Scorpio NRG CR PS Single Radius Primary Knee System .
Scorpio NRG CR & PSSingle Radius Primary Knee SystemSurgical ProtocolPRPosterior ReferencingThis document is intended to be used by healthcare professionals only.
Scorpio NRGPR Single Radius Primary Knee SystemSurgical ProtocolTable of ContentsXcelerate Instrumentation Surgical TechniqueFor Scorpio NRG Single Radius Primary Knee SystemExposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Femoral Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Femoral Intramedullary Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Distal Femoral Resection Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Distal Femoral Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Femoral A/P Sizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4A/P Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5A/P and Chamfer Bone Cuts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Notch Preparation for Scorpio PS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Option 1: Punch Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Compacting Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Option 2: Saw Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Compacting Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Femoral Trial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Tibial Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Option 1: Extramedullary Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Tibial Resection Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Proximal Tibial Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Option 2: Intramedullary Technique - IM Rod Placement . . . . . . . . . . . . . . . . . . . .16Rotation and Varus/Valgus Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Flexion/Extension Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Tibial Resection Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Proximal Tibial Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Tibial Baseplate Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Scorpio NRG Tibial Component Sizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Tibial Component Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Tibial Keel Punching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Patella Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Patella Trial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Tibial Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Tibial Bearing Insert Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Implantation of Femoral Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Implantation of the Patellar Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Scorpio NRG Tibial Punching Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Appendix 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Scorpio NRG Sizing Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Appendix 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Scorpio NRG PS Femoral Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Scorpio NRG PS Inserts - N2Vac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Scorpio NRG PS Tibial Inserts - X3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Appendix 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Scorpio NRG CR Femoral Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Scorpio NRG CR Tibial Insert - N2Vac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Scorpio NRG CR Tibial Insert - X3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Appendix 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Tibial Component Baseplate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Patella Component - N2Vac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Patella Component - X3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Use a standard anterior mid-line incision(Figure 1). Previous incisions may be used orincorporated to decrease the risk of skin slough.FemoralPreparationExposure Enter the capsule through a medial parapatellarapproach approximately 1cm from the medialborder of the patella.Figure 1 Incise the quadriceps mechanism longitudinally toallow adequate patellar eversion and sufficient kneeflexion (Figure 2).Figure 2Femoral PreparationFemoral Intramedullary Alignment Use 3/8" diameter drill to enter the intramedullarycanal of the femur (Figure 3).Figure 31
Scorpio NRGFemoralPreparationPR Single Radius Primary Knee SystemSurgical Protocol The drill hole is located approximately 1cm anteriorto the femoral attachment of the posterior cruciateligament and slightly medial to the mid-line of thedistal femur (Figure 4). Removal of osteophytes from the margins of theintercondylar notch may aid identification oflandmarks. It is recommended that the drill hole be slightlyenlarged. This can be accomplished by toggling thedrill, using a rongeur, or inserting an axial reamer.3/8" Drill HoleFigure 4 Place the 5/16" T-Handle Rod through the FemoralAlignment Guide and insert the assembly into theintercondylar drill hole (Figure 5). Advance the rodslowly into the intramedullary canal. A suctionsource may be attached to the suction fitting on therod to reduce the potential for excessive canalpressurization. Place the Femoral Alignment Guide in contact withthe more prominent distal femoral condyle and alignthe guide by referencing the posterior condyles or theepicondyles. The Femoral Alignment Guide can bepartially stabilized by advancing the medial and/orlateral fixation spikes and gently impacting them intodistal bone.Figure 5 The Femoral Alignment Guide is designed for use oneither the left or right knee and can be set at anyvalgus angle between 3 and 9 .Valgus Angle SettingIM HandlePull Knob to SetValgus AngleFigure 62Set the instrument to the desired angle by pulling theknob of the Femoral Alignment Guide and placing itin the appropriate notch (Figure 6). Handles may beattached to the sides of the guide to aid in alignmentand stabilization.
The Xcelerate System offers 8mm, 10mm and 12mmDistal Femoral Resection Guides.Note: Removing 8mm of distal bone correspondsto the 8mm distal thickness of the Scorpio NRGFemoral Components.Distal FemoralResection GuideLocking KnobFemoral AlignmentGuideFigure 7AlignmentRodAlignmentHandleFigure 8FemoralPreparationDistal Femoral Resection Level Select the appropriate Distal Femoral ResectionGuide and assemble it to the Femoral AlignmentGuide by positioning the Resection Guide over thetwo pegs on the alignment guide. The resection guideis locked into place by pushing and turning thelocking knob 1 4 turn clockwise (Figure 7).Note: The components shall be positioned to avoidexcessive hyperextension. Excessive femoral flexion andtibial slope should be avoided when implanting thecomponents. Implant positioning resulting in excessivehyperextension may result in premature wear anddamage to the implant. Prior to pinning the Distal Femoral Resection Guideto the femur, an optional external alignment checkmay be performed. Attach the Alignment Handle tothe Distal Femoral Resection Guide and insert theAlignment Rod into the handle (Figure 8).Alignment is correct when the rod intersects thecenter of the femoral head and roughly parallels theaxis of the femur in the lateral view. Once acceptablealignment is confirmed, remove the handle and pinthe Distal Femoral Resection Guide to the anteriorfemur using two 1/8" drill pins. The Drill-Pin Driver can be attached directly to thereamer, drill fitting, or a Jacob s Chuck. The drillpins are loaded into the driver and drilled throughthe “0” set of holes on the resection guide. The pinsare automatically released from the driver as it ispulled back. After the resection guide is pinned in place, thealignment guide is removed. Release the resectionguide from the alignment guide by pushing androtating the locking knob 1/4 turn counter-clockwise.Remove the IM rod, and the Distal FemoralAlignment Guide, leaving the Distal FemoralResection Guide in place (Figure 9).“X” PinHolesNote: If the “X” Pin hole is used, this pin must beremoved prior to repositioning or removing the DistalFemoral Resection Guide.Figure 9Note: A Blade Runner may be used to further assess theresection.3
Scorpio NRGFemoralPreparationPR Single Radius Primary Knee SystemSurgical ProtocolDistal Femoral Resection Once the resection level is determined, make thedistal femoral resection (Figure 10). Xcelerate Instruments are designed to provide precisecontrol of the sawblade during bone resections. Usinga 0.05" (1.27mm) thick saw blade produces the mostaccurate resections.1/8” Drill Pins Once the distal femoral resection is complete, removethe guide and check the cut is smooth and flat. Remove the 1/8" drill pins with the Pin Puller.Distal FemoralResection GuideFigure 10Femoral A/P Sizing The A/P Sizer is designed to set the desiredexternal rotation and to provide adjustment of theanterior/posterior position when needed. Attach the Modular Handles to Sizer. Set the A/Padjustment indicator to “0” (Figure 11).Figure 11 Adjust the Sizer to the desired degree of externalrotation and position the instrument flush on the flatdistal femur, sliding the feet of the Sizer under theposterior condyles (Figure 12). Note that the mediallateral width of the implant can be assessed by referencingthe width of the anterior portion of the sizer at eachimplant size. If desired, rotation can be further adjustedby using the Modular Handles to reference and parallelthe epicondylar axis. Tighten the locking knob.Note: It is important that the A/P adjustmentindicator be set to zero prior to placing the A/P Sizer onthe distal femur. Failure to set the indicator to zero maylead to incorrect sizing of the femur.Option to pinFigure 124Note: Option to pin (Figure 12).
FemoralPreparation Snap the Femoral Stylus into position on theanterior surface of the Sizer. Using the BladeRunner, determine the implant size that gives theoptimum anterior fit (Figure 13). Place the appropriate size drill bushing into theA/P Sizer, taking care to ensure it is correctlyoriented. Using a 1/8" drill pin, prepare thedistal peg holes.Note: If you plan to use the Scorpio UniversalNotch block with lugs you can check your positionin the medial lateral with the A/P sizer.Figure 13A/P AdjustmentAnteriorresectiontoo proudAnteriorresectiontoo deep On occasion the femur will fall between two implantsizes. Preparing for the smaller size may potentiallynotch the femur. Preparing for the larger size prevents notching butmay lead to overstuffing of the patello-femoral joint(Figure 14). The A/P Sizer has been designed toavoid both these situations by allowing the overallposition of the drill holes to be adjusted to providethe optimum anterior resection.Figure 14 When an adjustment of the A/P sizer is necessary,loosen the locking knob and reposition the A/Padjustment indicator until it indicates the“-2” position (Figure 15).Figure 155
Scorpio NRGFemoralPreparationPR Single Radius Primary Knee SystemSurgical ProtocolAdjustedAnteriorresectiontoo proudOriginal too deepAnterior resection2mmFigure 16Cutting BlockImpactor/ExtractorImpaction HandleFigure 17 This will shift the position of the peg holes 2mmanteriorly, raising the level of the anterior resectionand preventing notching of the anterior cortex(Figure 16). However, it will remove an additional2mm of bone from the posterior condyles, increasingthe flexion gap. Care must be taken to properlybalance the flexion and extension gaps in thissituation. When the A/P Sizer is adjusted to the 2mm mark,the level of the anterior resection is moved posteriorly2mm. The amount of posterior bone removed isreduced. This is useful in cases where the flexion gapis particularly loose.A/P and Chamfer Bone Cuts Assemble the Cutting Block Impactor/Extractor tothe Impaction Handle. Insert the two prongs of the Cutting BlockImpactor/Extractor into the two distal holes on thecutting guide. Position the corresponding Femoral 4:1 CuttingBlock into the pin holes and impact until the blockis seated flush on to the distal femur. Additionalfixation can be achieved by pinning the Femoral 4:1Cutting Block to the bone. Impact the Cutting Block Impactor/Extractor using amallet while guiding alignment of the Femoral 4:1Cutting Block with the other hand. Use of a 0.05” (1.27mm) thick, 18mm wide saw blade isrecommended Complete the remaining four bone resections The recommended bone resection sequence for theFemoral 4:1 Cutting Block is:1. Anterior Cortex2. Posterior Condyles3. Posterior Chamfer4. Anterior Chamfer Extract the Femoral Cutting Guide by using the CuttingGuide Impactor/Extractor Do not remove the Femoral 4:1 Cutting Block from thebone by impacting on the backside of block.Extraction with the Cutting Block Impactor/ExtractorFigure 186 Assemble the Cutting Block Impactor/Extractor to theImpaction Handle. Insert the two prongs of the Impactor/Extractor into thetwo distal holes on the Femoral 4:1 Cutting Block. Extraction can be achieved by pulling on the attachedhandle. If additional force is needed, the Slaphammer maybe attached to the end of the Impaction Handle.Note: Additional fixation support should be provided for thecutting block to ensure block stability during disengagementof the adapter when used on osteoporotic bone.
The Scorpio Universal Preparation Block Instrumentis used after completion of the five femoral bone cuts. Select the appropriately sized Universal Notch Block.The block sits on the anterior, anterior chamfer anddistal cuts. The anterior geometry represents the leftand right lateral flanges of the implant of the samesize. The sides are marked LL and RL for left lateraland right lateral, respectively.Scorpio UniversalNotch BlockFigure 19FemoralPreparationNotch Preparation for Scorpio PS Position the Notch Block on the prepared distal femur,aligning the lugs with the holes made by the FemoralCutting Guide. Tap into place with the mallet(Figure 19). To further aid the positioning, if usingpegless blocks, note that the block is also the samewidth as the implant of its respective size.Note: Pins used with the size 3, 4 and 5 Notch Blocksshould be used with no more than one pin per side toavoid the potential for the pins intersecting with eachother. Pins should be used on the contra-lateral side fromeach other. For example, if a pin is placed through themedial anterior chamfer hole, a second pin should onlybe placed on the lateral side through either the chamferor anterior flange hole. Towel clamps may be used foradditional stability if necessary in the indicated holes onthe distal plane.Figure 20 Once the Notch Block is seated flush against theanterior, anterior chamfer and distal cuts of thefemur, drill 1/8" headless pins through the angledholes (“X”) on the anterior and/or anterior chamfersurfaces of the block (there are 4 “X” holes each at15 ) (Figure 20). Towel clamps may be used on the medial andlateral sides of the distal portion of the block.It is recommended to use at least the 2 anterior pinholes, even if towel clamps are used. Stryker recommends the following instructions beused when using the Size 3 Notch Preparation Guide:Size 3 Notch Block Notch PreparationPins used with the size 3 Notch Block should onlybe placed in through the anterior chamfer to avoidhitting the notch punch.Do not place pins through the anterior flange.Towel clamps may be used for additional stabilityif necessary, in the indicated holes on the distal plane.7
Scorpio NRGFemoralPreparationPR Single Radius Primary Knee SystemSurgical ProtocolOption 1: Punch TechniqueNote: If the femoral bone is sclerotic, Option 2 (SawTechnique) should be used for the notch preparation. Assemble the appropriately sized Notch Punch to thepunch handle. Guide the Notch Punch into the tracks on the distalface of the Notch Block (Figure 21). The rails on thesides of the cutting edge fit into the tracks on theinside walls of the block.Notch PunchFigure 21 Using a mallet, impact the Punch until it reachesthe end-stop and is fully seated in the NotchBlock (Figure 22).Figure 22 Remove the Punch from the tracks with a Slaphammerif necessary (Figure 23).Notch PreparationSlaphammer FittingNote: It is not uncommon for the area of bone beingprepared to be removed by the punch at the time ofextraction. In this instance, it is still necessary to cleanout remaining soft tissue and compact.Note: Using an osteotome or rongeur, remove themargin of the intercondylar bone necessary to ensurethat all soft tissue is cleared from the intercondylar areaof the femur. (It is important to remove all soft tissue inthe femoral notch prior to compacting bone to avoidfuture potential soft-tissue impingement).SlaphammerFigure 238
Assemble the appropriately sized Notch Compactorto the punch handle (Figure 24). Guide the Notch Compactor into the tracks on thedistal face of the Notch Block.FemoralPreparationCompacting TechniqueNotch PunchFigure 24 Using a mallet impact the compactor until it reachesthe end-stop and is fully seated in the Notch Block(Figure 25).Figure 25 Remove the Compactor from the tracks with aSlaphammer if necessary (Figure 26).Notch PunchSlaphammerFigure 269
Scorpio NRGFemoralPreparationPR Single Radius Primary K
Scorpio NRG CR & PS Single Radius Primary Knee System Surgical Protocol PR This document is intended to be used by healthcare professionals only. Posterior Referencing
partnership with Sunora Energy Solutions, an NRG subsidiary. NRG’s El Segundo facility was selected as the runner-up in the Natural Gas Plant of the Year category during POWER-GEN International's Projects of the Year awards. NRG retail subsidiary Reliant won the presti
to the steering tube (part. 5, Fig. 1) and then . NRG MC2 50 2T LC -1997 NRG MC2 50 2T LC 1998- NRG 50 2T LC NRG MC3 DT 50 2T . Now attach the brake disc modifi ed in this way to the original wheel by fi rmly tightening the three screws using Loctite 242-type thread glue. Respect the disc rotation
NRG Oncology welcomes you to Exhibit at the upcoming NRG Oncology SemiAnnual Meeting! NRG Oncology invites you to participate as an exhibitor at the upcoming NRG Oncology SemiAnnual Meeting held at the Manchester Grand Hyatt in San Diego, A from Februa
NRG Well Management, an NRG Group Company, provides well engineering and project management solutions to the global upstream Oil and Gas Industry. Our world class managerial and technicalservice offering covers the complete exploration, appraisal, development, production and decommissioning well lifecycle. Since 2007, NRG has provided safe and
BALF-NRG-01D3 BALF-NRG-01D3 with QFN type BlueNRG DocID026543 Rev 5 5/15 2 BALF-NRG-01D3 with QFN type BlueNRG Figure 12: Application board EVB (2 layers) Figure 13: Recommended balun land pattern (EVB) SMT 320 µm 180 µm 254 µm TOP and SPT 220 µm.
NORTH NODE IN SCORPIO 3 PERSONAL CHALLENGES Scorpio North Nodes’ Achilles’ heel is comfort (“The goal of life is to be comfortable; I need lots of possessions to survive”), which can lead them into the trap of an
potential impact on research at the February 2019 Semi-annual NRG meeting NRG is the NCI Cooperative Group that ACI is a member of Presented at the July 2019 Semi-annual NRG meeting Medical Oncology Pharmacy Subcommittee Meeting Full presentation Medical Oncology
accounting and bookkeeping principles, practices, concepts and methods featured in the unit and there was good evidence of preparation and practice with regard to structure, format and presentation of accounting data and information among the sound financial statements, double-entry bookkeeping and cash budgets submitted. That said, this is not a unit solely of numbers or arithmetic and there .
