Femoral Instrumentation
For NexGen® Cruciate Retaining &
NexGen Legacy® Posterior Stabilized Knees
Surgical Technique
Table of Contents
Introduction............................................................................................................... 2
Preoperative Planning.......................................................................................... 3
Surgical Approach................................................................................................ 3
Patient Preparation............................................................................................... 4
Appendix 1......................................................................................................... 59
Surgical Technique
2 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Introduction
Successful total knee arthroplasty depends in part The Mini-Incision TKA technique has been developed
on re-establishment of normal lower extremity to combine the alignment goals of total knee
alignment, proper implant design and orientation, arthroplasty with less disruption of soft tissue. To
secure implant fixation, and adequate soft tissue accommodate this technique, some of the original
balancing and stability. The NexGen Complete Knee Multi-Reference 4-in-1 Instruments have been
Solution and Multi-Reference 4-in-1 Instruments are modified. However, if preferred, a standard incision
designed to help the surgeon accomplish these goals can be used with the instruments. Prior to using a
by combining optimal alignment accuracy with a smaller incision, the surgeon should be familiar with
simple, straight-forward technique. implanting NexGen components through a standard
incision.
The instruments and technique assist the surgeon
in restoring the center of the hip, knee, and ankle Total knee arthroplasty using a less invasive
to lie on a straight line, establishing a neutral technique is suggested for nonobese patients with
mechanical axis. The femoral and tibial components preoperative flexion greater than 90°. Patients
are oriented perpendicular to this axis. Femoral with varus deformities greater than 17° or valgus
rotation is determined using the posterior condyles or deformities greater than 13° are typically not
epicondylar axis as a reference. The instruments candidates for an MIS technique.
promote accurate cuts to help ensure secure
component fixation. Ample component sizes allow Please refer to the package inserts for complete
soft tissue balancing with appropriate soft tissue product information, including contraindications,
release. warnings, precautions, and adverse effects.
Preoperative Planning 6°
Mechanical Axis
mechanical axis and, after soft tissue balancing, will be
parallel to the resected surface of the proximal tibia.
Surgical Approach
The femur, tibia, and patella are prepared
independently, and can be cut in any sequence
using the principle of measured resection (removing
enough bone to allow replacement by the prosthesis).
Adjustment cuts may be needed later.
Transverse Axis
90°
4 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Patient Preparation
To prepare the limb for MIS total knee arthroplasty,
adequate muscle relaxation is required. This may be
accomplished with a short-acting, nondepolarizing
muscle relaxant. The anesthesiologist should adjust
the medication based on the patient’s habitus and
weight, and administer to induce adequate muscle
paralysis for a minimum of 30-40 minutes. It is
imperative that the muscle relaxant be injected prior
to inflation of the tourniquet. Alternatively, spinal or
epidural anesthesia should produce adequate muscle
relaxation.
Slightly flex the knee and remove the deep third of the
fat pad.
The tendonous portion of the vastus medialis extends Place a bent hohmann retractor in the lateral gutter
distally to insert at the midpole of the medial border and lever it against the robust edge of the tendon that
of the patella. Be careful to preserve that portion of has been preserved just medial and superior to the
the tendon to protect the vastus medialis muscle patella. Retract the patella and extensor mechanism
during subsequent steps. An incision along the inferior into the lateral gutter. If necessary, mobilize the vastus
border of the vastus medialis to the superior pole of medialis either from its underlying attachment to
the patella will result in a tear, split, or maceration the synovium and adductor canal, or at its superior
of the muscle by retractors. Incise the underlying surface when there are firm attachments of the
synovium in a slightly more proximal position than is overlying fascia to the subcutaneous tissues and skin.
typical with a standard subvastus approach. This will Depending on surgeon preference, the fat pad can be
allow a two-layer closure of the joint. The deep layer excised or preserved.
will be the synovium, while the superficial layer will be Flex the knee. The patella will stay retracted in the
the medial retinaculum and the myofascial sleeve of lateral gutter behind the bent hohmann retractor,
tissue that has been left attached to the inferior border and the quadriceps tendon and vastus medialis will
of the vastus medialis. lie over the distal anterior portion of the femur. To
Carry the synovial incision to the medial border of improve visualization of the distal anterior portion
the patella. Then turn directly inferiorly to follow the of the femur, place a thin knee retractor along the
medial border of the patellar tendon to the proximal anterior femur and gently lift the extensor mechanism
portion of the tibia. Elevate the medial soft tissue during critical steps of the procedure. Alternatively,
sleeve along the proximal tibia in a standard fashion. bring the knee into varying degrees of extension to
improve visualization by decreasing the tension on the
extensor mechanism.
7 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Surgical Technique
Figure 1a Figure 1b
Figure 1e
Figure 2c
Figure 2a
Figure 2b Figure 2d
Figure 2e
Figure 2f Figure 2g
Figure 3a Figure 3b
Note: Remove any osteophytes that interfere with Attach the MIS locking boom to the mini A/P sizing
instrument positioning. guide. Ensure that the skin does not put pressure
on the top of the boom and potentially change its
While holding the mini A/P sizing guide in place, position. The position of the boom dictates the
secure the guide to the resected distal femur using exit point of the anterior bone cut and the ultimate
short 3.2 mm (1/8 inch) headed screws or predrill position of the femoral component. When the boom
and insert short head holding pins into one or both is appropriately positioned, lock it by turning the
of the holes in the lower portion of the guide. Do not knurled knob (Figure 3b).
overtighten or the anterior portion will not slide on the
distal femur.
14 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 3d
Figure 3c Figure 3e
There are four external rotation plates: 0°/3° Left, Careful attention should be taken when placing the
0°/3° Right, 5°/7° Left, and 5°/7° Right. Choose the headless pins into the appropriate external rotation
external rotation plate that provides the desired plate as these pins also set the A/P placement for the
external rotation for the appropriate knee. The MIS femoral finishing guide in the next step of the
0° option can be used when positioning will be procedure. It is important to monitor the location of
determined by the A/P axis or the epicondylar axis. the anterior boom on the anterior cortex of the femur
Use the 3° option for varus knees. Use the 5° option for to help ensure the anterior cut will not notch the femur.
knees with a valgus deformity from 10° to 13°. The 7° Positioning the anterior boom on the “high” part of
option requires a standard exposure, and is for knees the femur by lateralizing the location of the boom can
often lessen the likelihood of notching the femur.
15 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 4a
Step Three: Size Femur and Establish Step Four: Finish the Femur
External Rotation (cont.) Anterior Referencing Technique
Unlock and rotate the boom of the guide medially Select the correct size MIS femoral finishing guide
until it clears the medial condyle. Then remove the (silver colored) or MIS flex femoral finishing guide
guide, but leave the two headless pins. These pins will (gold colored) as determined by the measurement
establish the A/P position and rotational alignment of from the A/P sizing guide. An additional 2 mm
the femoral finishing guide. (approximately) of bone is removed from the posterior
condyles when using the flex finishing guide.
Figure 4c
Figure 4b Figure 4d
Figure 4e
3
2
Figure 4f Figure 4g
Optional Technique
To check the location of the anterior cut and determine Use a 1.27 mm (0.050-in.) narrow, oscillating saw blade
if notching will occur, securely tighten the locking to cut the femoral profile in the following sequence for
boom attachment to the face of the finishing guide. optimal stability of the finishing guide (Figure 4g):
Make certain that the attachment sits flush with the
1 Anterior condyles
femoral finishing guide (Figure 4e). Connect the MIS
locking boom to the attachment (Figure 4f). The boom 2 Posterior condyles
indicates the depth at which the anterior femoral cut 3 Posterior chamfer
will exit the femur.
4 Anterior chamfers
18 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 4i
Figure 4h Figure 4j
Figure 4l
Figure 4k Figure 4m
Figure 4o
1
4
3
2
Figure 4n Figure 4p
Remove any lateral osteophytes that may interfere Use a 1.27 mm (0.050-in.) narrow, oscillating saw blade
with guide placement. Position the finishing guide to cut the femoral profile in the following sequence for
mediolaterally. The width of the finishing guide optimal stability of the finishing guide (Figure 4p):
replicates the width of the NexGen CR Femoral
Component. The width of the flex finishing guide
1 Anterior condyles
replicates the width of the NexGen LPS, LPS-Flex, and 2 Posterior condyles
CR-Flex Femoral Components. 3 Posterior chamfer
When the proper rotation and the mediolateral and 4 Anterior chamfers
anteroposterior position are achieved, secure the
finishing guide to the distal femur. Use the screw
inserter/extractor to insert a 3.2 mm headed screw
or predrill and insert a hex-head holding pin through
the superior pinhole on the beveled medial side of
21 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 4r
Figure 4q Figure 4s
Posterior Referencing Technique (cont.) Option One: MIS Notch/Chamfer Trochlear Guide
Use the patellar/femoral drill bit to drill the post holes The MIS notch/chamfer trochlear guide consists of 2
(Figure 4q). pieces for each size, the MIS notch/chamfer guide and
the MIS trochlear guide. Matching sizes must be used.
Use the 1.27 mm (0.050-in.) narrow, reciprocating
saw blade to cut the base of the trochlear recess The MIS notch/chamfer trochlear guide may be used
(Figure 4r) and score the edges (Figure 4s). Remove to complete the chamfer cuts, the trochlear groove,
the finishing guide to complete the trochlear recess the intercondylar box and to drill the peg holes after
cuts. the anterior and posterior cuts have been made with
the MIS femoral finishing guide.
Figure 4t Figure 4u
Position the MIS Notch/Chamfer Insert two short headed pins or short
Guide flush against the femur screws through the anterior flange
Figure 4v Figure 4w
Secure the MIS Notch/Chamfer Guide to the femur Cut the sides and base of the intercondylar box
Figure 4y
Apply the matching size MIS Trochlear
Guide with the holes aligned
Figure 4x Figure 4z
Cut the anterior and posterior chamfers MIS Trochlear Guide secured
to MIS Notch/Chamfer Guide
Figure 4aa
Cut the sides and base of the trochlear groove
Option One: MIS Notch/Chamfer Trochlear Guide Using the MIS Notch/Chamfer Guide
(cont.) to downsize the femur
Protect the tibia. Use a reciprocating saw through If there is a need to downsize the femur, the MIS notch/
the slots in the trochlear guide to cut the sides and chamfer and trochlear guide can be used for sizes C-G
base of the trochlear groove (Figure 4aa). Remove standard implants and the notch/chamfer guide can
the trochlear guide, and insert an osteotome over the be used for all flex sizes.
resected tibial surface below the trochlear groove.
Then use the reciprocating saw to finish the trochlear Note: Size A, B and H MIS trochlear guides cannot
cuts. be used for downsizing.
Remove the MIS notch/chamfer guide. Select the preferred size notch/chamfer guide and
pin to the distal femur with two short spring screws
or 3.2 mm (1/8-inch) headed screws (48 mm length).
Alternatively, insert two hex headed pins. Ensure that
the guide is seated on the anterior and distal femur.
Use a reciprocating saw to recut the sides of the
intercondylar box. Use an oscillating saw to recut the
anterior and posterior chamfers.
26 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Surgeon Notes and Tips • Remember that the incision can be moved both
• Although a sequence of femoral cuts has been medial-to-lateral and superior-to-inferior as needed
provided, the cuts may be made in any sequence. to gain optimal exposure.
It is recommended for the surgeon to complete the • To facilitate the use of the mobile window, when
cuts in a consistent sequence to help ensure that all resecting on the medial side, use retraction on the
cuts are performed. However, the peg holes should medial side while relaxing the lateral side. Likewise,
be drilled prior to assembling the MIS trochlear when resecting on the lateral side, use retraction on
guide. the lateral side while relaxing the medial side.
• If the MIS femoral finishing guide is used, the flexion
gap should equal the extension gap.
27 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 4bb
Ankle Bar
Tibial Cut Guide
MIS Tibial
Adjustable Rod
Ankle Clamp
or Spring
MIS Distal Tubercle Anchor
Telescoping Rod
Figure 5a
MIS Tibial Cut Guide Assembly
Figure 5b Figure 5c
Arrows showing correct alignment
Figure 5d Figure 5e
Figure 5f Figure 5g
Figure 5h Figure 5i
Tubercle
Anchor Hole
Figure 5j Figure 5k
Figure 5l Figure 5m
m
2m
Figure 5o
Figure 5n Figure 5p
Figure 5q
Step Six:
Check Flexion/Extension Gaps
Use the spacer/alignment guides to check the flexion If the tension is significantly greater in extension than
and extension gaps. With the knee in extension, insert in flexion, re-cut the distal femur using the appropriate
the thinnest appropriate spacer/alignment guide instrumentation. This will enlarge the extension space.
between the resected surfaces of the femur and tibia
If the tension is significantly less in extension than
(Figure 6a). Insert the alignment rod into the guide
in flexion, either downsize the femur or perform
and check the alignment of the tibial resection (Figure
additional ligament releases.
6b). If necessary insert progressively thicker spacer/
alignment guides until the proper soft tissue tension
is obtained.
Figure 7c
Figure 7a
Figure 7b
Figure 7d Figure 7e
Figure 7f Figure 7g
2mm
Figure 7h
ON OFF
Figure 7i
Figure 7j Figure 7k
Suture Hole
Figure 7l Figure 7m
Figure 8a
Figure 8b Figure 8c
Figure 8d Figure 8e
Pin the plate in place with two short head holding pins.
48 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
E
H
F
A
B D
G
Figure 9a Figure 9b
If preferred, the femoral provisional may be positioned Insert the patellar provisional onto the resected
by hand. patellar surface. Perform a ROM to check patellar
tracking.
Translate the femoral provisional laterally until the
lateral peg of the provisional aligns with the drill hole When component position, ROM, and joint stability
in the lateral femoral condyle. Push the provisional have been confirmed, remove all provisional
in place beginning laterally, then medially. Be sure components.
that soft tissue is not trapped beneath the provisional
component.
50 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 9f
Figure 10a
Use the Tibial Impactor to impact the tibial base plate.
Figure 10c
Figure 10e
Use the bearing Inserter to insert the bearing onto the It is recommended to secure the taper plug/stem
tibial plate. extension using a replacement stem extension
locking screw: 00-5980-090-00 (available as a
With the bearing in place, insert the secondary locking separate sterile item) before implanting the tibial
screw (packaged with the anticular surface). component. This screw will hold the taper plug/
Use the LCCK deflection beam torque wrench with the stem extension in place when the tibial plate is
4.5 mm hex driver bit attached to torque the screw impacted.
to 95 in.-lbs. Alternatively, if using a stem extension, 2. Implant the tibial plate*. Remove the replacement
use the tibial plate wrench to assist when torquing the stem extention locking screw and discard. If
screw. Do not over or under torque. bone cement is being used, wait for the cement
to completely cure before inserting the articlular
surface. An bearing provisional may be inserted to
use as space while the cement cures.
57 | NexGen MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique
Figure 10f
Engraved Lines
Adjustable Stylus
Figure A
Figure B
Surgical Technique
Attach the MIS telescoping locking boom to the yoke Note: The stylus is designed to be rotated at only
on the appropriate MIS Quad-Sparing A/P sizing tower one position.
or MIS Multi-Reference 4-in-1 A/P sizing guide. The
position of the boom dictates the exit point of the saw The engraved lines on the stylus and the body of
blade for anterior bone cut and the desired anterior the telescoping locking boom must be in alignment
position of the femoral component. during sizing.
Adjustable stylus: The telescoping boom is attached Note: Clear any soft tissue or bony fragments that
to the yoke of the A/P sizing instrument (Figure B). interfere with the telescoping boom body prior to
The stylus tip is extended to the ideal point on the sizing.
anterior femoral cortex which is located slightly lateral
of patellar femoral groove, proximal of the lateral
condyle where the slope begins to flatten (i.e. valley).
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1800 West Center Street 0086
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is not valid unless there is a CE
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