downtown Park City. I’m sorry, Salt Lake City. I made that same mistake earlier. I’m from Chicago, and it’s wonderful to be in this beautiful area with this beautiful mountain view. Today we’re going to be talking a little bit about the technology that goes into a visionary knee. Dr. Joshua Hickman, who you’ll be introduced to in a minute, is going to be performing live surgery, and I’m going to help out by moderating. Before we get to the surgery I just want to cover a couple points that might help us this evening. First I just want to address what we’re going to be putting in. We’re going to be taking advantage of Smith & Nephew’s Verilast technology. Many of you are familiar with this; many may not be. The Verilast technology is a combination of materials that provide for optimal survivability of components, and this has been lab tested by Smith & Nephew. Essentially it’s using the Oxinium femoral component, which is an exceptionally smooth and hard surface on a highly cross-linked ultra molecular weight polyethylene insert, and to not bore you with the details but standard testing was performed out of three years’ wear on most systems and comparing the Verilast technology with conventional cobalt chrome been able to see wear characteristics markedly lower. They’ve been able to test it out to a simulated 30-year lifespan. Most individuals take approximately 30 to 44 million steps over that 30-year period. Testing these materials out that far we’ve been able to see marked reduction in wear characteristics. At the three-year benchmark, we saw 98% less wear compared to conventional cobalt chrome and poly. At the 30year mark there was only 81 – I’m sorry, there was 81% less wear in the Verilast group, which is excellent signs and the study is ongoing. Today for our implants the surgeon has chosen Legion knee system. We’ll talk about that a little bit as the case continues. With the Legion system, there’s the options for Oxinium or cobalt chrome on the femoral component. Standard tibia is stemmed. It’s asymmetric so it’s specific to right and left and has a broad spectrum of polyethylene inserts ranging from cruciate retaining all the way to constrained. This system also has, as you can see, the options of extending up to a revision system with augments, stems and offsets. The Legion system can be installed using the typical Legion conventional instruments, I’ll call it, which most of us are familiar with. It can be navigated or it can be used with Visionaire. What is Visionaire? And this is going to be what we’re going to address throughout this evening. But basically Visionaire is both a process as well as a molded patient-matched block. In essence, we’re using pre-operative long-leg x-rays to pre-operatively determine the patient’s mechanical and anatomic axises. With this information coupled with an MRI we’re able to obtain and maximize placement of our cuts using patient’s chosen reference points for where that cut designation should be and where our landmarks will be. And we’ll talk about this as the case goes on. Basically what we are going to get the computer to do is to provide a computer model. Now you don’t get the actual model because you have the patient, but in this situation the computer generated a bone model that is an exact replica of this patient’s femur, and basically using the pre-operative planning which we’ll go over, we’re able to get a patient-specific molded task with our cutting block and cutting slot built right in. And this slot is what you are going to determine your pre-operative setting. Very accurate as far as how that’s placed, and we have the same thing on the tibial side where we’re going to get a – a patient-matched block that determines exactly our placement, verifies our rotation, and determines where our cut level is going to be. Having said all that, we’re going to go over to pre-operative planning right in the operating room, so to get to the reason why we’re here, to see Dr. Hickman, I’d like to introduce everybody to Dr. Hickman. Josh, take it away. Great. Hello. Welcome. This is a – this is our patient for today. She’s a 62-year-old female with significant tricompartmental DJD. You can see here’s her AP x-ray. She has significant osteophytes, both on the femur and the tibia. You can see them posteriorally. Clinically she has a significant flexor contracture of ten degrees. And

OR Live bah 2777 show so, as you can see here, this is our surgical alignment plan. And what we’ve done is we’ve taken all the information from her radiographs and from her MRI. We’ve taken her clinical information, and though this looks busy, we’ve used that information to come up with a plan to create blocks which allow us to accurately replicate her mechanical axis as well as her axis in the coronal plane. She has a flexion contracture, so as you can see here, instead of taking the routine nine-and-a-half millimeters distal cut, we’re going to take an extra two millimeters. We’re able to plan that before the surgery. The nice thing about this system is that we take the information, we take the plan that we want to project onto the patient to actually recreate that alignment. We then can see how that’s going to translate onto the patient’s anatomy. We can see that we’re not going to notch. We can see that in the coronal axis, the AP axis is replicated. The epichon – we have our rotation parallel to the epicondylar axis, and even though she has a dysmorphic or slightly abnormal femur, we can see that our – our implants are going to fit nicely. We can also see this on the tibia side as well. We can go ahead and get started. I’d like to introduce our – our folks in the room today. We have Rob Sumpter, he’s our Physician’s Assistant. He works with me. He’s excellent. Marie is assisting us. Craig is our Surgical Technician, who’s excellent. Amanda, our nurse in the room. And Steven, our anaesthesiologist. We’ll hold off on the last names to protect the innocent, so. The other thing I want to show everyone is there – there’s several things about the Visionary system that I think are very important. One is that it offers an opportunity for improvement of patient outcomes and reproduce ability and alignment, which I think have very marketable clinical benefits. In addition, I think it offers some cost savings. You can see here, this is all we need to perform the procedure. Instead of eight pans, which is a traditional Legion total knee, we’re using two pans. The other important aspect in addition to cost savings, they’re sort of the, what I like to call the intangibles of the operation. And what I mean by that is – is because there’s less equipment, I think you can appreciate this compared to a standard total knee, the – it – it allows for a very nice flow in the OR. It allows for a decreased level of stress among the nursing staff and the – the surgical technician so that they can really more easily focus on their job and we can focus on our job. Josh, as you’re getting started you hit on some of those points, are you actually studying these things within your hospital, these – these economic advantages? We have. With Intermountain Healthcare’s excellent organization for documenting costs. And what we found is that each pan costs between $80 and $140 to sterilize, both in personnel costs as well as material costs. So if you eliminate six pans, you’re essentially saving $600 to $700 immediately each case you do. Obviously, if you’re doing many cases, that’s a significant savings. We also found that we decreased our turnover times in the rooms by about ten minutes per case, so it’s essentially limited to anaesthesia time. We’re going to go ahead and get started here. Again, what I like to do before we get started. She has a flex contraction, we can’t get full extension. I always like to sort of get a sense of her balance before we – before the operation. Knife. We do a standard medial parapatellar approach. And in this case, we’ll probably not do quite as small an incision as we usually do. Pickups. Josh, do you ever let the patient bully you into doing a midvastus or subvastus? We used to do some subvastus approaches. I never liked the midvastus approach. I never felt too confident in the closure or the strength of the closure. So I just do a regular – I barely snip a little bit of the quads as we go up. While he’s talk – while he’s doing his exposure, I’ll talk a little bit about the molds that he’s going to be putting in. The mold is actually based on the true topography of the femoral and the tibial surface. So you’re going to see these osteophytes. You leave the osteophytes alone in this situation, and that allows the mold to very well interdigitate and fit in a very defined position. And he’ll show you how it’ll just slide on. But you got to leave the osteophytes alone. Which is unique. Most patients – most guys like to take those right at the beginning. Before we get too deep into the surgery, you want to talk about your references on CR versus PS? And what are we doing today? We’re going to do a PS knee in her. Can I have a \INAUDIBLE\, please. The nice thing about our templating, she was really between a three and a four. She had a very long, very large medial femoral condyle. In that situation I’m doing a PS. I’ll go up a size so I decided to use a four on her. The – if I were doing a CR, and I do quite a few CRs, in this situation we would probably down – try to use the size three. Can I have the teleclamp, please? I see you’re starting with the patella first. Is that so that you gain more exposure? Yeah, I like to do that so we can – you know, it just gives me a little bit more room. I think for efficiency some people like to do it last. I think that’s a reasonable approach. I take a little bit of fat pad just so I can see. Do you do anything to protect the resected patella while you’re doing the rest of the case? Yeah, we have a – a specific button that – that protects that for us. Yeah, sure. I know the answer to this but I’ll ask it anyway. Do you resurface every patella?

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OR Live bah 2777 show I do. You know, I do it for various reasons. I think there’s good evidence to suggest, particularly in Europe, that, at least in my opinion, an unacceptable high incidence of pain associated with an un-resurfaced patella. So that makes me just a little bit nervous. I know there’s – there’s certainly studies that show that it’s – Josh, we didn’t talk about your – your indications. Who do you choose to do Visionaire on? I do Visionaire on everybody I can. I think that with this system we’re at, you know, and we touched on it before. It allows you to accurately replicate not only the mechanical access, but what I think is critical is the axis of the femur in the coronal plane and the tibia in the coronal plane. And – 32. And – and so, with that in mind, and we looked at 60 of our first cases and took longstanding radiographs, and we perfectly replicated the mechanical axis, or at least the plan that we were attempting preoperatively. There are also some studies currently under review that will be published soon that look at rotation with CT as well as with longstanding digital x-rays showing the reproducibility of this particular process. And when you have that kind of reproducibility, I don’t see why you don’t do it in everybody you can. Now obviously if you have hardware present, it’s difficult. I’ve had a few patients that have hardware, but if it’s an old tibia staple from an HTO or an interfering screw from an ACL, it’s usually far enough from the joint line that the engineers can still get enough data to get a mold. I’ve had a couple situations where the plate’s come up a little too high, and now anything that’s – that’s right at that level, the joint line, hardware-wise, we’ll exclude. Yeah, that’s great. I, you know, you certainly try to give it a go and if you can – if it’s acceptable, then you can proceed. I haven’t – I haven’t been that lucky so far. This patient definitely looks like she needed the total knee. Yeah, I think she’s a good candidate. Now a couple things. What – what – what you’ve noticed, hopefully, is that he’s not had to drill an intermedullary canal, so we have one less thing to bleed postoperatively. He’s got enough exposure that he’s able to fully see the distal femur here, and what he’s doing is he’s putting that – that block in place, and it really will only sit in one place. Once he has it firmly down he’s going to be able to secure it. Now, Josh, what would you do if you really didn’t appreciate or remember that the patient had a flexion contracture and you didn’t template that in. And you want to take a little bit more femur. What would you do? That’s a great question. I’ll show you here in a second. Short. Short. Short. Summer, bring the camera in. I want – I want – I think this is a good shot. So I think you – can you see this? Yeah, we can see it great. So you can see how well this block conforms to the knee. So it has osteophytes, it incorporates those osteophytes. CT-based systems just don’t give you this. I’ve used multiple systems actually, and this one, it fits the end of the block perfectly. Josh, can you point out on that – on that frontal view the alignment lines that are built into the jig so you can visually confirm the rotation? Absolutely. So the nice thing here – so we’ve got our block set. You can see there’s a line here that represents Whiteside’s line, the AP axis. These holes represent our axis based on the epicondyles. We’re going to move these. We’re going to use those later. Those are the same – they – they fit the peg for your – for your chamfered cutting block, correct? Absolutely. But it also sets our rotation for the femoral component as well. And when I’m working with the engineer, I like to look at the epicondyles and the epicondylar axis as well as the AP axis. Josh, I have a question from the audience for you. Shoot. The question is, do you change extra rotation of the femur depending on deformity, and if so, more or less rotation vargus versus valgus? You know, I don’t. I base it all – I try to – I think our best studies are those based on the epicondylar axis, and I try to replicate that. And – and – and replicate that also with – with the AP axis. I try not to – to sort of overcorrect for any deformity that I have, be it patella femoral issues that you might see in – in a valgus knee. Or any other issues. I don’t know if that’s the way you do it. I do it the same way. I base it and I don’t change it. So the other nice thing – so we’ve made our cut. It depends on how you do it. I’m more of a measured – I like to sort of combine a measured resection and a gap balancing technique. There are certainly those who stick with a specific gap balancing technique. And if you were to cut the femur – the tibia and proceed straight to a – a check of your distal cuts, you could do that. And then you could come back and then use these pins and say, okay, I’m tied in extension, I want to re-cut more distal femur, you certainly can use your – your standard cutting guide which fits nicely over these pins and corresponds to your – your distal cut. So if you want to take two more millimeters, you can. I’ve talked – \INAUDIBLE\ simpler.

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OR Live bah 2777 show I’ve talked to some surgeons who are apprehensive cutting through that – that molded block the first time because they can’t see their saw. So my answer to them is to do what you did. Take the block off with those pins and then just set it at – that metal block – that jig that they would normally use. And check it. And that works very well as well. And there’s certainly no – no harm in that. The other nice thing, Rob – Rob was nice to – we’re a little tight here. Our incision’s kind of small. So – got that Marie? So if you can see here, our pins made a nice replication of the epicondylar axis here. I don’t know if you can see that rotation there. We can see it very well. So again we – we – you okay? Right there. Might relax a little bit. We can always make this bigger if we have to. At this point, do you – do you trust that it’s always going to be what you template? Do you do anything to visually confirm that it really is a size four? Well I look at – I still – oh, for the sizing? Yes. Abso – I mean, I absolutely, I mean, I still look at the size of the block, I look at where I anticipate our cut. I mean I – unfortunately I’ve done enough of these that based on our sort of schematic that we have pre-op, it tends to accurately correspond every time so you start to not worry about it as much. You certainly can use an angel wing to check that if you’d like, your anterior cut. That’s a good first step, for those that are not confident initially. But the reproducibility of this, I’ve been impressed with. You know, and that’s really important. I think that getting accurate alignment, we know that accurate alignment on the tibia, both from finite element analysis as well as clinical analysis and studies, you get the tibia off three degrees, you have a higher revision rate, a higher failure rate overall. Your coronal alignment is critical on the femur and the tibia for long-term success of the implant. And the way this reproduces that, the mechanical axis, both in the coronal plane, the AP axis and sagittal plane. I think we’re going to see improvements in the longevity of the implants. Less revisions which really is another cost – potential cost saving. So you talk about short and long-term cost savings with this procedure. We’re looking at – in our multicenter study, we’re looking at outcomes, a prospective randomized – we’re looking at the journey with conventional instruments in Visionaire, and those are the exact things that we’re looking at. We’re looking at accuracy of our cuts, alignments, post-operative function, complications, all the typical study parameters. But it – it’s, anecdotally we’ve seen improved range of motion early and higher patient satisfaction. Well, it’s well documented in navigated studies that you get – certainly get less blood loss when you don’t violate the intramedullary canal. Ken Cherry has shown that as well with Visionaire. I think it’s particularly valuable in those centers and surgeons who do, say, you know, your 50 to 100 range. Having that sort of confidence in your accuracy of your alignment is valuable. Get that – yeah. It’s really tight. \INAUDIBLE\. Sure can. Good. So, I also will double check – I’ll check to make sure that our schematic, we have sort of a nice footprint here, grand piano footprint that you’ll see if you’ve got the femur rotated correctly. And it definitely matches up nicely with our – knife? We’re having a hard time with that side, aren’t we. \INAUDIBLE\. Any pearls for managing the soft tissues as far as the meniscus or the ACL/PCL? Well, I think, you know, obviously if you’re doing, you know, so I’ve released the ACL at this stage, and then it’s important to – pickups and a knife – get rid of the meniscus, particularly the lateral meniscus before you set your block. I’m going to be in the way of the camera here for a second. But that’s very, you know, you need to have a nice clear view so you can – as well as a nice – you need to clean that anterior cortex of the tibia as well so you can place the block accurately and consistently. She’s real tight on this lateral side, so -. You okay, Marie? I’ll typically take the anterior half to both the medial and lateral meniscus. If the posterior comes with it, great. If it doesn’t, I don’t worry about it and I will get it after I’ve done my resection, it makes it a little bit easier. So again, this block has a – a Y that lines up with the medial third of the tubercle, and it helps set your rotation. I think our block is sitting nicely here. The – the feet – the nice thing about the block – lock it in – the nice thing about the block, it really only fits well in one place. And the more deformity, the easier the fit. Absolutely. So these – these pins establish our rotation of the tibia. Too long? And what you can do, you don’t have to do – too long – you don’t have to do this always, but in your first few cases, I say check it every time, I’ve gotten in the habit. But you – a heading. You can check your alignment – perfect – sort of the way you would traditionally, and I don’t know if you can see that. She has some deformity in the tibia, but this lines up nicely with the second digit, in line with the crest of the tibia, and if you can see, you can see from the side our slope is – is sort of what you would expect from a perfect ect – extra-medullary alignment. I’ve seen this same thing, Josh, and for the sake of time we didn’t dwell on those pre-operative planning x-rays, but the long leg digital x-ray has an over or interposed line of where that alignment’s going to be. And what I

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OR Live bah 2777 show found in the OR, using that extramedullary guide, you’re able to confirm that it’s going to mimic exactly what was on the pre-operative plan. Um hmm. We have another internet question. How much time do you spend on pre-operative planning? I think that’s a great question. I mean, you can spend, and I think you may have touched on it a little bit before – not going to be enough – you could spend as little or as much as you want. If you had a complicated case – I had a case earlier today that had a significant valgus deformity, very active gentleman. I did an CR in him. He had a history of an MCL injury as well. So I spent a lot more time thinking about what I want to do with him, the size of my implant, than, say, a traditional vargus knee that I just – you can say, oh, I’ll do my usual parameters, there’s no flexion contracture, it can take you a minute to do and you’re done. Versus spending, you know, ten or fifteen minutes thinking about it. Yeah. Our – our process is pretty timely. Typically we’re going to get our long leg x-rays, we’re going to have an idea of where we’re at. It’ll be on our – on our plan, so when I see the information after the molds are – are provisionally designed, we just spend, on average, less than five minutes. I may have a chance to show that again, but – so what we’ve done is I leave these two smooth pins in in case you needed to re-cut. It’s very rare that you have to. This particular case, we may have to. She had some significant defects on the medial side. I only took two millimeters. But you can see how you can come back, pin this, drop it down two millimeters, crop it down another two millimeters if you need to. I’m going to leave those pins in place. Did I take the wrong drill? I planned for a cut of nine millimeters off the lateral side. Doing a great job. Let’s see. \INAUDIBLE\. So I think I know the answer, but you didn’t poll your staff in the OR. What technique do they prefer? Well, we can talk to Craig back here, and Amanda. I know Marie’s answer. But they – they fight to do the Visionaire cases. It’s a much – it sort of goes – so, again, the kind of things we’re talking about – I don’t know if you can see in here. Can you hold that, Marie? You can see the holes that we’ve created – pickups and a knife – on the tibia. We use those – that determines our rotation so we’ve – we’ve really sort of locked in our rotation based on our MRI, which again produces a nice reproducible product. We weren’t able to see that, Josh. Let me show that to you again, and get some of this fat out of the way. Can the boom show that? It’s just a little bit – yeah – the contrast – yeah, we can see it now. Just point out the holes. They’re not real easy to see. What I made is very clear. You can see the hole there. There you go. Yep. You can see the hole there. And at this stage, I size. But, no, they love the Visionaire. And they constantly talk to other surgeons about \INAUDIBLE\ why they don’t use it. Did you ever get any resistance from your hospital because of the potential additional cost early? No, I really – I really didn’t. I think that for the hospital they quickly recognized that it saves money. Let’s see the alignment right one more time. We didn’t get any resistance in our health systems, but I’ve heard from some other surgeons that there was initial resistance from the hospital. I think the data that you’re going to be producing and others will help confirm that it’s in the best interests of the hospital. Many hospitals also realize that by being able to capture the cost of the MRI, they were actually seeing improvement in their revenue. So once they looked at the big picture, that resistance faded away. Yeah, there’s no question. And if you add some of these initial cost savings, less FTEs, quicker turnovers, less money for pans and instrumentation, savings on the blood side, it becomes pretty substantial and quickly outraced the cost of the system initially. So there – there’s, you know, I think the payers are some of the ones that are the most resistant, not the – not the providing facilities as much. Yeah, \INAUDIBLE\ there we go. How would you say your patient satisfaction is? Let’s get our pins. The patients have been very happy. They – they, you know, I don’t try to sell them so much on the idea that this is some magical thing. I just say that this is a tool that I think will produce accuracy at a more reproducible level. And I tell them, you know, someone who does 300 or 400 of these a year, usually not an issue. But, you know, even doing as many, I still find myself saying, gosh, I probably wouldn’t do it this way if it wasn’t for the information I gleaned from my preoperative templating and sort of what we knew from the information going in. So I’m learning stuff even though I think I can do it pretty well every time, and I just think it just helps the surgeon do it better. And that can only be better for the patient. As far as the things that we can also track like length of stay, length of physical therapy, postoperative pain medicines, what have you found in your first 50 or so? Well, honestly, I did not see a huge – we saw differences in blood loss for sure. And I think that can bear out clinically. We definitely saw a slight reduction in our patients’ stay, so we were kind of in the just over two range,

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OR Live bah 2777 show two-day range. We kind of brought that down to about 1.8. It’s nice having the information here that we have recorded for us. But – so I’ve noticed that, I think, you know, patient pain and satisfaction - \INAUDIBLE\ hammer – those things are such difficult things to measure. But I’ll tell you, the ease – the ease of the O – the OR, the flow, the nurses can focus on what they’re supposed to be doing, which is taking care of the patient. The tech can worry about the back table. The surgeon doesn’t have to worry about the back table. In fact, what was interesting, we had a – a surgical tech today who came in from Primary Children’s, which is a children’s hospital, never seen, done joint replacement before, was very helpful in helping, you know, deliver instruments from the back table with no experience essentially. And that’s particularly valuable in places where they don’t do a lot of surgery. They don’t do, you know, they don’t do, you know, they’re doing 50, 100, 200 joints a year. That really relieves stress on the surgeon, makes the flow of the operation go nicely. So let’s – let’s try all this. Let’s get a nine. And a pickup. Josh, you’re doing a great job. You’re making it look very simple. Your whole team’s doing great. Well, these guys are the best, that’s for sure. Let me get the trough first. I tell you Jim, we’re worried a little bit this is going to be a little bit tight. We may have to re-cut, which is actually okay. It’s always easier to cut more than wish you hadn’t. Well, what I find interesting is that, you know, the guys at Smith & Nephew are finding Visionaire is taking over a larger and larger percentage of their knees, and what they’re finding is the, at least among the Visionaires, they’re doing a lot less – nope. So she had a flexion contracture. We’re able to get that – actually, let me see my pin driver. Let me have my freer. Good job. It’s tight over there. Marie. So I used that button to sort of protect, give us a little more space. So before I take these pins out, they’re angled in such a way to stay out of the way of the tracking. We’ve got full extension. Not a – tracking’s pretty good. I think this is perfect. It looks good. So let’s take the – the pin driver. Her flexion – I didn’t mention her flexion pre-operatively. She only had about 110 degrees of flexion pre-op, and I think just with gravity we’re getting about 120. So, again, we can look at that again. I think that’s adequate full extension, maybe a touch of hyperextension, which is sort of what I’m aiming for. One of the reasons we took a few more millimeters. And that just is great. So I feel good about that. Large \INAUDIBLE\. Josh, earlier today we talked about some of the other things you do to help your patients postoperatively. I know preoperatively this patient received a spinal, as well as a femoral and saphenous block, is that right? They, in this particular incidence, they received just a femoral block, not a sciatic block. I mean sciatic. And – got it on too good. You can go ahead and mix. And open. So four femur, three tibia. She’s got good bone. So yes, everyone gets a spinal. Everyone gets preoperative Oxycontin. Preoperative Celebrex. And then everyone gets a nerve block. How about an intra-articular cocktail? I use a combination of toredol, an alpha blocker, which is clonidine, and some Ropivacaine. \INAUDIBLE\. Suction. Ropivacaine. And – and we sort of bring that to a pretty large volume with saline. And I inject that in the posterior cap so and sort of the surrounding tissues. We’ve been real happy with that. And that’s been shown to reduce pain. And other people have looked at that exact cocktail, and it’s shown to help reduce the amount of IV pain medications they use post-op. Now I use a – I try not to use any IV pain medications post-op. We use a long-acting narcotic and a short-acting narcotic in addition to toredol. And they go home with a short-acting narcotic. What are you using for cement today? We’re using Simplex. There’s no antibiotic in this cement. Do you ever use antibiotic impregnated? I do on my revisions. You know, if I had a patient with a history of an inter, you know, septic arthrosis in the past, that has been out over a year and we’re considering a total, then I would certainly use antibiotic cement in that situation. I’m not sure what you use. I use – I use antibiotic impregnated cement when I have a higher risk patient, somebody with a lot of other comorbidities, sub-optimal circulation, diabetics, and then all revisions. But I think getting back to your question, I didn’t answer it appropriately. The- the flow, sort of these intangibles that we talked about, the flow in the OR is just so nice with this. The turnovers are so quick. It’s really important the nursing staff doesn’t feel like they have to constantly clean the room and – and open instruments and do all these things. They can kind of focus on the patient. The tech, it takes, you know, seven minutes for them to get the case open. Yeah, we’re seeing the same thing. The morale factor is huge.

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OR Live bah 2777 show But I mean the real reason to do it is, I think, it produces a superior clinical result and I think, you know, we’re finding that it’s reducing the outliers. And like what I was getting at before is that they’re seeing, you know, in these Visionaire cases, they’re just not seeing people use 13, 15 polys, they’re not taking these, you know, sort of making these, you know, it’s not, you know, it’s easy to – to find yourself taking too much tibia using traditional methods. Can I have a wet lap? And we’re seeing a lot less of those kind of outliers which, you know, worked fine, but come revision time could compromise the result. Great. Doing great. So we just put a little bit. Hey, Josh, how about if earlier in the case, with all this preoperative planning and spending a week to get the molds, what happens if it lands on the floor? That’s another nice thing about the system. I mentioned before, there’s something about, you know, Smith & Nephew created these, you know, it’s all an in-house thing. They take a lot of feedback from surgeons to – to sort of get a product that works well. It’s not going to an outside agency. And one, I think it allows the blocks to fit very well and so surgeons are confident in the way it works. With that said, you know, the other nice thing about these blocks is you drop them on the floor, you can sterilize them three times. Now – I think it’s three. Maybe it’s four. But – You got to be pretty clumsy to go to four. We – we, you know, we’ve had our moments, but I don’t think we’ve hit that – that one yet. Nine. Nine. What? Let me just tell you, Craig doesn’t drop anything, so. It’s always the other guy. Or the resident if the resident’s in the room. Freer. A little bit of irrigation. Good. A little bit of cement. Now, the other thing in our post-op, I use a drain. There are many people who have gone and do not use a drain because they’ve seen such a decrease in blood loss. We’re certainly seeing that. I’ve just had such a tradition of using drains. We’re currently looking at that and seeing if we can get away with not using drains, so that’s sort of a process in the works for us. Ken Cherry has gotten away from using drains. That’s certainly been a cost savings for them. And, you know, did not feel confident doing it before Visionaire but certainly felt confident after. Looks great. We don’t drain any of our knees. And we may get there, but currently we’re not. Josh, earlier in the case you were talking about choosing PS for this patient. When do you choose CR? So, I use CR – can I have a lap, please – in the more active patient. One that, you know, there – there are a lot of active – they’re both – there are two different kind of active people here in Salt Lake. There are ranchers. I take care of a lot of ranchers, ex-rodeo guys. And they’re extremely hard on their knees and their joints. They’re working. They’ve got to earn a living. I then have the sort of the recreational athlete who’s out there and they’re skiing on their knee. I mean, you tell them, you know, you try to tell them to be reasonable, but you have a lot of those types of patients. And those patients I’ll use the CR. I feel a little more confident with, you know, with Verilast and with a CR component in those active patients. And sort of the lesser demand patient I’ll definitely do a PS. I think they find it a little easier to get their motion back. Do you have any exclusion criteria based on deformity or range of motion? Well certainly large flexion contractures, we use a PS. Something where I think, you know, I’m going to have to raise the joint line to some degree. Those with significant deformity that’s greater than 15 degrees. I mean, she had a various deformity here of a little over four-and-a-half, five degrees. That’s not, you know, we could have certainly done a CR if I consider – you know, in this situation. So, anything greater than 15 degrees. I like a CR in valgus knees. Some more. I think it gives a little bit more restraint to that medial side. So I – I would use that. I don’t restrict a CR, PS in people who are rheumatoids or inflammatory arthropocies, and there’s really not a criteria for age, though I tend to do more PSs in the older population. And this is our little mix. Take one more look. And she was, you know, she was a little – our exposure was a little tight and maybe we should have done a little bit more in terms of incision, in terms of – of – but I don’t – I think that we were still able to see what we needed to see and I think you could see that the ease of getting the blocks on, it was not that difficult, and, so it – it’s a very user-friendly device. Looks right. So what’s our tourniquet time on that, about 45? So, our tourniquet’s about 41, you know, we’re doing a lot of talking, obviously. The normal flow, obviously, is much less. I think that this is a – it saves you steps. But, you know, it’s not about doing something fast. I think it allows you to do it more efficiently, with less stress, and potentially more accurately, at least eliminate some of these outliers. I think that’s where the real value is. How long do you keep the drain in? We actually – there is a reinfusion drain that we use, and it comes out tonight. So we don’t keep it that long. You can open up that nine. Well, we want to see this final poly go in. Oh, absolutely. How we doing? Is it \INAUDIBLE\ yet? We don’t want to rush it, though, you’ve been doing an awesome job.

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OR Live bah 2777 show Always – I like to focus a little bit on the \INAUDIBLE\. Make sure we don’t have any cement. It’s a little bit of a tight space. That’s great. A little more suction. Josh, I just got another question from the audience. Do you have any concerns on the post strength with the highly cross-linked ultra high ultramolecular weight poly? You know, that – that’s something that has not been an issue and the strength has held up nicely on – on the – on the PS post. With regard to the Legion, at least. I see you’re being real meticulous clearing out the channels for where that poly has to lock. Any tricks there? Well, you know, the key is just to make sure you can see. Yeah, let me take \INAUDIBLE\. You know, you just have to be careful not to put too much cement on. You know, there’s a – there’s a – sort of a just right amount obviously. How we doing on the cement hardening? Good. We have tourniquet down. Yeah. So again, you know, there’s just – it’s always one of those things, you know, some knees just bleed more than others, but overall, at least looking at this, you know, it’s fairly objective that – so that’s kind of the way I put it in. Often you can just slide it in with your fingers and it’ll lock down. You can sometimes use a device. You can sometimes tap it down. That’s locked. And we’re good to go. Good to close. Any other thoughts? No, Josh Any thoughts – maybe I should say any other thoughts or concerns? No, the audience hasn’t had any more questions. I think you did an absolutely fantastic job. On behalf of Smith & Nephew, I would like to thank your patient for volunteering to help us out tonight. The hospital’s been great accommodating us and the crew to get this done and, Josh, you did a great job. Hey, thanks. On behalf of everybody, we’re signing out.

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