Surgical Technique - MTI International
Zimmer Segmental SystemTrabecular Metal ProximalTibial ComponentSurgical Technique
INTROZimmer Segmental System Trabecular Metal Proximal Tibial ComponentIntroductionThe Zimmer Segmental System is designed to addresssignificant bone loss resulting from oncology, trauma,and/or the salvage of previously failed arthroplasty.Proximal Tibial Replacement OptionsThe system includes a Trabecular Metal Proximal TibialComponent that enables tissue attachment to the implantvia sutures and/or arms included in the optional TissueAttachment Kit (Fig. 1).The Trabecular Metal Proximal Tibial Component may beimplanted with the NexGen Rotating Hinge Knee Distal FemoralComponent or the Segmental Distal Femoral Component(Fig. 2). Refer to the NexGen RH Knee Surgical Technique(97-5880-002-00) and Segmental Distal Femoral SurgicalTechnique (97-5850-004-00) before performing a TrabecularMetal Proximal Tibial Component implantation. (The RH KneeSurgical Technique has been updated with specific instrumentsregarding the Segmental Trabecular Metal Proximal Tibia. Pleasereview revision 4 or higher before performing a proximal tibialreplacement.)Fig. 1System CompatibilityThe Segmental Trabecular Metal Proximal Tibial Component maybe implanted with the Segmental Distal Femoral Component,Segmental Stems, Segmental Stem Collars, and SegmentalSegments as well as the NexGen RH Knee Tibial/FemoralComponents, VerSys Hip System 12/14 Heads and theLegacy 12/14 Heads (Fig. 3).The Segmental Proximal Femoral Components and IntercalarySegments may be used with both Fluted Stems (cemented)and Variable Stiffness Stems (press-fit) in many stem lengthsand diameters. Variable Stiffness Stems are not indicated foruse in the knee with the Segmental Proximal Tibial Componentsin the United States. All Stems are compatible with bothTrabecular Metal Collars and Tivanium Ti-6Al-4V Alloy Collars.Option 1Option 2*Option 3*Fig. 2Proximal Tibial Replacement Options:Option 1: Segmental Trabecular Metal Proximal Tibial ComponentOption 2: NexGen RH Knee Non-Modular Proximal Tibial Component*Option 3: NexGen RH Knee Modular Proximal Tibial Component** Refer to NexGen RH Knee Surgical Technique(97-5880-002-00 revision 4 or higher)INTRO. 1
Zimmer Segmental System Trabecular Metal Proximal Tibial ComponentSegmentalTrabecular MetalProximal FemoralTissue Attachment Kits38mmoffset46mmoffsetSegmentalTrabecular MetalProximal FemoralComponentsINTROSegmental ProximalFemoral Component(38mm offset)NexGen StemComponentsSegmental Segments,Stems and Collars(Variable Stiffness Stems arenot indicated for use in theknee with the SegmentalDistal Femoral Componentsin the United States)Trabecular MetalFemoral ConesRH Knee Distal Femoraland RH Knee CementShield PolyethyleneInsert ComponentsSegmental Knee DistalFemoral and SegmentalKnee PolyethyleneInsert ComponentsSegmentalIntercalarySegmentsNexGen PatellarComponentsRH KneeTibial BaseplateComponentsSegmental SystemMale-Female Segments,Fluted Stems, VariableStiffness Stems,and Stem CollarsSegmental Knee HingePost and ArticularSurface ComponentsSegmentalProximalTibia TissueAttachmentKitSegmentalTrabecular MetalProximal TibialComponentsTrabecular MetalTibial ConesSegmental Segments,Straight Stems and Collars(Variable Stiffness Stems arenot indicated for use in theknee with the SegmentalTrabecular Metal Proximal TibialComponents in the United States)NexGen StemComponentsNexGen KneeSegmental SystemRH KneeFig. 3INTRO. 2
INTROZimmer Preference CCI Surgical TechniqueTable of ContentsSECTION1PAGEStep 1: Tibial PreparationStep 4: Tissue AttachmentAssessmentStep 4: Tissue AttachmentAssessment101.1 Resect Proximal Tibia14.1 Assess Tissue Attachment101.2 Ream Canal34.2 Perform Trialing101.3 Plane Tibia41.4 Counterbore Proximal Canal(Variable Stiffness Stems Only)5SECTION5PAGEStep 2: Initial Femoral/PatellarPreparationSECTIONStep 3: Trial ReductionPAGEStep 5: Final Distal FemoralPreparation & Trialing(NexGen RH Knee Femoral only)116Step 5: Final Distal FemoralPreparation & Trialing1165.1 Finish Femoral Preparation115.2 Assemble & Insert FemoralProvisional Components115.3 Insert Hinge PostExtension Provisional115.4 Evaluate Patellar Tracking11PAGEStep 3: Trial Reduction77SECTIONTOC. 1101Step 2: Initial Femoral/PatellarPreparation34PAGEStep 1: Tibial PreparationSECTION21SECTION3.1 Prepare StemProvisional73.2 Prepare ProximalTibial Provisional93.3 Prepare DistalFemoral Provisional93.4 Establish Flexion/ExtensionGap & Stability93.5 Re-establish the Joint Line96PAGEStep 6: Provisional DisassemblyStep 6: Provisional Disassembly1212
Zimmer Preference CCI Surgical TechniqueSECTION7Step 7: GastrocnemiusTransfer PreparationStep 7: GastrocnemiusTransfer PreparationSECTION8PAGESECTION13913PAGEStep 8: Final Assembly& ImplantationStep 8: Final Assembly& Implantation8.1 Assemble Tibial ConstructBack-Table Assembly1414Step 9: Tissue Attachment22Step 9: Tissue Attachment229.1 Attach Tissue22PAGEStep 10: Final GastrocnemiusTransfer & ClosureStep 10: Final GastrocnemiusTransfer & Closure14242415Male-Female Segment Assembly15Stem Assembly16Stem Collar Attachment16T ibial Component Implantation with17Fluted StemT ibial Component Implantation with18Variable Stiffness StemIn Vivo AssemblyPAGESECTION10INTROAPPENDIXAPAGEAppendix A: Component Disassembly 25APPENDIXBPAGEAppendix B: NexGen RH Knee &Segmental Articular Surface/HingeKit Compatibilities2819 ale-Female Segment AssemblyM(Optional)19Tibial Assembly20Intraoperative Disassembly208.2 Assemble DistalFemoral Construct208.3 Implant Distal FemoralConstruct & Articular Surface21TOC. 2
SECTION1Step 1: Tibial PreparationStep 1: Tibial Preparation1.1 Resect Proximal Tibia Extend the leg in a reproducible position. Assess bone and soft-tissue quality, and determinethe appropriate resection level (Table 1 & Fig. 4).TECHNIQUE TIPProximal TibiaStem/Collar1.AResecting the tibia first will facilitate visualization of the distal femur.Size 1, 2, or 370mm forImplant 8mm minimumfor ArticularSurface8mm minimum70mmProximal Tibia110mm2mm TaperConnection30mmStem/CollarFig. 430mmSegmentsTotal mm50mm**162mm55mm**167mm60mm172mm35 30mm179mm40 30mm184mm40 35mm189mm80mm192mm40 45mm199mm60 30mm204mm60 35mm209mm100mm212mm60 45mm219mm80 30mm224mm80 35mm229mm120mm232mm80 45mm239mm100 30mm244mm100 35mm249mm140mm252mm100 45mm259mm120 30mm264mm120 35mm269mm160mm272mm120 45mm279mm140 30mm284mm140 35mm289mm180mm292mm140 45mm299mmTable. 1Proximal Tibia Resection with Stems, Collars, and Segments*Each large taper connection adds 2mm to the total length**Available Soon1
SECTIONStep 1: Tibial Preparation Measure from the articular surface of the proximal tibia,and make a horizontal line to mark the proposed resectionlevel based on preoperative planning and the implantconfiguration.PolyethyleneThickness8mm Min Make a vertical mark below the resection level to referencetibial rotational alignment. Resect the bone at the selected level.112mmSegmentalArticularSurfaceNotes:70mm— While the distal femur is being prepared, ensure thatthe remaining intact tissues and gastrocnemius transfertissues are in a stable position on the operating table.— The overall length and rotational alignment of the resectedtibia should be carefully recorded and incorporated intothe selection of segment length and stem rotation.— The Segment Articular Surface is labeled as the articularsurface thickness plus 4mm (the thickness of a RH KneeTibial Baseplate). For example, a 12mm Segmental ArticularSurface is 8mm thick at the bearing space, accounting for a4mm thick tibial tray (Fig. 5a & 5b).Fig. 5aPolyethyleneThickness8mm Min12mmSegmentalArticularSurface4mm TrayThicknessFig. 5bRefer to NexGen RH Knee Surgical Technique (97-5880-002-00revision 4 or higher.)2
SECTION1Step 1: Tibial Preparation1.2 Ream Canal Select the desired Stem type and length (Table 2).Stem Diameter (mm) R eam the proximal tibial canal until the reamercontacts cortical bone in the isthmus.Stem IMLengthStem Type9Reaming ConsiderationsStraight Stems10111213141516171819130mm Straight (Fluted & Variable Stiffness)190mm Straight (Fluted)190mm Bowed (Variable Stiffness)*250mm Bowed (Fluted)* Start with straight reamers from the VerSys Hip System.Table. 2Bowed Stems* F lexible reamers are recommended (Pressure SentinelIntramedullary Reaming System Expanded Hip Set orZMR Hip System Flexible Reamer Set). Stem Types and Lengths* Bowed Stems are not commonly used in the Tibia, but are availableas part of the Segmental System.Variable Stiffness Straight Stems For optimal fit, the Segmental 3/4mm Reamers may be used. F lexible reamers may be used to allow for point contactin the canal. I f insertion is difficult, consider reaming an additional timewith the final 0.5mm or 3/4mm reamer diameter used.Variable Stiffness Bowed Stems* I t may be necessary to ream to a diameter equal toor slightly greater than the diameter of the Stem toaccommodate any difference between the bow ofthe Stem and the anatomy of the patient.Stem Size(mm)Min. Ream Diameterfor Fluted Stems(mm)Min. Ream Diameterfor VS 13.5151714.5161815.5Notes:— T he diameter indicated for a Stem represents the actualouter diameter (including the height of the splines forVariable Stiffness Stems).— F luted Stems require a different reamed diameter thanVariable Stiffness Stems to account for the cement mantle;therefore, determine reamer diameter from Table 3.— V ariable Stiffness Stems are not indicated for use in theknee in the United States.171916.5182017.5192118.5Table. 3Minimum Reamer DiametersInstruments3VerSys HipReamer(See ZSS Profiler)KT-5853-013-0000-7899-073-00Pressure SentinalIM Reamer(See ZSS Profiler)00-2228-000-03ZMR Hip SystemFlexible Reamer(See ZSS Profiler)00-9975-000-11Segmental3/4mm Reamer(See ZSS Profiler)KT-5853-014-00
SECTIONStep 1: Tibial Preparation1Planer1.3 Plane Tibia T hread the Segmental Planer Pilot (130mm long) for thestem diameter selected onto the Femoral/Tibial Planer(Fig. 6).Planer PilotFig. 6Stem SizeTECHNIQUE TIP1.BTo facilitate insertion in a curved medullary canal, use a Planer Pilot1mm-2mm smaller than the stem diameter chosen (Table 4).TECHNIQUE TIP1.CIf the canal is bowed, use the shorter Planer Pilots from the SegmentalVariable Stiffness Stem Instrument Kit (KT-5853-008-00).Planer PilotDiameter(Fluted)Planer PilotDiameter(Variable mm17mm17mm16mm18mm18mm17mm19mm19mm18mmTable. 4Recommended Planer Pilot Diameters Attach the assembly to a drill/driver with a Zimmer adapter. Plane the proximal tibia until the bone is smooth and flat. R emove the Planer Pilot from the planer by insertingthe pin on the Segmental Collar Provisional Sizer throughthe cross-hole and, while securing the noncutting end ofthe planer, turning the shank counterclockwise (Fig. 7).Note: If the anatomy requires the use of a shorter Planer Pilot,use the 75mm Segmental Planer Pilots.Fig. 7InstrumentsSegmentalPlaner Pilot(See ZSS egmental CollarProvisional Sizer00-5853-056-104
SECTION1Step 1: Tibial PreparationCounterboreReamer Stop Plate1.4 Counterbore Proximal Canal(Variable Stiffness Stems Only)Counterboring the proximal portion of the canal is requiredbecause the full diameter of a Variable Stiffness Stem proximalto the splines is 0.25 to 0.5mm greater than the reameddiameter of the canal.CounterboreReamer Tip Thread the Counterbore Reamer Tip into the CounterboreReamer Stop Plate (Fig. 8). Insert the assembly into a drill/driver.Fig. 8Counterbore Reamer Tip Insert the pin on the Segmental Collar Provisional Sizerthrough the cross-hole of the reamer tip and turn theCollar tightly to secure it to the stop plate (Fig. 9).Segmental CollarProvisional SizerFig. 9 Insert the assembly into the reamed canal and counterborethe proximal canal (Fig. 10).Note: The Counterbore Reamer Stop Plate will serve as a stopwhen the appropriate depth is achieved.Fig. 10InstrumentsCounterboreReamer Tip(See ZSS Profiler)00-5851-073-XX5CounterboreReamer Stop Plate00-5851-073-01Segmental CollarProvisional Sizer00-5853-056-10
SECTIONStep 2: Initial Femoral/Patellar Preparation2Step 2: Initial Femoral/Patellar PreparationUsing the NexGen RH Knee Femoral ComponentRefer to the NexGen RH Knee Surgical Technique(97-5880-002-00 revision 4 or higher) for preparationof the distal femur and patella.Using the Zimmer Segmental System DistalFemoral ComponentRefer to the Segmental Distal Femoral SurgicalTechnique (97-5850-004-00) for preparation of thedistal femur and patella.Caution: When using the Segmental Proximal TibialComponent, the Segmental One-Piece Hinge Post mustbe used (Fig. 11). The NexGen RH Knee Modular Hinge Postand Hinge Post Extension are not indicated for use with theZimmer Segmental System Proximal Tibia or SegmentalDistal Femur.Fig. 116
SECTION3Step 3: Trial ReductionStep 3: Trial Reduction3.1 Prepare Stem Provisional Use the Segmental Collar Provisional Sizer to select theCollar size that provides the best coverage of the bonesurface (Fig 12).Fig. 12StemDiameterSmooth Collar(Item #) (Dimension A)Trabecular Metal Collar(Item #) (Dimension A)25mm for 9-16mm Stems(00-5852-040-25) Confirm that the Stem and Collar sizes are compatible(Table 5).9-16mmNote: The collar sizer may be threaded onto the Planer Pilotto facilitate Collar selection.30mm for 9-16mm Stems(00-5852-042-09)30mm for 9-16mm Stems(00-5852-040-30)35mm for 9-16mm Stems(00-5852-040-35)17-19mm20mm30mmTable. 5Stem Collar Compatibility ChartInstrumentsSegmental CollarProvisional Sizer00-5853-056-107SegmentalPlaner Pilot(See ZSS Profiler)00-5851-070-XXDimension A30mm for 17-19mm Stems(00-5851-042-17)30mm for 17-19mm Stems(00-5852-041-30)35mm for 17-19mm Stems(00-5852-041-35)
SECTIONStep 3: Trial Reduction3 Select the appropriate Segmental Stem Provisional (Table 6).Stem SizeProvisional StemDiameter (Fluted)Provisional StemDiameter (VariableStiffness) Thread the Segmental Collar Provisional onto the SegmentalStem Provisional (Fig. 13).9mm9mm8mm Insert the assembly into the tibial canal.10mm10mm9mmTECHNIQUE TIP3.A— If the provisional assembly does not easily fit into a bowed canal,it may be necessary to perform additional reaming or to use thenext smaller size Stem Provisional (Table 6).— For Variable Stiffness Stems, if the provisional size that matchesthe Stem size fits in the canal, there will likely not be enoughpress fit. Consider preparing for a larger stem diameter,or consider cementing a Fluted m19mm19mm18mmTable. 6Recommended Stem Provisional DiametersHole forThreadingCollarAnterversionPocketsNotes:— If using a Smooth Collar, only the 30mm diameter collaris available.— The diameters of the Segmental Stem Provisionalsrepresent the actual diameters of the Stems, e.g., a 14mmStem provisional has a nominal 14mm outer diameter.— The same set of provisionals is used for both the 130mmSegmental Fluted Straight Stem and the 130mm VariableStiffness Straight Stem. Refer to Table 6 for provisionaldiameter recommendations per Stem type.Fig. 13ThreadedExtraction HoleProvisional StemThreadedProvisional Collar— Anterversion pockets allow for adjustment in 20 degreeincrements.InstrumentsSegmental StemProvisional Bowed(See ZSS Profiler)Segmental StemProvisional Straight(See ZSS Profiler)Collar Provisional(See ZSS Profiler)00-5853-056-XX8
SECTION3Step 3: Trial Reduction3.2 Prepare Proximal Tibial Provisionals Attach the Segmental Proximal Tibial Provisional (Table 7)and any Segment Provisionals to the Stem Provisionalconstruct, ensuring that the rotational alignment marksare properly positioned and all tabs are engaged in thecorresponding pockets. If desired, lightly impact the provisional components. Insert a temporary suture in the distal mediolateralhole of the Proximal Tibial Provisional to secure theextensor mechanism.NexGen RH Knee Femoral SizeUsing the NexGen RH Knee Femoral ComponentRefer to the NexGen RH Knee Surgical Technique(97-5880-002-00 revision 4 or higher) for assembling thefemoral provisional, balancing the knee and re-establishing thejoint line (Table 7).3.3 Prepare Distal Femoral Provisional3.4 Establish Flexion/Extension Gap & Stability3.5 Re-establish Joint LineSegmentalProximalTibial ar Provisional(See ZSS Profiler)00-5853-056-XXF/3Compatibility between Segmental Distal Femoral and Segmental ProximalTibial components. Interchangeability Chart - Segmental Knee System(using Segmental Distal Femoral and Segmental Proximal Tibial Components)InstrumentsSegmental StemSegmental StemProvisional Bowed Provisional Straight(See ZSS Profiler)(See ZSS Profiler)FTable. 8Note: After selecting the final articular surface thickness,verify the tibial rotation and update mark, if necessary.Proximal 51-003-10ESegmental Distal Femoral SizeSegmentalProximalTibial Size3.3 Prepare Distal Femoral Provisional3.4 Establish Flexion/Extension Gap & Stability3.5 Re-establish Joint LineDSegmental Proximal Tibial / RH Knee Compatibility Chart.Interchangeability Chart - Segmental Knee System (using RH Knee Femoraland Segmental Proximal Tibial Components)— OR —Refer to the Segmental Distal Femoral Surgical Technique(97-5850-004-00) for assembling the femoral provisional,balancing the knee and re-establishing the joint line (Table 8).CTable. 7Caution:— When using the Segmental Proximal Tibial Component, theSegmental One-Piece Hinge Post must be used. The NexGenRH Knee Modular Hinge Post and Hinge Post Extension arenot indicated for use with the Zimmer Segmental SystemProximal Tibia or Segmental Distal Femur.— The Hinge Post Provisional used for trial reduction isavailable only in the shortest length, which may be shorterthan the final Hinge Post being implanted. Thus, moredistraction may be necessary to assemble the final implant.Using the Zimmer Segmental System DistalFemoral ComponentBSegmentProvisional(See ZSS Profiler)KT-5853-004-00RH Knee ArticularSurface Provisional(See ZSS Profiler)
SECTIONStep 4: Tissue Attachment Assessment4Step 4: Tissue Attachment Assessment4.1 Assess Tissue Attachment Insert the Tibial Tissue Depth Tool into the octagonalhole of the Proximal Tibial Provisional. Place the tissue next to the gauge on the top surfaceof the provisional and gently compress the tissue.TECHNIQUE TIP4.AFor the Depth Tool to indicate the correct amount of tissue available,the thickness of the tissue must be less thick than the bottom of theetch line (groove on the Depth Tool). If the tissue is greater than 4mm in thickness,make adjustments to decrease the thickness ordo not use the Segmental Tissue Attachment Arms. If the tissue thickness is 4mm or less, insert the Tibial ArmProvisionals (Figs. 14 & 15) on either side of the patellarligament and into the octagonal holes of the Proximal TibialProvisional, ensuring that the etchings on the Tibial ArmProvisionals match those on the Proximal Tibial Provisional. Check to ensure that soft tissue will adequately coverthe Attachment Arm Provisionals, as well as the areasof Trabecular Metal Material, to prevent metal fromcontacting skin tissue.Fig. 14Notes:— The Tissue Attachment Arms can be used to attach tissuethat is up to 4mm thick or less, in any of the configurationsshown in Figure 15.— Tissue thicker than the etch mark/groove indicating 4mmon the Depth Gauge will prevent proper engagement of theattachment arms/bolt thread.Fig. 154.2 Perform Trialing Place the joint through a range of motion, and performany necessary soft tissue releases. If necessary, increase the thickness of the Articular SurfaceProvisional until the desired joint stability and range ofmotion is achieved. Verify the rotation of the Proximal Tibial Provisional. If thedesired position is different than the initial mark made onthe tibia, make a new mark.InstrumentsTibial TissueDepth Tool00-5851-000-15Proximal 51-003-10Segmental StemTibial ArmProvisional BowedProvisionals00-5851-001-11 12 (See ZSS Profiler)Segmental StemProvisional Straight(See ZSS Profiler)Collar Provisional(See ZSS Profiler)00-5853-056-XXSegmentProvisional(See ZSS Profiler)KT-5853-004-0010
SECTION5Step 5: Finalize the Femoral Preparation & Final TrialingStep 5: Final Distal Femoral Preparation &Trialing (NexGen RH Knee Femoral Only)Refer to the NexGen RH Knee Surgical Technique(97-5880-002-00 revision 4 or higher) for final femoralpreparation and trialing.5.1 Finish Femoral Preparation5.2 Assemble & Insert FemoralProvisional Components5.3 Insert Hinge Post Extension Provisional5.4 Evaluate Patellar TrackingCautions:— The Segmental One-Piece Hinge Post must be used withthe Segmental Trabecular Metal Proximal Tibial Component(Fig. 16). The NexGen RH Knee Modular Hinge Post and HingePost Extension are not indicated for use with the ZimmerSegmental System Tibia or the Segmental Distal Femur.— The Hinge Post Provisional used for trial reduction isavailable only in the shortest length, which may be shorterthan the final Hinge Post being implanted. Thus, moredistraction may be necessary to assemble the final implant.Notes:— Use the RH Knee Segmental Hinge Post Provisional (notthe Segmental Distal Femoral Hinge Post Provisional – goldcolor on its superior end). The Segmental Distal FemoralHinge Post Provisional (gold) will not provide an accurateassessment of hyperextension during trial reduction.— To secure the Segmental/RH Knee Segmental Hinge PostProvisional to the NexGen RH Knee Femoral Provisional/Cutting Guide, cross-pin with the Segmental RH Knee HingePin Provisional— Do not use the Segmental/RH Knee Hinge Pin Aligner asthere may not be a trephine hole in the medial side of thebone to place the Hinge Pin Aligner through when trialing(common in oncology cases).— The Hinge Pin Aligner may be used to trial the HingePost Provisional if revising a NexGen RH Knee to add theSegmental Tibia, requiring the NexGen RH Knee TrephineGuide Instruments to drill a hole for the implant hinge pin.11Fig. 16
SECTIONStep 6: Provisional Disassembly6Step 6: Provisional Disassembly Place the NexGen Femoral Slaphammer Extractor intothe extraction slots on the Distal Femoral Provisional toremove the component and/or hinge post assembly.TwoGrooves Use the Segmental Taper Separator to disengage theProximal Tibial Provisional and the Male-Female SegmentProvisional (See Appendix A). Thread the Provisional Slaphammer Adapter (two grooves)(Fig. 17) onto the Slaphammer and thread it into theStem Provisional. Impact the Slaphammer to remove the Stem Provisional.Fig. 17Notes:— To protect the taper integrity of the provisional components,use only the Segmental Taper Separator with the turninghandle to disassemble the provisional construct.— The Femoral Stem Extractor can also be used to remove theentire provisional construct (Fig. 18).Fig. 97-12Slaphammer00-6551-006-00Proximal 51-003-10Segmental StemProvisional Bowed(See ZSS Profiler)Segmental StemProvisional Straight(See ZSS Profiler)Collar Provisional(See ZSS Profiler)00-5853-056-XXSegmentProvisional(See ZSS Profiler)KT-5853-004-00Femoral StemExtractor00-6601-002-0012
SECTION7Step 7: Gastrocnemius Transfer PreparationStep 7: GastrocnemiusTransfer Preparation Assess the need for a gastrocnemius transfer (Fig. 19). Determine whether adequate proximal tibial fasciaexists to reattach to the patellar ulargastrocnemiusrepair If the fascia is insufficient, consider a gastrocnemiustransfer. Assess the feasibility of a gastrocnemius transfer. Determine if there is an adequate length of patellarligament to allow reattachment to the gastrocnemiustransfer or implant to achieve function. A minimumof 3cm is optimal. Determine if there will be adequate attachment ofthe gastrocnemius muscle to the tibial implant andadjacent soft tissues. Identify the medial gastrocnemius muscle belly and itsmidline interphase with the lateral gastrocnemius muscle. Dissect the distal muscle tendon complex at its medialborder and deep surface. Carefully transect the tendon complex distally wherethe musculotendonous portion attaches to the proximalAchilles tendon.Notes:— The gastrocnemius transfer is strongly recommended inaddition to the patellar ligament.— The patellar ligament must be attached via sutureand/or Tissue Attachment Arms in a manner that willallow soft tissue healing to the patients remaining tibialtuberosity and the associated fascial envelope of theproximal tibia, and medial and lateral (antitibial) fasciaor periosteum.— The lateral gastrocnemius muscle could be used similarly.13Medialgastrocnemiustransected atthe ankleFig. 19Wrappingof medialgastrocnemius
SECTIONStep 8: Final Assembly & Implantation8Step 8: Final Assembly & ImplantationIt is important to implant the tibial construct before the distalfemoral construct to provide a platform for the articular surfaceand subsequent pressure for the Distal Femoral Componentwhile the cement is curing.8.1 Assemble Tibial ConstructThere are two options for assembling and inserting thefinal implants.Back Table AssemblyThe final construct can be completely assembled on the backtable and inserted as a single unit. This is the recommendedmethod.In Vivo Assembly The Stem and Collar can be assembled and inserted first,and then the Segment and Proximal Tibial Component can beassembled and impacted onto the implanted Stem (commonwhen using Variable Stiffness Stems).TECHNIQUE TIPStemDiameterSmooth Collar(Item #) (Dimension A)Trabecular Metal Collar(Item #) (Dimension A)8.AIf cementing a patellar component, consider using two batches ofbone cement. Use the first batch to cement the Collar to the Stem andto cement the patellar implant onto the bone. After the cement has set,use a second batch to cement the Fluted Stem when implanting thetibial construct.25mm for 9-16mm Stems(00-5852-040-25)9-16mmNotes:— All Segmental Stems must be used with Collars, and allCollars must be cemented to the Stems.— If implanting the complete construct as a single unit,all components of the construct must be assembledand impacted together before cementing the Collar tothe Stem. This prevents the impaction force from beingplaced directly onto the cemented Collar.— Before opening the implant packages, verify that the Collaris compatible with the Stem size on the label (Table 9).20mmTable. 9Dimension A30mm for 9-16mm Stems(00-5852-040-30)35mm for 9-16mm Stems(00-5852-040-35)— Avoid notching, scratching, or directly striking implantsduring assembly.— A space will exist between the components when thetapers are fully seated.30mm for 9-16mm Stems(00-5852-042-09)17-19mm30mm for 17-19mm Stems(00-5852-041-30)30mm for 17-19mm Stems(00-5851-042-17)35mm for 17-19mm Stems(00-5852-041-35)30mmStem Collar Compatibility Chart14
SECTION8Step 8: Final Assembly & ImplantationBack-Table Assembly Rest the tibial plateau of the Segmental Trabecular MetalProximal Tibial Component on the Segmental Tibial ImpactorBase on the back table (Fig. 20). Thoroughly clean and dry the tapers of all components.Male-Female Segment Assembly Insert the Male-Female Segment into the tibial implantwith the anteversion tabs aligned. Attach the Universal Impactor Handle to theSegment Impactor.Fig. 20 Apply the impactor assembly to the segment andimpact it with a two-pound mallet.A/PTECHNIQUE TIP8.BPosition the anteversion tabs in either the direct A/P or M/Lorientation to facilitate access for the Segmental Taper Separatorshould future disassembly be required (Fig. 21).M/LWarning: Impacting the taper more than once may loosenthe taper connection.Fig. 21InstrumentsTibial ImpactorBase00-5851-000-1415UniversalImpactor Handle6216-01-125Segmental Implant/Provisional FemaleTaper Impactor(Segment al TaperSeparator00-5851-020-00
SECTIONStep 8: Final Assembly & Implantation8Stem Assembly Thoroughly clean and dry the tapers before assemblingthe remaining components Insert the Stem into the tibial implant or Segment with theanteversion tabs aligned. For a Fluted Stem, protect the end of the Stem with gauze,and use a two-pound Mallet to solidly impact the Stem. For a Variable Stiffness Stem, slide the Variable StiffnessStem Impaction Sleeve over the Stem until the notches onthe sleeve capture the collar alignment tabs on the Stembase (Fig. 22). Solidly strike the impaction head of the sleeve with atwo-pound Mallet.Warning:— Impacting the Variable Stiffness Stem Impaction Sleevemore than once may loosen the taper connection.— Do not strike the tip of the Variable Stiffness Stem withany instrument, as this may damage the prongs createdby the slots.Fig. 22Stem Collar Attachment Apply cement in the doughy state to the base/taper endof the Stem.Collar Alignment Tab With the pockets toward the knee joint, slide the Collarover the Stem. Clean off excess cement while advancing the Collar tothe shank area where cement was applied. Ensure that the Collar is fully engaged into the tabs onthe Stem (Fig. 23). Allow the cement to fully harden before inserting theconstruct into the canal.Note: Be careful to prevent cement from contacting the taper,the anteversion adjustment pockets, and the external surfacesof Trabecular Metal Material specifically where the Collar willcontact the cortical bone.Fig. 23Pocket onTrabecular Metal CollarInstrumentsVariable Stiffn
Refer to the NexGen RH Knee Surgical Technique (97-5880-002-00) and Segmental Distal Femoral Surgical Technique (97-5850-004-00) before performing a Trabecular Metal Proximal Tibial Component implantation. (The RH Knee Surgical Technique has been updated with specific instruments regard
origin of measurement reference system, stress related considerations, reference designs and handling information can be found. For testing and prototyping, Xsens provides the MTi-630 and MTi-670 Development Kits (MTi-630-DK and MTi-670-DK) as well as a Starter Kit for the MTi-680G (MTi-680G-SK).
22. Biomet Surgical Technique for Ascent TKA. 23. Johnson & Johnson, DePuy Surgical Technique for PFC Sigma Rotating Platform TKA. 24. Zimmer Surgical Technique for NexGen TKA. 25. Biomet Surgical Technique for Vanguard TKA. 26. Knee product review, Smith & Nephew, 2006 27. Stryker
Zimmer NexGen MIS LPS-Flex Mobile Implant System Surgical Technique Fig. 5 Surgical Technique Surgical technique is an important factor to consider when attempting to maximize range of motion in total knee arthroplasty. Close attention must be paid to balancing the flexion and extension gaps
1.3 MTi 600-series product variants The MTi-6x0 module is a fully tested self-contained module available as an: - Inertial Measurement Unit (IMU), - Vertical Reference Unit (VRU), - Attitude and Heading Reference System (AHRS) - GNSS aided Inertial Navigation System (GNSS/INS).
to identify the generation of your MTi. The MTi product portfolio from Xsens currently has 11 family members ranging in functionality from inertial measurement units (IMU's) to a fully integrated GNSS/INS solution. All products contain a 3D inertial sensor assembly (ISA: gyroscopes and accelerometers) and 3D magnetometers, with optionally a
Surgical Technique of the selected implant system. Mako TKA with Triathlon Surgical Protocol (PN TRIATH-SP-21) Manual TKA Surgical Technique for KINETIS (PN 210468). C. MAKO TKA TERMINOLOGY Approach Zone A volume in space around the kn
Revision Knee Surgical Technique DJO Surgical, as the manufacturer of this device, does not practice medicine and cannot recommend this or any other surgical technique for use on a specific patient. The choice of the appropriate s
The NHS coronavirus action plan (issued on 3 March 2020), makes clear that ‘at all phases of a future pandemic, the NHS/HSCNI and local authorities have plans in place to ensure people receive the essential care and support services they need – and sometimes this might mean that other services are reduced temporarily’. It also states that as the disease moves into different phases ‘the .
