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Zimmer MIS Multi-Reference Surgical Technique

4-in-1 femoral instrumentation, for nexgen cruciate retaining & nexgen legacy posterior stabilized knees
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For NexGen
Cruciate Retaining &
®
NexGen Legacy
Posterior Stabilized Knees
®
Zimmer
MIS
®
Multi-Reference
4-in-1 Femoral
Instrumentation
Surgical Technique
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Summary of Contents for Zimmer MIS Multi-Reference

  • Page 1 Zimmer ® Multi-Reference ® 4-in-1 Femoral Instrumentation Surgical Technique For NexGen Cruciate Retaining & ® NexGen Legacy Posterior Stabilized Knees ®...

  • Page 3: Table Of Contents

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Surgical Technique Table of Contents For MIS Multi-Reference 4-in-1 Femoral Abbreviated Surgical Technique Instrumentation Introduction Preoperative Planning Surgical Approach Patient Preparation Incision and Exposure MIS Midvastus Approach MIS Subvastus Approach MIS Medial Parapatellar Arthrotomy...

  • Page 4: Abbreviated Surgical Technique

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Insert and Secure Drill 8mm Pilot Hole Mini Distal Femoral Cutting Guide Set External Rotation Set External Rotation (Anterior Referencing) (Posterior Referencing)
  • Page 5 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Cut Distal Femur Size the Femur Place Femoral Finishing Finish the Femur Guide; Adjust M/L & Pin (Anterior Referencing) 1. Anterior condyles 2. Posterior condyles 3. Posterior chamfer 4. Anterior chamfers...

  • Page 6: Introduction

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Introduction The femur, tibia, and patella are Total knee arthroplasty using a less invasive technique is suggested for prepared independently, and can be Successful total knee arthroplasty nonobese patients with preoperative cut in any sequence using the principle depends in part on re-establishment flexion greater than 90°.

  • Page 7: Preoperative Planning

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique 6° Preoperative Planning Surgical Approach Use the template overlay (available The femur, tibia, and patella are through your Zimmer Representative) prepared independently, and can be to determine the angle between the cut in any sequence using the principle...

  • Page 8: Patient Preparation

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Patient Preparation Incision and Exposure Divide the subcutaneous tissue to the level of the retinaculum. To prepare the limb for MIS total The incision may be made with the NOTE: Using electrocautery to...

  • Page 9: Mis Midvastus Approach

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique MIS Midvastus Approach two-pronged hooks to begin to gently evert the patella. Be careful to avoid Make a medial parapatellar incision disrupting the extensor insertion. into the capsule, preserving To help evert the patella, slowly flex...

  • Page 10: Mis Subvastus Approach

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique MIS Subvastus Approach be the synovium, while the superficial layer will be the medial retinaculum The subvastus medial arthrotomy and the myofascial sleeve of tissue that has been slightly modified to optimize has been left attached to the inferior minimally invasive surgery.

  • Page 11: Mis Medial Parapatellar Arthrotomy

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique MIS Medial Parapatellar Arthrotomy Minimally invasive total knee arthroplasty can be performed with a limited medial parapatellar arthrotomy. Begin by making a 10cm- 14cm midline skin incision from the superior aspect of the tibial tubercle to the superior border of the patella.

  • Page 12: Surgical Technique

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step One which will provide the most accurate Set the Mini Adjustable IM Alignment Establish Femoral Guide to the proper valgus angle reproduction of the anatomic axis. If the femoral anatomy has been altered,...
  • Page 13 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique The Standard Cut Plate must be NOTE: The Mini Micro Cut Plate can be Insert the IM guide into the hole in attached to the Adjustable IM used when templating has indicated the distal femur.

  • Page 14: Cut The Distal Femur

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Two Completely loosen the attachment Cut the Distal Femur screw (Fig. 2e) in the Distal Placement Guide. Then use the Slaphammer Extractor to remove the IM guide and While the Adjustable IM Alignment the Distal Placement Guide (Fig.

  • Page 15: Size Femur & Establish External Rotation

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Three MIS Screws are available in 3 lengths Read the femoral size directly from Size Femur and Establish (27mm, 33mm, 48mm). The length the guide between the engraved lines needed will vary depending on the on the sizing tower (Fig.
  • Page 16 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Attach the selected plate to the Mini If using a posterior referencing Careful attention should be taken when technique, remove the Mini A/P Sizing A/P Sizing Guide (Fig. 3d). Place two placing the headless pins into the Guide and go to page 19, “Step Four –...

  • Page 17: Finish The Femur

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Four When the M/L position of the Femoral Remove the headless pins from the Finish the Femur Finishing Guide is set, use the Screw Femoral Finishing Guide (Fig. 4c) with Inserter/Extractor to insert a 3.2mm the Headless Pin Puller.
  • Page 18 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Optional Technique Use a 1.27mm (0.050-in.) narrow, Use the 1.27mm (0.050-in.) narrow, oscillating saw blade to cut the femoral reciprocating saw blade to cut the To check the location of the anterior profile in the following sequence for base of the trochlear recess (Fig.

  • Page 19: Posterior Referencing Technique

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Posterior Referencing Technique Place the finishing guide on the distal If desired, attach the MIS Locking Select the correct size MIS Femoral femur, bringing the feet of the rotation Boom to the face of the finishing guide...
  • Page 20 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Use the 1.27mm (0.050-in.) narrow, When the proper rotation and the Use a 1.27mm (0.050-in.) narrow, mediolateral and anteroposterior oscillating saw blade to cut the femoral reciprocating saw blade to cut the...

  • Page 21: Mis Notch/Chamfer Trochlear Guide

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Option 1 Note: The distal mediolateral profile Use a reciprocating saw to cut the MIS Notch/Chamfer of the MIS Notch/Chamfer Guides, sides and base of the intercondylar box anterior to the tabs, can be used to (Fig.
  • Page 22 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Surgeon Notes & Tips Apply the matching size MIS Trochlear Guide to the MIS Notch/Chamfer Guide • Although a sequence of femoral with the holes in the Trochlear Guide cuts has been provided, the cuts aligned with the threaded holes in the may be made in any sequence.

  • Page 23: Mis Qs Notch Guide

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Option 2 Secure the MIS QS Notch Guide to MIS QS Notch Guide the femur with two 3.2mm (1/8-inch) Headed Screws or predrill and insert two 3.2mm (1/8-inch) Holding Pins Position the appropriate size MIS QS (Fig.

  • Page 24: Resect Proximal Tibia

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Five Assemble the Guide Resect Proximal Tibia The MIS Tibial Cut Guide Assembly consists of instruments for right or left Tibial Cut Guide (Fig. 5a). This step explains the alignment of the tibial cut to help ensure proper •...
  • Page 25 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique NOTE: The Tibial Cut Guide and Attach the Ankle Clamp or optional For a right knee, the right anchor is Spring to the Ankle Bar. Then slide inserted into the left hole (Fig. 5d).
  • Page 26 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Position the Guide NOTE: Be sure that only the low-profile portion of the cutting head extends Place the spring arms of the Ankle beneath the patellar tendon (Fig. 5h). Clamp around the ankle proximal to the...
  • Page 27 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Set the Final Resection Level Insert an MIS Screw near the tibial tubercle through the hole in the With the Tibial Cut Guide flush against Tubercle Anchor (Fig. 5j). the anteromedial edge of the tibia,...
  • Page 28 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Resect the Proximal Tibia Use the Hex-head Screwdriver to tighten all of the screws on the tibial Use a 1.27mm (0.050-in) oscillating assembly to maintain position. saw blade through the slot on the Tibial...

  • Page 29: Check Flexion/Extension Gaps

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Six Then flex the knee and check ligament Check Flexion/Extension balance and joint alignment in flexion. When using the MIS Flex Femoral Gaps Finishing Guide, the flexion gap will be approximately 2mm greater than Use the Spacer/Alignment Guides to the extension gap.

  • Page 30: Prepare The Patella

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Seven Prepare the Patella Patella Thickness Sharply dissect through the prepatellar — Implant Thickness bursa to expose the anterior surface of the patella. This will provide exposure = Bone Remaining for affixing the anterior surface into the Implant Thickness Guide Patellar Clamp.

  • Page 31: Resect The Patella

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Resect the Patella Patellar Reamer Technique Insert the appropriate size Patellar Total Surfacing Procedure Reamer Surfacing Guide into the Use the Patellar Reamer Surfacing Patella Reamer Clamp (Fig. 7e). Turn Guides as templates to determine the the locking screw until tight.
  • Page 32 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Insetting Technique Insert the appropriate size Patellar Turn the depth gauge wing on the Use the Patellar Reamer Insetting Patellar Reamer Clamp to the proper Reamer Insetting Guide into the Guides as templates to determine the indication for the correct amount of Patellar Reamer Clamp.

  • Page 33: Finish The Patella

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Finish the Patella For the NexGen The depth gauge wing on the Patellar All-Polyethylene Patella Reamer Clamp can be used instead Center the appropriate Patellar Drill For the NexGen Primary Porous Patella...

  • Page 34: Patella Protectors

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Option 1 A suture needs to be placed through The Patella Protector should be Patella Protectors the hole in the Patella Protector (Fig. part of the instrument count before 7n). Loosely tie a suture through the closing the wound.

  • Page 35: Perform A Trial Reduction

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Eight NOTE: During the trial reduction, After this self-centering process has Perform a Trial Reduction observe the relative position of the occurred, mark the position of the Femoral Provisional on the tibial...

  • Page 36: Tibial Position Based On Anatomic Landmarks

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Option 1 Attach the Universal Handle to the Generally, the handle aligns with the Tibial Position based on selected Tibial Sizing Plate/Provisional anterior aspect of the tibia. Rotate the by depressing the button on the handle...
  • Page 37 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Nine Insertion of Femoral Provisional using Optional MIS Femoral Perform Trial Reduction Inserter/Extractor In this step, a trial reduction is performed to check component position, patellar tracking, ROM, and joint stability.
  • Page 38 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Removal of Femoral Provisional Align implant or provisional onto If needed, turn adjustment knob (C) to using Optional MIS Femoral achieve desired rotation of the femoral prepared bone, impact end (H). Inserter/Extractor component (Fig.

  • Page 39: Implant Components

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Ten Position the PCL Retractor posteriorly, Attach the Femoral/Impactor/Extractor Implant Components the Collateral Soft Tissue Protector to the femoral component. Insert the laterally, and the Collateral Retractor femoral component onto the distal medially.
  • Page 40 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Component Implantation your index finger. This should lock the inserter to the base plate. Squeeze the handles of the inserter to seat the After the implants have been chosen, articular surface (Fig. 10c). Open the make one last check to ensure that the lever and remove the inserter.
  • Page 41 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Patellar Component Tibial Articular Surface NexGen Primary Porous Patella with Knee in 70°-90° flexion Trabecular Metal Material Use the Articular Surface Insertion Knee in 70°-90° flexion Instrument to attach the appropriate NOTE: If the implant post begins...
  • Page 42 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique gaps are not balanced, consider using For in vivo Assembly: *For cemented applications, apply a the taper plug in case, during final If preferred, 17mm or thicker articular layer of bone cement to the underside...

  • Page 43: Close Incision

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Step Eleven Apply cement to the anterior surface Apply cement to the Trabecular Metal Close Incision surface and post while in a doughy and pegs of the patellar component consistency. Locate the drilled post while in a doughy consistency.

  • Page 44: Appendix 1

    Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique Appendix 1 Surgical Technique Adjustable stylus: The Telescoping Boom is attached to the yoke of the Attach the MIS Telescoping Locking A/P Sizing instrument (Fig. B). The Boom to the yoke on the appropriate...
  • Page 47 Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique...
  • Page 48 Please refer to package insert for complete product information, including contraindications, warnings, precautions, and adverse effects. Contact your Zimmer representative or visit us at www.zimmer.com +H124975967002001/$090415R6L09E 97-5967-002-00 Rev. 7 0901-K17 3.5ML Printed in USA ©2003, 2008, 2009 Zimmer, Inc.

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