Vanguard Knee. Premier Total Knee Instrumentation SURGICAL TECHNIQUE

Vanguard Knee Premier™ Total Knee Instrumentation S U R GI C AL TEC H N I Q U E l i m a c o r p o r a te.c o m PREMIER™ TOTAL KNEE INSTRUMENTATION...
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Vanguard Knee Premier™ Total Knee Instrumentation

S U R GI C AL TEC H N I Q U E

l i m a c o r p o r a te.c o m

PREMIER™ TOTAL KNEE INSTRUMENTATION Index Introduction

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04

Patient Selection

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04

Preoperative Planning

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05

Approaches

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06

Mini-medial Parapatellar Approach, Option 1

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08

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10

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12

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16

Femoral 4-in-1 Resections

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18

PS Box Preparation

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20

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22

Tibial Sizing

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26

Tibial Stem Preparation

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27

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29

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30

Initial Skin Incision Approach Deep Exposure Mid-vastus Approach, Option 2 Initial Skin Incision Approach Deep Exposure Sub-vastus Approach, Option 3 Initial Skin Incision Approach Deep Exposure Distal Femoral Resection Intramedullary Adjustable Distal Resection, Option 1 Intramedullary Fixed Distal Resection Guide, Option 2 Distal Resection Femoral Sizing Fixed Rotation Feet, Option 1 Adjustable Rotation Feet, Option 2

Standard PS Box Guide, Option 1 PS Box Preparation with Mill, Option 2 Tibial Resection Extramedullary Tibial Resection, Option 1 Intramedullary Tibial Resection, Option 2

I-beam Stem Punch, Option 1 Cruciate Stem Punch, Option 2 Patellar Resection Surface Clamp Contents Patella Milling

Inset Single Peg Patella using the Vanguard Patella Mill ®

Trial Reduction

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32

Tibial Implant Insertion

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33

Femoral Implant Insertion

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34

Patellar Implant Insertion

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35

Locking Bar Insertion/Removal

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36

Instrumentation Layout

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38

LEONARDO DA VINCI: Vitruvian Man. Study of the proportions of the human body (1490) PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 3

PREMIER™ TOTAL KNEE INSTRUMENTATION Introduction

€ INTRODUCTION

€ PATIENT SELECTION Either a traditional or minimally invasive technique can

The Vanguard Knee System offers the flexibility to change

be utilized with Premier™ Total Knee Instrumentation.

from a cruciate retaining (CR) to a posterior stabilized (PS)

It is important to note that minimally invasive methods can

or posterior stabilized constrained (PSC) knee within a

be utilized on nearly all patients undergoing total knee

single system. The transition between each constraint

arthroplasty. However, it is important to have adequate

level can be made with ease, allowing the physician to

patellar mobility, which can be assessed on physical

evaluate soft tissue and bone deficiencies intraoperatively

examination prior to making the skin incision, as well as

without making a preoperative commitment to the level of

intraoperatively. If multiple scars from previous surgeries

constraint.

exist, skin incision placement will need to be evaluated,

®

as well as elements of scarring, which may decrease soft tissue mobility. If a high tibial osteotomy has been performed previously, a more traditional exposure is recommended, as this may require reconstructive methods which may be different from primary total knee replacement.

This Premier™ Total Knee Instrumentation surgical technique is utilized by Keith Berend, M.D., Biomet as the manufacturer of this device, does not practice medicine and does not recommend this device or technique. Each surgeon is responsible for determining the appropriate device and technique to utilize on each individual patient.

4 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Preoperative Planning

€ PREOPERATIVE PLANNING In order to assess bone stock, potential ligament instability and the anatomical axis, a 36” long standing A/P X-ray is recommended. Determine the angle between the anatomic and mechanical axis, assuring the distal femoral cut is perpendicular to the mechanical axis (Figure 1). Estimate femoral component size preoperatively by using lateral view X-rays and radiographic templates. Confirmation

of

the

appropriate

size

component

intraoperatively is critical for normal kinematics.

Figure 1

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 5

PREMIER™ TOTAL KNEE INSTRUMENTATION Approaches

€ APPROACHES Premier™ Total Knee Instruments are designed for use with both traditional surgical methods as well as minimally invasive techniques. Three basic procedures can be utilized for total knee arthroplasty: •

Option 1: Mini-medial Parapatellar (See page 4 for surgical technique)



Option 2: Mid-vastus (See page 5 for surgical technique)



Option 3: Sub-vastus (See page 7 for surgical technique)

The mini-medial parapatellar approach may be used initially. This approach can be easily extended or converted to a more extensive traditional approach, should additional exposure be necessary. The mid-vastus approach can create extensive exposure without violating the quadriceps tendon with only a small split in the vastus medialis obliquus (VMO) muscle. The sub-vastus approach preserves the quadriceps muscle and tendon, but requires careful assessment of patellar mobility as well as size and bulk of the quadriceps muscle mass.

6 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Mini-medial Parapatellar Approach, Option 1

€ MINI-MEDIAL PARAPATELLAR APPROACH, OPTION 1

INITIAL SKIN INCISION Make the skin incision centered over the medial one-third of the patella extending from 1cm above the superior pole of the patella to the tibial tubercle. The length of this incision will vary depending on the anatomy, but generally range between 4–6.” It is recommended to perform the skin incision in a flexed position which will help minimize the sensitivity with kneeling. It is extremely important to monitor the proximal and distal margins of the incision in order to make certain there is not increased tension from excessive retraction. Extension of the skin incision may be necessary during the procedure depending on the anatomy and the quality of the soft tissue. Keep in mind that the priority is to minimize the soft tissue trauma and to preserve the quadriceps muscle.

APPROACH Make a mini-medial parapatellar arthrotomy, beginning at Figure 2

the top medial corner of the patella and continuing down along the patellar tendon, ending at the patellar tendon insertion (Figure 2). Once the incision has been made, ensure the release of any soft tissue adhesions.

DEEP EXPOSURE With the knee in the extended position, perform the arthrotomy from 1–2cm above the superior pole of the patella, extending to the level of the tibial tubercle. Perform fat pad excision to facilitate exposure and to improve patellar mobility. Perform a medial release at this time to only release what is necessary for the existing deformity. This will also allow for easy placement of the medial retractors for protection of the medial collateral ligament as well as exposure of the proximal tibia later in the procedure.

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 7

PREMIER™ TOTAL KNEE INSTRUMENTATION Mid-vastus Approach, Option 2 Note: Because the patella is not everted in this technique, the patellar tendon may be tight and thus require greater retractor tension. Take special care not to violate the patellar tendon insertion point. A small-headed pin, suture or staple may be placed at the patellar tendon insertion to prevent avulsion.

MID-VASTUS APPROACH, OPTION 2

INITIAL SKIN INCISION Make the skin incision centered over the medial onethird of the patella extending from 1cm above the superior pole of the patella to the tibial tubercle (Figure 3). The length of this incision will vary depending on the anatomy, but generally range between 4–6.” It is recommended to perform the skin incision in a flexed position which will help minimize the sensitivity with kneeling. It is extremely important to monitor the proximal and distal margins of the incision in order to make certain there is not increased tension from excessive retraction. Extension of the skin incision may be necessary during the procedure depending Figure 3

on the anatomy and the quality of the soft tissue. Keep in mind that the priority is to minimize the soft tissue trauma and to preserve the quadriceps muscle.

8 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Mid-vastus Approach, Option 2

APPROACH Extend the capsular incision in a straight line proximally obliquely cutting across VMO muscle fibers. This is most easily performed with the knee flexed near 90 degrees. The VMO incision typically extends for a distance of 1–3cm. This length is partially dependent on the VMO insertion site onto the patella. If the VMO has a proximal patellar insertion, the VMO incision may be only 1–2cm. If the VMO inserts into the patella as far distally as midpatella, the incision into the VMO may reach 3–4cm. If it is later determined that a more extensile incision is required for proper exposure, the VMO incision can be continued straight proximally. Note: The strongest fascia for closure is on the deep surface of the VMO. When the capsule is closed, this deep fascial layer must be included in the sutures. Typically only two or three sutures are required to close the mid-vastus VMO extension of the capsular incision. Once the incision has been made, ensure the release of any soft tissue adhesions.

DEEP EXPOSURE With the knee in the extended position, perform the arthrotomy from 1–2cm above the superior pole of the patella, extending to the level of the tibial tubercle. Perform fat pad excision to facilitate exposure and to improve patellar mobility. Perform a medial release at this time to only release what is necessary for the existing deformity. This will also allow for easy placement of the medial retractors for protection of the medial collateral ligament as well as exposure of the proximal tibia later in the procedure. Note: Because the patella is not everted in this technique, the patellar tendon may be tight and thus require greater retractor tension. Take special care not to violate the patellar tendon insertion point. A small-headed pin, suture or staple may be placed at the patellar tendon insertion to prevent avulsion.

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 9

PREMIER™ TOTAL KNEE INSTRUMENTATION Sub-vastus Approach, Option 3

€ SUB-VASTUS APPROACH, OPTION 3

INITIAL SKIN INCISION Make the skin incision centered over the medial one-third of the patella extending from 1cm above the superior pole of the patella to the tibial tubercle. The length of this incision will vary depending on the anatomy, but generally range between 4–6”. It is recommended to perform the skin incision in a flexed position which will help minimize the sensitivity with kneeling. It is extremely important to monitor the proximal and distal margins of the incision in order to make certain there is not increased tension from excessive retraction. Extension of the skin incision may be necessary during the procedure depending on the anatomy and the quality of the soft tissue. Keep in mind that the priority is to minimize the soft tissue trauma and to preserve the quadriceps muscle.

APPROACH Figure 4

Make a horizontal arthrotomy along the inferior border of the VMO leaving a cuff of retinaculum for closure (Figure 4). Complete the arthrotomy in a standard manner along the medial patellar tendon. Once the incision has been made, ensure the release of any soft tissue adhesions.

10 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Sub-vastus Approach, Option 3

DEEP EXPOSURE With the knee in the extended position, perform the arthrotomy from 1–2cm above the superior pole of the patella, extending to the level of the tibial tubercle. Perform fat pad excision to facilitate exposure and to improve patellar mobility. Perform a medial release at this time to only release what is necessary for the existing deformity. This will also allow for easy placement of the medial retractors for protection of the medial collateral ligament as well as exposure of the proximal tibia later in the procedure. Note: Because the patella is not everted in this technique, the patellar tendon may be tight and thus require greater retractor tension. Take special care not to violate the patellar tendon insertion point. A small-headed pin, suture or staple may be placed at the patellar tendon insertion to prevent avulsion.

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 11

PREMIER™ TOTAL KNEE INSTRUMENTATION Distal Femoral Resection

€ DISTAL FEMORAL RESECTION Utilize the .375” intramedullary (IM) drill to penetrate the femoral canal to a depth of approximately 1.5 to 2” (3.5 to 5cm). Place the canal entry location 1cm above the insertion of the posterior cruciate ligament and slightly medial in the intercondylar notch (Figure 5).

INTRAMEDULLARY ADJUSTABLE RESECTION GUIDE, OPTION 1

DISTAL

Set the adjustable distal femoral resection guide to the desired valgus angle by pressing and turning the valgus angle dial. A valgus angle setting of 0 to 9 degrees is available. Select the depth of distal resection by turning the resection level dial. The distal resection depth can range from a simple 1mm clean-up cut for revision scenarios up to 11mm for severe flexion contractures (Figure 6). Figure 5

Note: The standard distal resection is 9mm, matching the distal thickness of the Vanguard® implant.

Figure 6

12 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Distal Femoral Resection

Assemble the IM rod and adjustable distal resection guide by inserting the IM rod through the central hole of the resection guide. Slowly introduce the IM rod to the femoral canal to depressurize the canal. Slide the adjustable resection guide until it rests flush with the distal femur. Attach the distal femoral cut block to the distal resection guide adaptor by sliding the magnetized distal block into the adjustable distal resection guide adaptor (Figure 7). Figure 7

Attach the adjustable distal guide adaptor and cut block to the adjustable femoral resection guide by sliding the two legs on the adaptor through the anterior holes of the resection guide. Continue sliding the adaptor until the block is sitting against the anterior cortex. Pin the resection block into place using 1/8” quick release drill pins in the most proximal pin holes of the block (Figure 8). To confirm the valgus angle, the alignment handle can be inserted into the adjustable distal resection guide adaptor and a ¼” alignment rod can be inserted and extended to the center of the femoral head (Figure 9). Remove the adjustable guide by disengaging the IM rod and pulling the guide and adaptor distally away from the distal resection block, leaving the distal resection block

Figure 8

in place.

Figure 9

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 13

PREMIER™ TOTAL KNEE INSTRUMENTATION Distal Femoral Resection

INTRAMEDULLARY ADJUSTABLE RESECTION GUIDE, OPTION 2

DISTAL

WChoose the appropriate left or right symmetrical valgus wing and slide it onto the IM rod. Introduce the IM rod to the femoral canal to depressurize the canal. Slide the valgus wing until it rests against the distal femur (Figure 10). The “left” or “right” engraving on the block must face distally based on the leg being prepared. By rotating, align the lower edge of the valgus wing with equal amounts of posterior condyle extending underneath the bottom of the block. Slide the distal resection block and valgus block adaptor Figure 10

into the anterior holes of the valgus wing until the resection block contacts the anterior femur. Pin the resection block into place using 1/8” quick release drill pins in the most proximal pin holes of the block (Figure 11). To confirm the valgus angle, the alignment handle can be inserted into the valgus block adaptor and a ¼” alignment rod can be inserted and extended to the center of the femoral head (Figure 12). Remove the valgus wing by removing the IM rod and pulling the valgus wing and valgus block adaptor distally away from the distal resection block, leaving the distal resection block in place.

Figure 11

Figure 12

14 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Distal Femoral Resection

DISTAL RESECTION Two resection slots of 0 or +3mm are available for the distal resection. The 0mm slot will resect 9mm from the most prominent part of the contacting distal condyle. If additional distal resection is required, the +3mm slot will resect 12mm. If additional distal resection is required beyond the +3mm slot, shift the resection guide proximal by utilizing the +2 or +4mm 1⁄8” pin holes. Use a .054” saw blade to complete the distal resection through the selected slot (Figure 13). Check the resected distal femur using a flat instrument. Recut or file as necessary to ensure proper resection. Note: Two distal femoral resection blocks can be used. One block utilizes the assistance of handles and the other relies on pins for fixation and stability (Figure 14). Figure 13

Figure 14

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 15

PREMIER™ TOTAL KNEE INSTRUMENTATION Femoral Sizing

€ FEMORAL SIZING Place the adjustable A/P Sizer flat against the resected distal surface with the feet in contact with posterior condyles of the femur.

FIXED ROTATION FEET, OPTION 1 Two options are available when utilizing posterior feet: 3 degree external rotation (left and right) and neutral (Figure 15).

ADJUSTABLE ROTATION FEET, OPTION 2 Figure 15

Adjustable dial feet can be used with the A/P Sizer. They are avaliable in left and right with the ability to set external rotation from 0 to 10 degrees. It is suggested that an initial setting of 3 degrees of external rotation be utilized (Figure 16). The femoral component size can now be read from the central scale. If the size indicated is in-between standard sizing or a larger flexion gap is desired, a choice may be made to choose the smaller size and shift the femoral 4-in1 block placement anteriorly. To shift the component anteriorly, turn the screw mechanism in the central portion of the sizer, which in turn raises the level of drill holes in 1mm increments (Figure 17).

Figure 16

Figure 17

16 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

A scale is located on the sizer to indicate how far the component will be anteriorly shifted.

PREMIER™ TOTAL KNEE INSTRUMENTATION Femoral Sizing

If M/L width is a concern, the appropriately sized M/L width checker can be inserted into the A/P Sizer to further evaluate the proper size of the femur (Figure 18). Drill the two 4-in-1 cutting block location holes utilizing the 1/8” drill pin (Figure 19). Note: The final M/L position of the component is not determined during this step, but is addressed later in the technique.

Figure 18

Figure 19

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 17

PREMIER™ TOTAL KNEE INSTRUMENTATION Femoral 4-in-1 Resections

€ FEMORAL 4-IN-1 RESECTIONS Choose the slotted femoral A/P 4-in-1 block that matches the selected size on the A/P Sizer and place it into the 1/8” holes drilled into the distal femur. A .054” feeler blade can be used to determine the amount of anterior bone resection (Figure 20). If the feeler blade indicates a probability of notching, use the A/P femoral shift block to adjust the cut block holes anteriorly in 1mm increments (Figure 21). Moving the block anteriorly will resect additional posterior condylar bone.

Figure 20

Figure 21

18 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Femoral 4-in-1 Resections

Handles can be attached into the sides of the femoral 4-in1 block (Figure 22). Ensure the A/P block is sitting flush against the distal femur. If additional stability is required, 1/8” drill pins can be placed in the side holes provided. Once the block position is satisfactory, resect the anterior and posterior bone, and the anterior and posterior chamfers, with a .054” saw blade (Figure 23).

Figure 22

Figure 23

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 19

PREMIER™ TOTAL KNEE INSTRUMENTATION PS Box Preparation

€ PS BOX PREPARATION The M/L width of the Standard PS Box Guide and Mill PS Box Guides mimic the dimensions of the final implant. Take care to position the guide to avoid overhang.

STANDARD PS BOX GUIDE, OPTION 1 Impact the size-specific box resection guide on the prepared distal femur (Figure 24). Secure the box resection guide with two 1/8” drill pins through the holes located in the anterior flange. Figure 24 Position the PS box chisel, with the beveled edge facing the distal femur, into the appropriate resection level; either bone conserving (BC), open box (OP), or closed box (CL) (Figure 25). Impact the PS box chisel to a depth approximately one-half CL

OP BC

the thickness of the femur. Using a .054” sawblade, resect along the interior of the box guide with an oscillating saw to the depth of the box chisel. Continue both cuts from the anterior portion through to the posterior. Finish impacting the box chisel until the intercondylar bone is removed (Figure 26).

Figure 25

Figure 26

20 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION PS Box Preparation

PS BOX PREPARATION WITH MILL, OPTION 2 Impact the size-specific box resection mill guide on the prepared distal femur. Secure the box resection guide with two 1/8” drill pins through the holes located in the anterior flange. Insert the appropriate size reamer into a power drill. Insert the tip of the reamer into the central hole in the posterior axle of the box resection guide (Figure 27). Under power, rotate the reamer around the axle anteriorly into the box guide. To guard against potential damage to Figure 27

the reamer tip, ensure the reamer is fully seated on the PS box mill pivot, maintain the reamer postion perpendicular to the axis of the pivot and avoid applying excessive force when milling. Use only as much force as necessary to aid the reamer’s advancement through the bone. Repeat this step with the reamer inserted in both the medial and lateral positions. If a bone conserving resection is desired, insert the appropriate magnet stop guide prior to reaming (Figure 28). Remove the box resection guide. Place the appropriate femoral box gauge into the resected intercondylar area to determine if appropriate depth and width of bone has been removed (Figure 29). Note: The closed box femur of the Vanguard® PS knee

Figure 28

requires the use of the CL resection level on the standard mill. The PS Box Mill removes sufficient bone for a closed box femoral component and can perform a BC resection by utilizing the appropriate size specific magnet stop.

Figure 29

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 21

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Resection

€ TIBIAL RESECTION

EXTRAMEDULLARY TIBIAL RESECTION, OPTION 1 With the knee flexed, place the spring loaded arms of the ankle clamp around the distal tibia just above the malleoli (Figure 30). Press the silver button on the body of the tibial resector to change the height of the resection block (Figure 31). Place the tibial resection block against the proximal tibia Figure 30

Figure 31

Figure 32

22 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

(Figure 32).

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Resection

Slope Adjustment Varus/Valgus Adjustment

From the sagittal view, depress the side of the EM guide bottom and adjust the EM guide along the perpendicular shaft of the guide bottom until the tubular body is parallel (for 0 degree posterior slope) with the shaft of the tibia (Figure 33).

Once adjustment of the resector axis is correct in the M/L Figure 33

view, rotate the resector until the shaft of the resector is just medial to the tibial tubercle. Push the gold button located on the top of the stylus to release the stylus locking mechanism and snap the stylus into the top of the cutting block (Figure 34).

When referencing the deepest portion of the unaffected condyle, set the stylus to read 8–10mm. Set the stylus to read 2–4mm when referencing the most affected condyle.

To confirm alignment, an alignment tower can be placed on the cut block and a ¼” alignment rod can be inserted into the lateral hole of the guide (Figure 35). Figure 34

Figure 35

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 23

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Resection

INTRAMEDULLARY TIBIAL RESECTION, OPTION 2 Fully flex the knee and identify the center of the tibial plateau. Utilize a .375” IM drill to enter the tibial canal. The point of entry is just posterior to the anterior cruciate ligament insertion (Figure 36). Upon removal of the drill, slide the T-handle fluted rod through the body of the tibial resection guide with the tibial resection block in place and slowly introduce the IM rod to the tibial canal to depressurize the canal. To properly position the resection head, a silver button is located on the left side of the body of the guide. Press the button and slide the resection guide forward until the tibial Figure 36

cut block becomes flush with the anterior cortex of the tibia (Figure 37). The posterior slope of the resection is controlled by using a cutting head with the desired slope. Note: The standard Vanguard® CR tibial insert has a 3 degree posterior slope built into the articular surface. Place the stylus along the side of the resection guide on the perfered condyle. The tibial stylus reflects the total amount of bone to be resected.

Figure 37

24 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Resection

Change the resection level by pressing the dial and rotating to the appropriate level. The dial will snap into place at each 1mm increment (Figure 38). When referencing the deepest portion of the unaffected condyle, set the stylus to read 8–10mm. Set the stylus to read 2–4mm when referencing the most affected condyle. To confirm alignment, an alignment tower can be placed on the cut block and a ¼” alignment rod can be inserted into the lateral hole of the guide (Figure 39).

Figure 38

Once the correct position is established, 1/8” drill pins are used to secure the cutting block to the tibia through the most distal pin holes of the cut block. This will allow resection of +2 or +4mm of the proximal tibial plateau (Figure 40). Remove the tibial resection guide, alignment tower and rod, leaving the tibial resection block in place. Resect the plateau using a .054” sawblade.

Figure 39

+4mm

Initial Position

+2mm

Figure 40

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 25

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Sizing

€ TIBIAL SIZING After a flat tibial resection has been made, select the appropriate tibial base plate that provides the best tibial coverage both A/P and M/L. Base rotation on position relative to the tibial tubercle and the malleolar axis. Make an extramedullary alignment check by placing the alignment rod through the lateral hole in the alignment handle (Figure 41). Slight

external

rotation

is

preferred

to

optimize

patellofemoral tracking. Perform an initial trial reduction to confirm proper rotation. When correct rotation has been determined, mark the position by extending the Figure 41

anterior mark of the baseplate onto the anterior tibia with electrocautery (Figure 42). Note: Take extra caution to avoid internal rotation of the tibial tray due to the presence of lateral soft tissue.

Figure 42

26 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Stem Preparation

€ TIBIAL STEM PREPARATION I-BEAM STEM PUNCH, OPTION 1 Assemble the punch guide tower to the tibial template utilizing the quick release lock (Figure 43). Introduce the starter reamer to provide an initial hole into the tibia (Figure 44). The starter reamer should be fully engaged in the punch guide before power is started.

CRUCIATE STEM PUNCH, OPTION 2 Figure 43

The starter reamer should not be used when preparing for insertion of the Biomet® CoCr Finned Tray. In this case, only the finned stem punch should be used (Figure 45). Note: To assemble the tibial punch, choose the appropriate tibial stem punch head. Attach the punch head by pressing the button on the top of the handle (inset, Figure 45). I-beam stems come in both cemented and noncemented punches.

Figure 44

Figure 45

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 27

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Stem Preparation

Carefully drive the trial punch into the guide until it mechanically stops (Figure 46). Note: A mechanical stop is designed to provide the correct punching depth. After the punch is fully seated, press the button on top of the punch handle to release the punch head. The punch head sits in the tibial trial plate and acts as the trial stem (Figure 47).

Figure 46

Figure 47

28 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Patellar Resection

€ PATELLAR RESECTION Tilt the patella to 90 degrees and remove the osteophytes and peripatellar tissues down to the level of the tendinous insertions of the quadriceps and patellar tendons. Determine the level of the cut through caliper measurement of the total patellar thickness (Figure 48).

SURFACE CLAMP Figure 48

Perform the initial patellar resection utilizing the patella clamp surface cut guide. Clamp the guide to perform a flat cut across the patella. A magnetic depth stylus may be utilized to determine the appropriate resection level (Figure 49).

VANGUARD® PATELLA OFFERINGS Diameter (mm) 25 1-peg 3-peg

Figure 49

28

31

34

37

40

Std.

N/A

8.0

8.0

8.4

10.0

10.0

Thin

6.2

6.2

6.2

7.8

8.5

N/A

Std.

N/A

8.0

8.0

8.4

10.0

10.0

Thin

6.2

6.2

6.2

7.8

8.5

N/A

Care should be taken to restore original patella thickness to prevent overstuffing of the patellofemoral joint. If a single peg patellar component is utilized, use the single peg patellar drill guide to locate the placement of the central peg. Drill the central hole using the 5/16” Series A patellar drill. Select a trial patellar component to optimize coverage without increasing patellar thickness beyond pre-resection height. If a 3-peg patellar component is to be implanted, place the appropriately sized 3-peg drill guide onto the resected patella and use the 1/4” patellar drill to prepare for the component pegs (Figure 50).

Figure 50

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 29

PREMIER™ TOTAL KNEE INSTRUMENTATION Patella Milling

€ PATELLA MILLING INSET SINGLE PEG PATELLA USING THE VANGUARD® PATELLA MILL Tilt the patella to 90 degrees and remove the osteophytes and peripatellar tissues down to the level of the tendinous insertions of the quadriceps and patellar tendon. Determine the patella thickness by using calipers. Size the patella using the mill bushings (Figure 51). Attach the size-specific bushing to the mill handle after the appropriate size patella has been determined. Based on patella size and thickness, determine if a standard or thin patella should be used. Firmly clamp the patella with the mill handle paying careful attention not to tilt the patella.

Figure 51

Attach the appropriate size-specific patella reamer to the reamer shaft (Figure 52). Attach the proximal shaft to a power drill. Insert the reamer basket into the mill bushing and allow the reamer’s central bit to rest on the apex of the patella bone.

Figure 52

30 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Patella Milling

Attach the appropriate thickness magnetic spacer (marked “Bit”) to the adjustable depth stop. Set the adjustable stop by depressing the button on its side and slide the stop down until the bottom of the spacer touches the mill bushing (Figure 53). Note: The magnetic spacer bit includes the depth of the peg. Do not sink the drill bit prior to setting the adjustable stop. Remove the magnetic spacer and ream until the adjustable stop touches the mill bushing. Remove the reamer assembly and then disengage the mill handle by pulling the thumb trigger towards the handle. Note: If a 3-peg patellar component is to be implanted, the appropriate sized surface reamer will be used to prepare Figure 53

the inset surface. The magnetic spacer marked with a red dot should be used to correctly establish the resection depth. The 3-peg drill guide is tapped into the prepared patella inset and the 1⁄4” patellar drill is used to make the holes for the component pegs.

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 31

PREMIER™ TOTAL KNEE INSTRUMENTATION Trial Reduction

€ TRIAL REDUCTION With all bony surfaces prepared and soft tissue debrided, complete a trial reduction with the trial components. Place and impact the trial femoral component on the femur with the femoral inserter (Figure 54). Select trial bearing inserts to determine the appropriate thickness of the tibial component. Select a single peg or three peg trial patellar component that corresponds to the diameter and thickness and place it onto the patella. When the trial components are in place, check range-of-motion and stability of the knee (Figure 55). If tightness is found M/L, in flexion or in extension, appropriate soft tissue releases must be performed. Figure 54

Note: If trialing a PS knee, insert the appropriate PS trial post to the insert bearing. If additional constraint is needed, utilize the PS Plus trial post. Note: If distal femoral pegs are selected to be added to the femoral component, drill for pegs through the designated holes provided in the femoral trial (Figure 55).

Figure 55

32 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Tibial Implant Insertion

€ TIBIAL IMPLANT INSERTION Assemble the modular tibial component, by choosing the appropriate stem (most primary cases will require a 40mm stem). The locking screw for the stem is included in the stem’s packaging. Place the stem taper on the bottom of the appropriate modular tibial baseplate. Be sure that the alignment keys match between stem and plate. Impact the tip of the stem once with a mallet to seat the stem taper. Note: The stem taper will hold the stem and plate together during insertion. The screw is tightened into the threads of the stem for added stem fixation. Plugs can be left in the screw holes of the baseplate if screw fixation is not used. Utilize the tibial impactor to firmly seat the component (Figure 56). Remove excess cement with a curette. Optional screw fixation: Using the drill guide and 1/8” drill, Figure 56

prepare a hole for screw acceptance. Note: The low-profile screws may be angled at 15 degrees in any direction to engage the best available cancellous and/or cortical bone. Frequent reference to the X-rays will guide the drilling and screw insertion sequence. With the baseplate firmly fixed, the provisional bearing may be reinserted, and a trial reduction performed to confirm joint tension and stability.

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 33

PREMIER™ TOTAL KNEE INSTRUMENTATION Femoral Implant Insertion

€ FEMORAL IMPLANT INSERTION Place the appropriate femoral component on the end of the femur and insert it manually as far as possible (until about 1cm of space remains between the component and the distal femur). Fully seat the component using the control femoral impactor (Figure 57). Remove the extruded cement with a curette. Running through a range-of-motion will help to pressurize the cement.

Figure 57

34 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Patellar Implant Insertion

€ PATELLAR IMPLANT INSERTION Place the appropriate patellar component into the patella and push it into position with finger pressure so the peg(s) engage(s) the prepared hole(s). Position the patellar clamp onto the component and tighten the handle until the clamp head contacts the component. Clamp tightly to compress the implant (Figure 58). Remove extruded cement with a curette. The clamp should be left in position until the cement cures.

Figure 58

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 35

PREMIER™ TOTAL KNEE INSTRUMENTATION Locking Bar Insertion/Removal

€ LOCKING BAR INSERTION/REMOVAL Place the appropriate polyethylene bearing insert on the tibial baseplate and push posteriorly as far as possible using finger pressure. The polyethylene bearing must be flat on the baseplate in all directions. The locking bar, packaged with the tibial baseplate, is inserted into the medial side of the anterior tibial baseplate/polyethylene interface as far as possible using finger pressure (Figure 59). The locking bar must be tight upon insertion and should be too tight to insert completely with finger pressure only. Place the large curved end of the locking bar insertion forceps in the notch on the locking bar. The smaller square end should be placed in the notch of the anterior post of the tibial baseplate. Make sure the smaller square end Figure 59

catches on the post of the tibial tray and does not block the path of the locking bar. Squeezing the forceps will gradually push the locking bar until it clicks into place (Figure 60). A visual and audible confirmation should be made to ensure complete locking bar insertion.

Figure 60

36 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595311 Vanguard® Premier Femoral Preparation Instrumentation—Top Tray

A B

C

D E

PRODUCT

F

LABEL

PART NUMBER

DESCRIPTION

SIZE

A

32-485051 32-485052

Vanguard MP 10 Degree Dial Right Feet Vanguard® MP 10 Degree Dial Left Feet

— —

B

32-487027 32-487007 32-487026 32-487006 32-487025 32-487005 32-487024 32-487004

Premier™ 7 Degree Left Valgus Wing Premier™ 7 Degree Right Valgus Wing Premier™ 6 Degree Left Valgus Wing Premier™ 6 Degree Right Valgus Wing Premier™ 5 Degree Left Valgus Wing Premier™ 5 Degree Right Valgus Wing Premier™ 4 Degree Left Valgus Wing Premier™ 4 Degree Right Valgus Wing

— — — — — — — —

C

32-485053 32-485055 32-485054

Vanguard® MP 3 Degree Left Posterior Feet Vanguard® MP Neutral Posterior Feet Vanguard® MP 3 Degree Right Posterior Feet

— —

D

32-487111

Femoral Cut Block Handle (PK/2)



E

32-487002

Distal Cut Block without Handle Attachment



F

32-487061 32-487062

Vanguard® Sizing Wing Vanguard® Sizing Wing

60/62.5/65mm 67.5/70/72.5/75mm

®

Additional Instrumentation (Not Shown) 32-487001

Distal Cut Block with Handle Attachment



32-487060

Vanguard® Sizing Wing

55/57.5mm

38 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595311 Vanguard® Premier Femoral Preparation Instrumentation—Bottom Tray

A

B

C

D F

G

E I

H

C

J

PRODUCT

K

LABEL

PART NUMBER

DESCRIPTION

SIZE

A

32-487000

Adjustable Distal Cut Guide



B

32-487010

Adjustable Distal Adaptor (Included In 32-487000)



C

32-487102 32-487103 32-487104 32-487105 32-487106 32-487107

D

32-485030

Vanguard® T-Style IM Rod



E

32-487035

Vanguard® Femoral Elevator



F

32-487070

Vanguard® A/P Shift Block



G

32-487040

Vanguard® T-handle



H

32-485025

Vanguard® IM Canal Drill with Step



Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Premier™ Premier™ Premier™ Premier™ Premier™ Premier™

Block Block Block Block Block Block

60mm 62.5mm 65mm 67.5mm 70mm 75mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 39

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595311 Vanguard® Premier Femoral Preparation Instrumentation—Bottom Tray (Continued)

I

K

J

PRODUCT

LABEL PART NUMBER

I

32-487030

J

32-485014 32-485015 32-485016 32-485017

K

32-487050

Vanguard® Vanguard® Vanguard® Vanguard®

DESCRIPTION

SIZE

Modular IM Rod



4 5 6 7

— — — —

Degree Degree Degree Degree

Block Block Block Block

Attatchment Attatchment Attatchment Attatchment

Vanguard® A/P Sizer - Fudger



Additional Premier Femoral Instrumentation (Not Shown) 32-487100 32-487101 32-487209 32-487208

40 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

Vanguard® Vanguard® Vanguard® Vanguard®

Premier™ Premier™ Premier™ Premier™

Block Block Block Block

55mm 57.5mm 72.5mm 80mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595312 Vanguard® Premier Tibial Preparation Instrumentation—Top Tray

A

PRODUCT

LABEL PART NUMBER

A

32-487260 32-487261 32-487262 32-487263 32-487264 32-487265 32-487266 32-487267 32-487268

DESCRIPTION Punch Punch Punch Punch Punch Punch Punch Punch Punch

Thru Thru Thru Thru Thru Thru Thru Thru Thru

Trial Trial Trial Trial Trial Trial Trial Trial Trial

Plate Plate Plate Plate Plate Plate Plate Plate Plate

SIZE 59mm 63mm 67mm 71mm 75mm 79mm 83mm 87mm 91mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 41

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595312 Vanguard® Premier Tibial Preparation Instrumentation—Bottom Tray

A

C

B

D

H

G

E

I

J

F

L K

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

A

32-487274

Vanguard® I-beam Cementless Punch Head/Trial



B

32-487275

Vanguard® I-beam Cement Punch/Trial



C

32-487276

Vanguard® Cruciate Punch/Trial



D

32-487272

Vanguard® Tibial Punch Handle



E

32-487277

Vanguard® Revision Punch Head/Trial



F

32-487550

Vanguard® Premier™ EM Tibal Body



G

32-487271

Vanguard® Tibial Starter Reamer



H

32-487269

Premier™ Tibial Punch Tower Modular



42 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

I

32-485560

Vanguard® Tibial Stylus



J

32-487555 32-487556 32-487557

Tibial Resection Head-Right with Align Tibial Resection Head-Left with Align Tibial Resection Head - Universal (Center)



K

32-487551

Vanguard® Premier EM Tibial Top



L

32-487598 32-487599

Vanguard® IM Tibial Resection Guide Vanguard® IM Tibial Resection Guide

6–13mm 1–8mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 43

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595301 Vanguard® Universal Instrumentation—Top Tray

E D

B

A

F

H

C G

H

J

H

L

K

PRODUCT

I

LABEL PART NUMBER

DESCRIPTION

SIZE

A

32-420160

Vanguard® Pin Inserter/Extractor



B

32-486257

Vanguard® Drill with Stop

1⁄8"

C

32-486265

Vanguard® Sterile Quick Release Drill Pin (PK/2)

1⁄8"

D

32-486255

Vanguard® Quick Release Trocular Pin (PK/2)



E

32-486000

Vanguard® Feeler Blade



F

32-486100

Vanguard® Lug Drill with Stop

1⁄4"

G

32-486260

Vanguard® Bone Nail Holder



MH

32-486250 32-486252 32-486253

Vanguard® Bone Nail (PK/2) N Vanguard® Bone Nail (PK/2) Vanguard® Bone Nail (PK/2)

Small Medium Large

I

32-486259

Vanguard® Quick-Release Drill Chuck



J

32-467618

Vanguard® Long Pin Inserter



K

32-486130

Tibial Trial Handle/Alignment Tower



L

32-486125

Vanguard® Locking Bar Inserter



44 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

L

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595301 Vanguard® Universal Instrumentation—Bottom Tray

A

C B

D E G F H

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

A

32-486135

Alignment Rod (PK/2)



B

32-486201

Vanguard® Femoral/Tibial Impactor



C

32-486150

Posterior Ostephyte Chisel



D

32-486210

Vanguard® Slaphammer



E

32-486205

Vanguard® Alignment CR Inserter



F

32-486202

Vanguard® Tibial Poly Impactor



G

32-486209

Vanguard® PS Box Impactor



H

32-486120

Vanguard® Hex Screwdriver

3.5mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 45

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595308 Vanguard® PS Box Resection Option 1—Chisel

A

B

E

D

C

A

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

A

32-487202 32-487203 32-487204 32-487205 32-487206 32-487207

Vanguard Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

B

32-487217

Vanguard® PS Box Chisel



C

32-487214

Vanguard® PS Box Gauge Angled



D

32-487215

Vanguard® Open Box Resection Gauge



E

32-487216

Vanguard® Closed Box Resection Gauge



®

PS PS PS PS PS PS

Box Box Box Box Box Box

Guide Guide Guide Guide Guide Guide

60mm 62.5mm 65mm 67.5mm 70mm 75mm

Additional PS Box Resection Instrumentation (Not Shown) 32-487200 32-487201 32-487209 32-487208

46 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

Vanguard® Vanguard® Vanguard® Vanguard®

PS PS PS PS

Box Box Box Box

Guide Guide Guide Guide

55mm 57.5mm 72.5mm 80mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595308 Vanguard® PS Box Resection Option 2 - Milling System

B

A

C

D

F

E

A

PRODUCT

LABEL PART NUMBER

C

DESCRIPTION

SIZE

Vanguard PS Box Mill Vanguard® PS Box Mill Vanguard® PS Box Mill Vanguard® PS Box Mill Vanguard® PS Box Mill Vanguard® PS Box Mill

60mm 62.5mm 65mm 67.5mm 70mm 75mm

A

32-487222 32-487223 32-487224 32-487225 32-487226 32-487227

B

32-487241 32-487242 32-487243 32-487244

C

32-487230 32-487232 32-487231

Vanguard® PS Box Reamer Vanguard® PS Box Reamer Vanguard® PS Box Reamer

Small Medium Large

D

32-487214

Vanguard® PS Box Gauge Angled



E

32-487215

Vanguard® Open Box Resection Gauge



F

32-487216

Vanguard® Closed Box Resection Gauge



®

Vanguard® Vanguard® Vanguard® Vanguard®

PS PS PS PS

Box Box Box Box

Mill Mill Mill Mill

BC BC BC BC

Insert Insert Insert Insert

60/62.5mm 65/67.5mm 70mm 72.5/75mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 47

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595319 Biomet Series A Patella Preparation Instrumentation—Top Tray

A

D

B

E

C

G

F

I

H

PRODUCT

J

LABEL PART NUMBER

K

DESCRIPTION

SIZE

A

32-484720 32-484722 32-484724 32-484726 32-484728

Series Series Series Series Series

A A A A A

Patella Patella Patella Patella Patella

Trial Trial Trial Trial Trial

Thin, Thin, Thin, Thin, Thin,

1 1 1 1 1

Peg Peg Peg Peg Peg

25mm 28mm 31mm 34mm 37mm

B

32-484700 32-484702 32-484704 32-484706 32-484708 32-484710

Series Series Series Series Series Series

A A A A A A

Patella Patella Patella Patella Patella Patella

Trial Trial Trial Trial Trial Trial

STD, STD, STD, STD, STD, STD,

1 1 1 1 1 1

Peg Peg Peg Peg Peg Peg

25mm 28mm 31mm 34mm 37mm 40mm

C

32-486502

D

32-484760 32-484762 32-484764 32-484766 32-484768 32-484770

Series Series Series Series Series Series

A A A A A A

Patella Patella Patella Patella Patella Patella

Trial Trial Trial Trial Trial Trial

STD, STD, STD, STD, STD, STD,

3 3 3 3 3 3

Peg Peg Peg Peg Peg Peg

25mm 28mm 31mm 34mm 37mm 40mm

E

32-484780 32-484782 32-484784 32-484786 32-484788

Series Series Series Series Series

A A A A A

Patella Patella Patella Patella Patella

Trial Trial Trial Trial Trial

Thin, Thin, Thin, Thin, Thin,

3 3 3 3 3

Peg Peg Peg Peg Peg

25mm 28mm 31mm 34mm 37mm

48 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

Patella Caliper Scissor Style



PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout

PRODUCT

LABEL PART NUMBER

DESCRIPTION Vanguard Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Patella Patella Patella Patella Patella Patella

Mod Mod Mod Mod Mod Mod

3 3 3 3 3 3

Peg Peg Peg Peg Peg Peg

SIZE Drill Drill Drill Drill Drill Drill

Guide Guide Guide Guide Guide Guide

25mm 28mm 31mm 34mm 37mm 40mm

F

32-486530 32-486531 32-486532 32-486533 32-486534 32-486535

G

32-486500

Patella Saw Guide



H

32-486515

Vanguard® Patella Modular Cement Clamp Head



I

32-486510

Vanguard® Patella Drill Guide/Cement Clamp Handle



J

32-486501

Patella Saw Guide Stylus



K

32-468470

Patella Drill with Stop 3 Peg



®

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 49

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout

€ 595319 Biomet Series A Patella Preparation Instrumentation—Bottom Tray

B A

C

D

E

F

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

Vanguard® Patella Clamp Handle



A

32-486800

B

32-486830 32-486831 32-486832 32-486833 32-486834

C

32-486805

Vanguard® Cement Clamp Bushing



D

32-486802

Vanguard® Patella Reamer Shaft with Stop



E

32-486810 32-486811 32-486812 32-486813 32-486814 32-486815

F

32-486880 32-486882 32-486884 32-486886 32-486888

50 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Patella Patella Patella Patella Patella

Patella Patella Patella Patella Patella Patella

Patella Patella Patella Patella Patella

25mm 28mm 31mm 34mm 37mm

Bushing Bushing Bushing Bushing Bushing

25mm 28mm 31mm 34mm 37mm 40mm

Reamer Reamer Reamer Reamer Reamer Reamer

Spacer Spacer Spacer Spacer Spacer

Drill Drill Drill Drill Drill

Tip Tip Tip Tip Tip

6.2mm 7.8mm 8.0mm 8.5mm 10mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595304 Vanguard® PS Femoral Trials

A

B

PRODUC T

LABEL PART NUMBER

A

32-483124 32-483126 32-483128 32-483130 32-483132 32-483134

B

32-483104 32-483106 32-483108 32-483110 32-483112 32-483114

DESCRIPTION Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

PS PS PS PS PS PS

PS PS PS PS PS PS

Femoral Femoral Femoral Femoral Femoral Femoral

Femoral Femoral Femoral Femoral Femoral Femoral

SIZE Left Left Left Left Left Left

60mm 62.5mm 65mm 67.5mm 70mm 75mm

Right Right Right Right Right Right

60mm 62.5mm 65mm 67.5mm 70mm 75mm

Trial Trial Trial Trial Trial Trial

Trial Trial Trial Trial Trial Trial

Additional PS Instrumentation (Not Shown) 32-483120 32-483122 32-483133 32-483136 32-483100 32-483102 32-483113 32-483116

Vanguard® Vanguard® Vanguard® Vanguard®

Vanguard® Vanguard® Vanguard® Vanguard®

PS PS PS PS

PS PS PS PS

Femoral Femoral Femoral Femoral

Femoral Femoral Femoral Femoral

Trial Trial Trial Trial

Trial Trial Trial Trial

Left Left Left Left

55mm 57.5mm 72.5mm 80mm

Right Right Right Right

55mm 57.5mm 72.5mm 80mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 51

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595305 Vanguard® CR Femoral Trial

A

B

PRODUCT

LABEL PART NUMBER

A

32-483024 32-483026 32-483028 32-483030 32-483032 32-483034

B

32-483004 32-483006 32-483008 32-483010 32-483012 32-483014

DESCRIPTION Vanguard Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® ®

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

CR CR CR CR CR CR

CR CR CR CR CR CR

Femoral Femoral Femoral Femoral Femoral Femoral

Femoral Femoral Femoral Femoral Femoral Femoral

SIZE Left Left Left Left Left Left

60mm 62.5mm 65mm 67.5mm 70mm 75mm

Right Right Right Right Right Right

60mm 62.5mm 65mm 67.5mm 70mm 75mm

Trial Trial Trial Trial Trial Trial

Trial Trial Trial Trial Trial Trial

ADDITIONAL CR INSTRUMENTATION (NOT SHOWN) 32-483020 32-483022 32-483033 32-483036 32-483000 32-483002 32-483013 32-483016

Vanguard® Vanguard® Vanguard® Vanguard®

Vanguard® Vanguard® Vanguard® Vanguard®

CR CR CR CR

CR CR CR CR

Femoral Femoral Femoral Femoral

Femoral Femoral Femoral Femoral

Trial Trial Trial Trial

Trial Trial Trial Trial

Left Left Left Left

55mm 57.5mm 72.5mm 80mm

Right Right Right Right

55mm 57.5mm 72.5mm 80mm

32-486123

Vanguard® Femoral Trial Pegs



32-486122

Vanguard® Femoral Peg Wrench



52 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595337 Vanguard® CR Standard Bearing Trials

B

A

D

C

E

F G

PRODUCT

LABEL PART NUMBER

DESCRIPTION

SIZE

A

32-483700 32-483702 32-483704 32-483706 32-483708

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Standard Standard Standard Standard Standard

CR CR CR CR CR

Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial

10x59mm 12x59mm 14x59mm 16x59mm 18x59mm

B

32-483720 32-483722 32-483724 32-483726 32-483728

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Standard Standard Standard Standard Standard

CR CR CR CR CR

Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial

10x63/67mm 12x63/67mm 14x63/67mm 16x63/67mm 18x36/67mm

C

32-483740 32-483742 32-483744 32-483746 32-483748

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Standard Standard Standard Standard Standard

CR CR CR CR CR

Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial

10x71/75mm 12x71/75mm 14x71/75mm 16x71/75mm 18x71/75mm

D

32-483760 32-483762 32-483764 32-483766 32-483768

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Standard Standard Standard Standard Standard

CR CR CR CR CR

Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial

10x79/83mm 12x79/83mm 14x79/83mm 16x79/83mm 18x79/83mm

E

32-483780 32-483782 32-483784 32-483786 32-483788

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Standard Standard Standard Standard Standard

CR CR CR CR CR

Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial

10x87/91mm 12x87/91mm 14x87/91mm 16x87/91mm 18x87/91mm

F

32-487100

Maxim® Trial Poly Puller



G

32-487999

Trial Poly Puller - Straight



PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 53

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595320 Vanguard® Anterior Stabilized Bearing Trials—Top Tray

A

PRODUCT

B

C

LABEL PART NUMBER

A

32-489020 32-489022 32-489024 32-489026 32-489028 32-489030

B

32-483896

C

32-489040 32-489042 32-489044 32-489046 32-489048 32-489050

54 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

DESCRIPTION Vanguard Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® ®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

SIZE Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

Vanguard® Universal Tibial Trial Removal Tool Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

10x63mm 12x63mm 14x63mm 16x63mm 18x63mm 20x63mm



10x67mm 12x67mm 14x67mm 16x67mm 18x67mm 20x67mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595320 Vanguard® Anterior Stabilized Bearing Trials—Bottom Tray

A

PRODUCT

C

B

LABEL PART NUMBER

D

DESCRIPTION

SIZE

A

32-489060 32-489062 32-489064 32-489066 32-489068 32-489070

®

Vanguard Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

10x71mm 12x71mm 14x71mm 16x71mm 18x71mm 20x71mm

B

32-489080 32-489082 32-489084 32-489086 32-489088 32-489090

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

10x75mm 12x75mm 14x75mm 16x75mm 18x75mm 20x75mm

C

32-489100 32-489102 32-489104 32-489106 32-489108 32-489110

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

10x79mm 12x79mm 14x79mm 16x79mm 18x79mm 20x79mm

D

32-489120 32-489122 32-489124 32-489126 32-489128 32-489130

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Anterior Anterior Anterior Anterior Anterior Anterior

Stabilized Stabilized Stabilized Stabilized Stabilized Stabilized

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

10x83mm 12x83mm 14x83mm 16x83mm 18x83mm 20x83mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 55

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595338 Vanguard® 5-in-1 Universal Bearing Trials—Top Tray

A

B

G

F

A

PRODUCT

D

C

B

C

LABEL PART NUMBER

E

H

D

E

DESCRIPTION

SIZE

A

32-483800 32-483802

Vanguard® Universal 5-in-1 Bearing Trial Vanguard® Universal 5-in-1 Bearing Trial

10x59mm 12x59mm

B

32-483820 32-483822

Vanguard® Universal 5-in-1 Bearing Trial Vanguard® Universal 5-in-1 Bearing Trial

10x63/67mm 12x63/67mm

C

32-483840 32-483842

Vanguard® Universal 5-in-1 Bearing Trial Vanguard® Universal 5-in-1 Bearing Trial

10x71/75mm 12x71/75mm

D

32-483860 32-483862

Vanguard® Universal 5-in-1 Bearing Trial Vanguard® Universal 5-in-1 Bearing Trial

10x79/83mm 12x79/83mm

E

32-483880 32-483882

Vanguard® Universal 5-in-1 Bearing Trial Vanguard® Universal 5-in-1 Bearing Trial

10x87/91mm 12x87/91mm

F

32-483900 32-483901 32-483910 32-483911

Vanguard® PS Modular Trial Post Vanguard® PS Plus Modular Trial Post Vanguard® PS Trial Post Locking Vanguard® PS Plus Trial Post Locking

— — — —

G

32-483896

Vanguard® Universal Tibial Trial Removal Tool



H

32-483906 32-483907 32-483908 32-483909

Vanguard® SSK PS Trial Post Locking Vanguard® SSK PS Trial Post Locking Vanguard® SSK PSC Trial Post Locking Vanguard® SSK PSC Trial Post Locking

Small Large Small Large

56 Surgical Technique PREMIER™ TOTAL KNEE INSTRUMENTATION

PREMIER™ TOTAL KNEE INSTRUMENTATION Instrumentation Layout € 595338 Vanguard® 5-in-1 Universal Bearing Trials—Bottom Tray

A

PRODUCT

B

D

C

E

LABEL

SIZE

A

32-483804 32-483806 32-483808 32-483810 32-483812 32-483814

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Universal Universal Universal Universal Universal Universal

DESCRIPTION 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

SIZE 14x59mm 16x59mm 18x59mm 20x59mm 22x59mm 24x59mm

B

32-483824 32-483826 32-483828 32-483830 32-483832 32-483834

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Universal Universal Universal Universal Universal Universal

5-in-1 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

14x63/67mm 16x63/67mm 18x63/67mm 20x63/67mm 22x63/67mm 24x63/67mm

C

32-483844 32-483846 32-483848 32-483850 32-483852 32-483854

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Universal Universal Universal Universal Universal Universal

5-in-1 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

14x71/75mm 16x71/75mm 18x71/75mm 20x71/75mm 22x71/75mm 24x71/75mm

D

32-483864 32-483866 32-483868 32-483870 32-483872 32-483874

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Universal Universal Universal Universal Universal Universal

5-in-1 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

14x79/83mm 16x79/83mm 18x79/83mm 20x79/83mm 22x79/83mm 24x79/83mm

E

32-483884 32-483886 32-483888 32-483890 32-483892 32-483894

Vanguard® Vanguard® Vanguard® Vanguard® Vanguard® Vanguard®

Universal Universal Universal Universal Universal Universal

5-in-1 5-in-1 5-in-1 5-in-1 5-in-1 5-in-1

Bearing Bearing Bearing Bearing Bearing Bearing

Trial Trial Trial Trial Trial Trial

14x87/91mm 16x87/91mm 18x87/91mm 20x87/91mm 22x87/91mm 24x87/91mm

PREMIER™ TOTAL KNEE INSTRUMENTATION Surgical Technique 57

Limacorporate spa Via Nazionale, 52 33038 Villanova di San Daniele Udine - Italy Tel.: +39 0432 945511 Fax: +39 0432 945512 E-mail: [email protected] www.limacorporate.com Lima Implantes slu Fontsanta, 46 5ª planta 08970 Sant Joan Despí - Barcelona Tel.: 93 480 85 05 Fax: 93 419 65 27 Lima France sas Les Espaces de la Sainte Baume Parc d’ Activité de Gemenos - Bât.A5 30 Avenue du Château de Jouques 13420 Gemenos - France Tel: +33 (0) 4 42 01 63 12 Fax: +33 (0) 4 42 04 17 25 E-mail: [email protected] Lima O.I. doo Ante Kovacic, 3 10000 Zagreb - Croatia Tel.: +385 (0) 1 2361 740 Fax: +385 (0) 1 2361 745 E-mail: [email protected] Lima Switzerland sa Birkenstrasse, 49 CH-6343 Rotkreuz - Zug Switzerland Tel: +41 (0) 41 747 06 60 Fax: +41 (0) 41 747 06 69 E-mail: [email protected] Lima Japan kk Shinjuku Center Building, 29th floor 1-25-1, Nishi-shinjuku, Shinjuku, Tokyo 163-0629 - Japan Tel.: +81 3 5322 1115 Fax: +81 3 5322 1175 Lima CZ sro Do Zahrádek I., 157/5 155 21 Praha 5 – Zličín – Czech Republic Tel.: +420 222 720 011 Fax: +420 222 723 568 E-mail: [email protected]

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Lima Netherlands Havenstraat 30 3115 HD Schiedam The Netherlands Tel: +31 (0) 10 246 26 60 Fax: +31 (0) 10 246 26 61 [email protected] www.limanederland.nl

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Vanguard™ Trademark is licensed to Limacorporate spa for use only in Denmark and Sweden. For product information, including indications, contraindications, warnings, precautions and potential adverse effects, see the package insert. This material is intended for the sole use and benefit of the Limacorporate S.p.A. sales force and physicians. It is not to be redistributed, duplicated or disclosed without the express

limacorporate.com

written consent of Limacorporate S.p.A..

This publication is not intended for distribution in the U.S. The Vanguard™ Knee is manufactured by Biomet. The Vanguard™ Knee is distributed in Denmark and Sweden by Limacorporate spa

B.6110.23.000.1081500

Manufacturer

Legal Manufacturer Biomet Orthopedics P.O. Box 587 Date of Manufactu 56 E. Bell Drive Warsaw, Indiana 46581-0587 Do Not Reuse USA

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