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Surgival Genutech CCK Surgical Technique

Total knee revision system
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Surgical Technique
Genutech
CCK total knee revision system
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  • Page 1 Surgical Technique Genutech CCK total knee revision system ®...

  • Page 3: Table Of Contents

    Table of contents SURGICAL TECHNIQUE 1. TIBIAL TIME (I) 1.1 Intramedullary fixation 1.2 Assembly and fitting of the tibial cutting guide 1.3 Tibial resection 1.4 Measuring of the tibial tray 1.5 Measuring of the interline 2. FEMORAL TIME 2.1 Measuring of the femoral component 2.2 Intramedullary fixation 2.3 Distal cut 2.4 Femoral cuts...

  • Page 4: Surgical Technique

    Surgical Technique 1. TIBIAL TIME (I) Set 0. Upper tray 1.1 Intramedullary fixation Diaphyseal intramedullary reaming To ensure good stability on the diaphyseal axis of the reamer, which serves as a guide and support during surgery, intramedullary reaming is performed, with a depth according to the length of the stem which is going to be used.
  • Page 5 Set 0. Lower tray Intramedullary reaming guided by cannulated reamers During this step use the stem of the diaphyseal reamer as a guide. Depth: In order to install the 70 mm stem, ream until the first 70 mark is level with the tibia surface and if, on the other hand, the stem must be 102 or 200 mm, ream until the second 120-200 mark.

  • Page 6: Assembly And Fitting Of The Tibial Cutting Guide

    Surgical Technique Set 0. Lower tray Insertion of the metaphyseal sleeve Once the guided cannulated reaming has been completed at the chosen depth, insert a metaphyseal sleeve to ensure that there is the necessary sta- bility to secure the cutting guides, thus ensuring optimal cutting accuracy and congruency in how the tibial tray is positioned in relation to the stem. The diameter of the sleeve being used is the same as the diameter of the last cannulated reamer which was used, installing a short metaphyseal sleeve if the reaming was performed in order to insert a 70 mm stem, or a long one if reaming has reached the second mark (120-200) to insert a 120 or 200 mm stem.
  • Page 7 Graduation for displacement control Transverse connector Fixation screws Tibial cutting guide Telescopic guide system Tibial cutting guide Tibial clamp Fitting of the tibial cutting guide On the tibial cutting guide there is a threaded displacement measuring system, which allows you to have strict control over the steps we take. This system must be adjusted into position 0 before it is used.
  • Page 8 Surgical Technique Set 1. Upper tray Installation of the revision probe of 0-8 or 0-12 mm In the most favourable cases, where you only need to make a thin cut to sanitise the tibial surface, with the “0” end (short arm) of the probe, look for the most depressed area of the tibial plateau to ensure that the cut being made is always below said point.

  • Page 9: Tibial Resection

    PRIMARY TIBIAL SURGERY Set 1. Upper tray When performing primary tibial surgery by implanting a semi-constrained prosthesis tibial component, install the “0-10” rod on the tibial cutting guide. Firstly, the “10” end of the probe must be directed towards the most depressed area of the most prominent plateau and then, with the arm of the rod in position “0”, probe the most depressed area of the plateau with the most wear.

  • Page 10: Measuring Of The Tibial Tray

    Surgical Technique Note: · Should there be any difficulties when removing the intramedullary system because of an obstructing metaphyseal sleeve, this can be reamed with the tip of the sleeve inserter/extractor and it can be released by tapping it outwards. ·...

  • Page 11: Measuring Of The Interline

    Set 2. Upper tray 1.5 Measuring of the interline In order to measure the interline, fit the lower edge of the interline sizing guide’s flange onto the ATT. As the average interline ranges approximately from 25 mm (Size 1: 23 mm, Size 2: 24 mm… Size 5: 28 mm) it is possible to determine the thickness of the tibial insert to be used in advance in order to maintain the articular interline.

  • Page 12: Femoral Time

    Surgical Technique 2. FEMORAL TIME Set 2. Upper tray Let us consider two situations: a) Implantation of a semi-constrained TKR on a knee with no previous surgery (primary surgery). b) Implantation of a semi-constrained replacement in a prosthetic replacement (revision surgery). 2.1 Measuring of the femoral component Revision surgeries: using revision femoral sizing guides.

  • Page 13: Intramedullary Fixation

    Set 0. Upper tray 2.2 Intramedullary fixation Diaphyseal intramedullary reaming In order to ensure good stability for the axis of the diaphyseal reamer, which serves as a guide and support during surgery, gradual intramedullary reaming is performed with a depth according to the length of the stem which is going to be used. Diameter of the reaming: The recommended diameters for this reaming are normally around Ø9-10 or 11 mm, although the suitability of the final diameter for the femoral diaphysis to be used is always at the discretion of the surgeon and, through gradual reaming, it may even be close to that of the inner cortex diameter fitting.
  • Page 14 Surgical Technique Set 0. Lower tray Diameter: Carry out gradual reaming in order to carve the cavity which will house the femoral stem. F-70 F-70 Cavity to house stem Note: When using a 200 m stem, the diameters of the reamers (diaphyseal and cannulated) will be the same, because in order to reach a reaming depth of 200 mm, you use part of the length of the reaming which has already been completed to secure the diaphyseal reamer.
  • Page 15 Set 0. Lower tray Insertion of the metaphyseal sleeve Much like for the tibial time, in order to give the system greater possible stability for subsequent assemblies and surgeries, a metaphyseal sleeve is installed, occupying the position which has been machined with the cannulated reamer and which is subsequently occupied by the femoral stem. The diameter of the sleeve being used is the same as the diameter of the last cannulated reamer which was used, inserting a short metaphyseal sleeve if the reaming was performed up to the 70 mark, or a long one if reaming has reached the 120-200 mark.

  • Page 16: Distal Cut

    Surgical Technique Set 2. Upper tray 2.3 Distal cut On the axis of the diaphyseal reamer insert the distal cutting mask, which has been installed on the 5° angular guide which crosses the axis. Then insert the mask until it comes into contact with the distal part of the femur, supporting the mask’s upper visor on its front and secure with threa- ded pins of Ø...

  • Page 17: Femoral Cuts

    2.4 Femoral cuts Positional adjustment of femoral cutting mask Remove the distal cutting mask and the angular guide and set up the reamer with its sleeve. Place the cutting guide of the previously selected size on the handle of the reamer (see 2.1) with the insert positioner and the concentric positioner. A “Revision”...
  • Page 18 Surgical Technique Set 3. Once the rod is touching it, externally rotate the cutting mask by 3°. Note I: The medial-lateral displacement resulting from this off- setting must be carried out as deemed appropriate by the physician, seeking to centre the femoral component, although it must be noted that rotating towards the ex- ternal part has the advantage of reducing the tension on the patella and is conducive to it being centred on the...
  • Page 19 Alignment Alignment of bar with tibial crest Tibial axis Reading of the offset In this position the offset reading is taken, if an offset has been necessary, because the stem must be fixed to both the trial and final femoral components.
  • Page 20 Surgical Technique Fixation of the cutting mask with threaded pins Subsequently, secure the cutting mask to the femur with threaded pins of Ø 4.4 mm and then remove the rod, the concentric or eccentric positioner, the insert positioner, the metaphyseal sleeve and the diaphyseal reamer. Note: It is recommended to insert the thread as far as possible, only leaving one or two threads outside the cortex to ensure that the system has optimal fixation and stability.
  • Page 21 Intercondylar cut When the intercondylar cut template has been fitted on the slots of the appropriate cutting insert for to the size of the femur, the cuts are made from the front of the femur. Intercondylar cut template In order to guide the saws better there is the option of installing the intercondylar insert of the appropriate size and frontally finishing the sides of the intercondylar box.

  • Page 22: Verification Of Stability During Flexo-Extension

    For example: · If the necessary increase is 2 mm, the thickness of the tibial insert must be increased by 2 mm, because the Genutech CCK system does not have 2 mm femoral supplements.

  • Page 23: Reaming To House The Femoral Post

    This femoral recutting mask is secured using pins of Ø 3.4 mm (the holes marked with arrows indicate the entry position for the inclined pins, which are necessary to ensure the mask is properly secured). Set 4. Upper and lower tray 2.6 Reaming to house the femoral post The necessary distal and posterior supplements are fitted onto the intercondylar mask in order to impact it onto the femoral cuts which have been made, securing it with 2 pins located on the front edge.
  • Page 24 Surgical Technique Set 4. Upper and lower trays With the intercondylar mask fitted, create the housing for the femoral post by reaming up to the maximum depth possible with the Ø 16 mm reamer designed for that purpose. Note: During this step you must be careful with the potential obstacles for the posterior cortex, above all at small sizes when the offset has been per- formed close to the lower polar positions.

  • Page 25: Assembly Of The Trial Femoral Component

    Set 4. Lower tray Set 5 2.7 Assembly of the trial femoral component Stem: it is recommended to go a size smaller than the reaming diameter, but this will be at the sole discretion of the surgeon. For 70 mm stems it is recommended to use the same diameter, and for 120 and 200 mm stems, to use a size which is smaller than the reaming diameter to avoid the “tip effect”.

  • Page 26: Tibial Time (Ii)

    Surgical Technique 3. TIBIAL TIME (II) Set 4. Lower tray Set 5 Optionally, at the discretion of the surgeon, before removing the femoral component, the trial insert of a suitable size is fitted on the tibial tray and flexion and extension movements are performed to adapt the rotation of the tibial component to the femoral component. In a suitable place, mark the tibia with an electric scalpel, a mark in the centre of the tibial tray which will help to select the rotational positioning of the tibial component.
  • Page 27 In this situation observe which number is showing on the measuring system opposite the longitudinal mark on the chisel. This is the position in which the stem must be fixed to the tibial tray. In this position the tibial template is fixed to the tibia with pins. At this moment you can optionally perform a flexo-extension check, by fitting the trial insert onto the tray, taking care to use the housings marked on the template for pins.
  • Page 28 Surgical Technique Box 1. Lower tray Preparation of the housing for the tibial tray Once the trial tibial insert has been removed (if this final adjustment of the rotation of the tibial component has been made during flexo-extension), it is possible to reinforce the tibial template with more pins and then impact the chisel, to the depth which has been marked on it. Then create the housings for the fins of the keel through a keel impactor which will be placed on the eccentric or concentric keel.
  • Page 29 Then, remove the entire system. In the figure below it is possible to see that the intramedullary axis and the housing for the post of the tibial tray are not properly centred, due to the offset. Set 1. Lower tray If tibial supplements have been used, use the hemi-keel (right or left) to assist with the anterior-posterior cut which is made around the two plateaus so that there is no obstruction for the tibial supplements.
  • Page 30 Surgical Technique Set 6. Upper and lower trays Fitting of the Tibial Component The trial tibial tray and the stem are fitted in the predetermined position. It is then impacted and the corresponding tibial insert is fitted (see annexes VII and VIII).

  • Page 31: Mobility / Stability Check

    4. MOBILITY / STABILITY CHECK Trial components The check is carried out with the trial femoral and tibial components fitted to assess the mobility, stability and alignment of the limb.

  • Page 32: Patella Time

    Surgical Technique 5. PATELLA TIME Box 7. Lower tray Measuring of the thickness For the prosthetic replacement of the patella there are two factors to consider: Leave a minimum bone thickness to avoid the risk of a fracture (12-14 mm). Avoid the hyper pressure which would be caused by a prosthetic knee which is thicker than the original.

  • Page 33: Final Implant

    6. FINAL IMPLANT Final check Fit the final prosthesis (tibial, femoral and patella component) but, prior to fixing the polyethylene insert to the tibial tray with bolts, perform the mobility and stability test again. After performing the check and ensuring that it is to be used as the final insert, it is finally fixed to the tibial tray, inserting the metal-reinforced post of the tibial insert and anterior safety bolt.

  • Page 34: Annexes

    Surgical Technique ANNEX I EXAMPLES OF DIAPHYSEAL AND CANNULATED REAMING ACCORDING TO THE STEM TO BE IMPLANTED TIBIA Insertion of 70 mm stems in tibia. T-70 T-70 1st DIAPHYSEAL 2nd CANNULATED REAMING REAMING T-70 T-70 Insertion of 70 mm stems in the tibia (greater intramedullary stability). T-70 T-70 1st DIAPHYSEAL...
  • Page 35 Insertion of 120 mm stems in tibia. T-120 T-120 1st DIAPHYSEAL 2nd CANNULATED REAMING REAMING T-120 T-120 Insertion of 120 mm stems in tibia. T-200 T-200 1st DIAPHYSEAL 2nd CANNULATED REAMING REAMING ø ø ø T-200 T-200 ø The diameters of the diaphyseal reamer and cannulated reamer must be the same, because the 200 mm stem uses part of the depth created by the diaphyseal reamer.
  • Page 36 Surgical Technique FEMUR Insertion of 70 mm stems in femur. F-70 F-70...
  • Page 37 Insertion of 70 mm stems in the femur (greater intramedullary stability). F-70 - 120 - 200 F-70...
  • Page 38 Surgical Technique Insertion of 120 mm stems in femur. F-120 F-120...
  • Page 39 Insertion of 200 mm stems in femur. F-200 F-200 The diameters of the diaphyseal reamer and cannulated reamer must be the same, because the 200 mm stem uses part of the depth created by the diaphyseal reamer.
  • Page 40 Surgical Technique ANNEX II Box 0. Upper tray RETAINER CABLE OF DIAPHYSEAL REAMERS If the surgeon believes that there is a possible risk of the diaphyseal reamer being fully inserted into the intramedullary cavity of the bone when can- nulated reaming is performed, he or she has a retainer cable for these diaphyseal reamers. Given that the instruments used for the following steps are cannulated, using it will not alter the surgical steps described in these instructions.
  • Page 41 ANNEX IV WRENCH (14 mm wide) If vertical movement of the tibial cutting guide is harder than usual, there is a wrench which enables you to easily rotate the sheave of the tibial cutting guide. ANNEX V PIN IMPACTOR The pin impactor can also be used as an extractor rod, passing it through holes made for that purpose for instruments which, because of the way in which they are operated, can become stuck or difficult to extract (keel impactors, femoral component inserter/extractor, etc.).
  • Page 42 Surgical Technique ANNEX VI BALL-HEAD SCREWDRIVER OF Ø 2.5 mm To facilitate the screwing of the posterior supplements into the femoral components, the Genutech CCK set of instruments has a ball-head screwdriver (Box 6 – Upper tray) to enable oblique screwing/unscrewing.
  • Page 43 ANNEX VII CLIPPING AND EXTRACTION OF TIBIAL INSERTS Clipping is performed manually, by first resting the back of the insert on the tibial tray and then pressing both pieces until they clip together. To extract the tibial insert, insert the flat tip of the extractor in one of the slots which is left in the tibial insert when it has been clipped into the tibial tray, turning it slightly (do not pry open).
  • Page 44 TIBIAL IMPACTORS The Genutech CCK set of instruments (Box 6 Upper tray) contains a tibial tray impactor and a second impactor which is designed to enable the fully assembled tibial component to be impacted, protecting both the tibial post and the surface of the joint. This impactor of the tibial component can also help to clip the tibial insert into its tray in the (unlikely) event of it being impossible to do so manually.
  • Page 45 ANNEX IX PATELLAR COMPRESSION CLAMPS The Genutech CCK set of instruments (Box 7 Lower tray) contains a patellar compression clamp to cause bone cement overflow and maintain pressure during the necessary setting time so that the patella is properly fitted.
  • Page 46 Implants Cemented femoral revision component Ref. D8023120E Ref. D8023110E Ref. D8023220E Ref. D8023210E Ref. D8023310E Ref. D8023320E Ref. D8023420E Ref. D8023410E 4,5 mm offset revision stem Ref. D8024101E 10 mm 70 mm Ref. D8024401E 16 mm 70 mm ø ø Ref.
  • Page 47 Revision tibial insert 10 mm 18 mm 12 mm 20 mm 14 mm 22 mm 16 mm 24 mm 18 mm 10 mm 20 mm 12 mm 22 mm 14 mm 24 mm 16 mm 10 mm 18 mm 12 mm 20 mm 14 mm 22 mm...
  • Page 48 Set of Instruments Set of Instruments ® Complete Set of Genutech CCK Revision Instruments Ref. D8501000 Genutech ® CCK Set 0. of intramedullary drilling instruments Case 0: Ref. D8307100 Upper tray Revision diaphyseal reamer protection Revision diaphyseal Ref. D8271420 reamer Diameter Ref.
  • Page 49 Genutech ® CCK Set 1. of tibial instruments Case 1: Ref. D8307200 Upper tray Support handle for tibial Revision telescopic guide system template Ref. D8277120 Ref. D8220520 Support base for revision telescopic 14 mm open-end wrench guide Ref. D8271470 Ref. D8277122 Distal clamp for tibial guide Revision telescopic guide carriers Ref.
  • Page 50 Set of Instruments Set of Instruments ® Genutech CCK Set 2. of tibial/femoral instruments Case 2: Ref. D8307300 Upper tray Revision interline sizing guide Ref. D8277140 Revision 5° angular guide Primary femoral sizing guide Ref. D8271055 Ref. D8271450 Revision femoral sizing guide Distal cutting mask Size...
  • Page 51 Genutech ® CCK Set 4. of femoral trial instruments Case 4: Ref. D8307500 Upper tray Distal trial Posterior trial supplement supplement Size Thickness Size Thickness Ref. D8126150 4 mm Ref. D8126010 4 mm Ref. D8126190 8 mm Ref. D8126015 8 mm Ref.
  • Page 52 Set of Instruments Set of Instruments Genutech ® CCK Set 5. of stem trial instruments Case 5: Ref. D8307600 Upper tray Revision trial offset stem Diameter Length Diameter Length Diameter Length Ref. D8176102 Ref. D8176101 10 mm 70 mm 10 mm 120 mm 10 mm 200 mm...
  • Page 53 Genutech ® CCK Set 6. of tibial trial instruments Case 6: Ref. D8307700 Upper tray Revision trial tibial tray Size Ref. D8133100 Tibial tray impactor Ref. D8133200 Ref. D8133300 Ref. D8220615 Ref. D8133400 Ref. D8133500 Tibial component impactor Trial tibial Ref.
  • Page 54 Set of Instruments Set of Instruments Genutech ® CCK Set 7. of patella tools/instruments Case 7: Ref. D8307800 Upper tray Fixation screw for trial Tornillo suplemento tibial Pin extractor Headless pin tibial tray de prueba Diameter Length Ref. D8220280 Ref. D8210166 3,4 mm 80 mm Ref.
  • Page 56 0086 0318...

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