Surgical Technique with VERILAST Technology

Transcription

1 Surgical Technique with VERILAST Technology years I

2 BICON-PLUS Contents Indications... 1 Contraindications... 1 Case studies... 2 Preoperative planning... 5 Surgical technique... 5 Postoperative treatment for the primary procedure Cup revisions Sterilization Implants Instrumentation Optional instruments Nota Bene The following technique is for informational and educational purposes only. It is not intended to serve as medical advice. It is the responsibility of treating physicians to determine and utilize the appropriate products and techniques according to their own clinical judgment for each of their patients. For more information on the BICON-PLUS, including its indications for use, contraindications, and product safety information, please refer to the product s label and the Instructions for Use packaged with the product.

3 Indications In principle, the BICON-PLUS cups can be used for all types of arthrosis. Special surgical techniques are, however, necessary in the case of larger defects after traumatic injury, dysplastic forms and in revisions of loosened total endoprostheses. Primary Idiopathic coxarthritis Secondary coxarthritis with hip dysplasia Secondary coxarthritis with post-traumatic conditions such as femoral neck or pertrochanteric fractures or fractures in the region of the acetabulum Secondary coxarthritis following infantile hip deformities (Perthes disease, epiphysiolysis) Condition following earlier operations, such as osteosynthesis, displacement osteotomy and condition following pelvic osteotomies Revision Loosening of cemented and cementless cups Condition following girdlestone Condition following previous osteosyntheses in the pelvic region Contraindications Primary Pronounced deformities of the bony acetabulum resulting from severe osteoporosis with head collapse (RDA: rapid destructive osteoarthritis, subchondral insufficiency fracture) Pronounced defects to the bony acetabulum following fractures or infections Revision Major defects of the bony acetabulum loss of half or more of the bony circumference Excessive atrophy of the bony structure Pelvic ring dissociations following fractures and implant loosening 1

4 Case studies Case 1, 48-year-old female patient Fig. 1 Fig. 2 Pronounced left dysplastic arthrosis. Postoperative image. Regular position of cup and shaft. Fig. 3 Fig. 4 Monitor-based ap image, 6 months postoperatively. Full titanium shell contact with surrounding bone years postoperatively. Unchanged good bone contact in all 3 positions. Load balancing of the acetabulum has resulted in a reduction of the cranial sclerotic zone. 2

5 Case 2 59-year-old male patient Fig. 1 Pronounced idiopathic left coxarthrosis. Fig. 2 Fig Monitor-based ap image, postoperatively. Distance between the front end of the titanium cup and the bony acetabulum (1) and also at the cranial cup body (2) years postoperatively. Complete filling of the gap medially and, to a large extent, cranially, indicating stable osteointegration. 3

6 Case 3, 76-year-old female patient Fig. 1 Pronounced idiopathic right coxarthrosis. Fig. 2 Fig. 3 Monitor-based ap image 3 months postoperatively. Gap between the bony bed and the cranial and medial sides years postoperatively. The gap in relation to the bony bed has been filled, indicating osteointegration of the implant. 4

7 Preoperative planning Most clinics nowadays have digital surgical planning software. In many cases this involves the BICON-PLUS cup implant with the various implant sizes. Digital images with a calibration ball are taken to preoperatively asses the sizing accurately. As we know the dimensions of the calibration ball, positioned at cup level, the size of the selected cup implant can be accurately assessed. If no digital planning modules are available conventional X-ray templates enlarged by 15% can be used for planning. However, it is important to bear in mind that precise preoperative size determination using X-ray templates is only an approximation for the cup, in view of the fact that the effect of an intra-operative medialization of the implant through an X-ray template can hardly be simulated. The correct cup size is, therefore, exclusively determined during surgery on the basis of the definitive reamer size. Surgical technique Positioning and approach The BICON-PLUS cup can be used for minimally invasive and standard approaches. To illustrate these uses the minimally invasive anterolateral approach in a supine position as defined by Pflüger (modified Watson-Jones) and the standard approach are described. The operation is performed with the patient lying supine. The pelvis is held as horizontal as possible. The joint capsule is then opened and the femoral neck is removed according to the detailed description in the surgical technique booklet for the SL-PLUS stem. The capsule is removed as far as is necessary to allow precision work to be performed on the bone. The acetabulum is prepared for cup implantation with 3 Hohmann retractors. The retractors are positioned so that the reaming instruments are not hampered or damaged. 5

8 Transgluteal approach 1 Greater trochanter 2 Gluteus medius muscle 3 Vastus lateralis muscle 4 Tensor fasciae latae muscle Anterolateral approach 1 Greater trochanter 2 Gluteus medius muscle 3 Vastus lateralis muscle 4 Tensor fasciae latae muscle 5 Gluteus minimus muscle In the past the transgluteal approach according to Bauer was preferred. 1,2 In recent years, however, the modified anterolateral approach according to Watson Jones has been adopted in order to meet the requirements of minimally invasive surgery. This takes better account of the muscles and leaves the tendon insertions of the gluteus medius and minimus muscles and the vastus lateralis muscle intact. 2,3,4 The exposure of the acetabular region is even better with this approach than with the transgluteal approach, and thus ideally suited to the implantation of a BICON-PLUS cup. 1 R. Bauer et al: «Operative Zugangswege in Orthopädie und Traumatologie.» , Thieme Zweymüller K. (2007). «Good results with an uncoated grit-blasted tapered straight stem at ten years.» «In: Interact Surg 2: ; Springer Verlag. 3 Pflüger G., Junk-Jantsch S., Schöll V. (2006). «The anterolateral approach in supine position for minimally invasive implantation of hip endoprotheses.» In: Interact Surg 1: 21-25; Springer Verlag. 4 Kim C. Bertin, Heinz Röttinger «Anterolateral Mini-incision Hip Replacement Surgery A Modified Watson-Jones Approach.» CORR, Nr. 429, pp (2004) 6

9 Preparation of the acetabular bed The bone bed is prepared with the reamers specifically designed for this purpose, comprising medialization reamers with sharp-cutting threads at the front end and standard double-cone cup reamers. Basically, we advise machine reaming since this provides greater precision. The angle of implantation also has to be established with the first reamer: The BICON-PLUS cups are positioned at an angle of to the transverse plane and at an angle of to the sagittal plane. A correct cup position is the basis for a balanced range of movement and optimal adduction/abduction. It minimizes the risk of dislocation/luxation and prevents impingement. In primary surgery, almost always start with the medialization reamer, unless using sizes 01 and 0, where the medialization reamer is not used. This reamer is generally applied axially in the center of the bony acetabulum or, in the case of dysplastic arthrosis, at a location that may appear to be most suitable in terms of implant bone coverage. Attention must be paid to the height of the rotation center and the availability of bony structures to sufficiently stabilize the implant. The depth of the medialization can be decided according to the particular situation (different offset anatomies) and can be defined in the preoperative digital planning module. Here the lamina interna (medial pelvic cortex) should not be cut through. 7

10 By using the medialization reamer, chiseling can be avoided to remove sclerotic areas of the socket floor/a sclerotic cup wall. It has been shown that this type of chiseling often leads to excessive widening of the cup bed and thus to poor conical cup seating. After preparing the acetabulum with the medialization reamer, the biconical reamers are used. Standard reamers are applied until the desired/planned cup size is achieved. The planned cup size can be easily changed to meet the intraoperative situation. By applying pressure at a precisely defined angle of reaming, the line of reaming is extended towards the circumference of the acetabulum. If the direction of reaming needs to be adapted as a result of the bone situation, e.g. in a cranial, ventral or dorsal direction, this can be done with any reamer. Reaming is controlled by applying pressure accordingly in the selected direction. As already mentioned, the double cone of the implant is adapted to the spherical shape of the acetabulum so that only a minimum of bone substance has to be sacrificed. The definitive cup size can only be determined intraoperatively on the basis of the last reamer size used. Note If the special 01 and 0 sizes are to be implanted, only the corresponding standard reamer is used. In this case the medialization reamer is not used. 8

11 Implantation of the cup shell During the reaming procedure, the surgeon can assess the bone quality and decide which cup shell to use. The implant appropriate for the bone situation can thus be chosen: the Standard cup for hard and sclerotic bone, or the Porous cup for soft and porotic bone. The implantation procedure is the same for both cup shells (Standard and Porous). The spring piece of the definitive size (01...9) is positioned in the cup. It is important to ensure that the spring element grips firmly in the sector opening. Important The spring piece must match the cup size in order to prevent any damage to the implant or instruments. Connect the jolly rod with the spring piece. Push the matching clamp rod (sizes 01/0 or 1 9) through the jolly rod, twist into position and tighten until the cup is clamped in place. Please note Clamp rod size 01 0 is not secured in the jolly rod. This means that the clamp rod can fall out of the jolly rod if it is not connected with the spring piece. Position the cup with the turning instrument in front of the acetabulum. 9

12 Alternatively the turning instrument can be fitted in situ. Connect the spring piece and the cup using the optional positioning instrument ( ). Insert into the spring piece in the direction of the oval milled groove with the hook on the outside, pressing on the screw at the back. Position the instrument and release the screw so that the hook remains in the shell. Tighten the screw.... press on the screw at the back. The positioning instrument cannot be used for sizes 01 and 0. For size 1 the instrument can only be connected in one place. Guide the entire package in front of the acetabulum. 10

13 Then connect the ratchet with the support plate to the jolly rod. The cup shell is first centered in the bony double cone by counterclockwise rotation. This helps to prevent tilting of the titanium shell. The right depth of the BICON-PLUS cup is reached when the implant base is on or about one millimeter above the bony base of the cup. The distance to the base of the implant should never be too great. The cup is screwed in clockwise. The cup shell and the bony base of the cup must be parallel to ensure secure fixation. While screwing in the cup, the instrument can be simply released, if necessary, and remounted. If the implant is tilted towards the cup bed and as a result conical seating is not attained, the cup shell must be unscrewed and repositioned along the axis. The depth can be checked manually with the measuring hook (probe hook). The measuring hook is inserted through one of the 3 slits in the spring piece until it touches the base of the shell and the distance to the bony cup base is probed. It is important to ensure that the cup is not overtightened. If possible the penetration depth should ensure that all threads at the ventral margin of the cup are covered in bone. Otherwise there is the risk of impinging the psoas tendon. Important When the apex of the cup shell makes full contact with the bone, stop screwing in. The firm cone anchorage cannot be improved further now. 11

14 Further rotation may, in cases where the bone is soft, lead to a loss of stability in the implant by destroying the bony thread. In hard bone overtightening can cause a fracture in the acetabular cup base. In the case of a very hard bone, repeated short turns forwards and backwards can increase the cutting ability of the teeth. In the case of extremely hard bone, the support plate can be mounted on the ratchet handle to increase the torque. If the cup is positioned correctly, even maximum torque would never break the bony circumference of the acetabulum during the screw-in procedure. When the cup is screwed in place the ratchet can be removed. Release the clamp rod until it has a little axial room. Then remove the jolly rod along with the clamp rod and the spring piece. The three sectors of the cup shell are open during the screwing procedure. They not only allow full view of the correct positioning of the cup, but also allow spongiosaplasty of the socket floor after completing the screwing procedure. After this the sectors are closed with an instrument that is exclusively designed for the sector torque module so that there is not the slightest contact between the PE-insert and the surrounding bone. The sectors should only be closed by a single rotary movement, as repeated opening and closing may impair the function of the sectors. 12

15 Trial insert A trial insert system is available to determine the ideal insert - standard or antilux - and to assess the elevation of the antilux insert. These trial inserts should be used to simulate joint play and the range of motion and to determine whether to use an antiluxation or constraint insert. In difficult primary, and particularly revision, procedures, the use of a trial insert is recommended in all cases so that the femur can then be prepared to accept the stem. After the ideal position and stability has been achieved for the detachable rasp and trial stem, the surgeon can then decide on the type of cup insert to be selected in combination with the ideal head size and neck length. Handling the trial instruments The appropriate trial insert (internal diameter 28 green, internal diameter 32 blue, 36 rust) is mounted on the turning/setting instrument (standard 28, 32, 36, antiluxation 28, 32). Finally, the turning/setting rod is pushed in and gently engaged. The trial insert is placed in the cup shell and fixed in place by turning the turning/setting rod clockwise. The turning/setting rod is now pressed out of the holder with the thumb until it strikes home. This uncouples the instrument from the trial insert that is now fixed in the cup shell. 13

16 To remove the trial cup the turning/setting instrument, together with the engaged turning/setting rod is placed in the trial insert and the latter is loosened and then removed by rotating the turning/setting rod counterclockwise. Important If the surgeon plans to use a constraint inserter, the correct neck length must first be determined using a standard trial insert. The constraint inserter is positioned using the impactor head for the insert. Constraint inserters cannot be inserted into the shell with the centering module. Once the constraint insert is positioned, the trial head of the same size should no longer be maneuvered, as this would snap in. The definitive ball is maneuvered into the constraint insert with pronounced external rotation of the leg, after the insert has been cleaned of irrigation fluid and blood as thoroughly as possible. Before introducing the definitive insert, always clean the cup shell very thoroughly. Ensure that no soft tissues are interpolated between the cup shell and insert in order to drive home the insert into the cone structure of the shell. 14

17 Correct assembly of the insertion system First place the centering module adapter loosely on the base module, then add the centering module and finally the appropriate inserter (standard, antiluxation or ceramic/ ceramic). The sleeve of the base module, which has to be pulled back at first until the inserter is engaged, is now pressed down to fix the inserter in place. Intraoperative assembly of the Ti-cap on XLPE insert Before an XLPE insert can be used, the supplied Ti-cap (1 unit in reserve) must be assembled using the corresponding inserter. The Ti-cap is positioned by hand on the nipple of the XLPE insert. The centering sleeve ( ) of the inserter is then positioned on the XLPE insert (centering physically perceptible) and the punch of the inserter ( for insert size 1 9 or for insert size 01/0) is introduced into the centering sleeve. Apply gentle pressure to the punch as far as it will go until the Ti-cap is secured on the XLPE insert with an audible snap. Important The size shown on the centering sleeve (01+0 and 1-9) must correspond to the insert size used by placing the side with the corresponding size on the insert. The original cup insert is now firmly mounted and introduced into the cup shell. 15

18 Fixing the cup insert A gentle rotation simplifies the centering procedure of the insert in the metal cup. If contact is made, the cup insert is driven centrally into the shell by a gentle hammer blow to the base module. The inserter/centering module and the centering module adapter are then disconnected from the base module. The corresponding impactor head is fitted onto the base module and the insert is then firmly anchored in the shell. Please note Unnecessarily heavy blows on the inserter may damage the articular surface of the insert. Use the rasp to check that the insert is firmly seated and that there is a uniform distance between the PE section and the metal circumference. It is important to note that the inserts have a size dependent lateralization of the ball head center to the cup margin ranging from 0 to max. 4.6 mm, and that they are therefore not flush with the shell. Marginal osteophytes projecting above the cup entry level must be carefully removed; otherwise they could cause impingement which would increase the risk of luxation or restrict movement. Note The shoulder raised by 15 in the antiluxation insert (measured from the center of the insert) is used as a luxation protection and should be positioned in the direction in which there is the greatest risk of luxation. The antiluxation insert cannot, however, compensate for problems posed by a cup that is implanted at too steep an angle (>50 ). The dysplasia insert is impacted into position in the same way as the standard insert. 16

19 Using the BIOLOX Delta Ceramic Insert Indications and Contraindications As a rule all indications, contraindications and recommendations for total hip joint replacement with other bearings apply for the use of BIOLOX delta cup inserts. The following contraindications should also be taken into account for ceramic inserts: The inclination of the shell must not be under 40 or over 50. The anteversion of the shell must not be under 10 or over 20. If it is not possible to achieve the recommended cup position (e.g. insert replacement with a cup that demonstrates good osteointegration or in the case of dysplasia), no ceramic insert may be used. Standard or antiluxation inserts made of PE (XLPE / PE) are a safe and reliable alternative for these cases. The risk of impingement should be avoided at all times. Revision involving a broken ceramic-insert or replacing a metal insert In the case of a revision involving a fractured ceramic component, femoral ball head and insert have to be revised. Remove all loose identifiable fragments and thoroughly irrigate and lavage the operative site. Following a ceramic fracture or when replacing a metal insert, ceramic/ceramic bearings have been shown to be the most suitable treatment from a tribiological point of view, as ceramic or metal particles press into a PE insert and could cause increased abrasion when using hard/soft bearings. Revision of a broken ceramic femoral head A special ceramic revision femoral ball head coupled with a metallic taper adapter should be used if the femoral taper is intact. Metal or OXINIUM femoral ball heads with a polyethylene insert shall not be used for revising fractured ceramic components. In case the taper is damaged or no appropriate ceramic revision femoral ball head is available, the femoral stem must be revised to provide a suitable femoral taper to attach a new ceramic ball head. Postoperative treatment Postoperative treatment depends on multiple factors (in particular the surgical approach, the stem prosthesis used, any concomitant diseases, etc.). Indications on postoperative rehabilitation should be provided in accordance with clinical judgement and the standard procedures of the respective hospital. 17

20 Removal of a firmly mounted insert If an insert needs to be removed for any reason, an inlay extractor is available for this purpose. The inlay extractor screw is gently driven home at the outer margin of the insert by means of the slap hammer, and then fully screwed home. The insert then normally comes out with a single blow. If, in exceptional cases, it cannot be removed even with repeated blows, the process must be repeated at another site. The inlay extractor can be effective only at the margins and must not be placed in the holes intended for the inserter. In case the insert cannot be removed with the inlay extractor, it can be levered up with the help of one or two cortical screws. Ideally, the screws are placed into the insert at the lateral plane of the cup parallel to the outer cup wall. While drilling, ensure that the metallic cup floor is reached without its being damaged by further drilling. The screws are then tightened. Once the base is reached the insert is pressed out of the cup. In many cases one screw is sufficient; however, sometimes a second screw at a distance of 1 2 cm may be helpful. Normally the position of the first screw is at 3 o clock (left hip) and at 9 o clock (right hip). This procedure is not possible in the case of smallest sized PE/ceramic inserts due to the thinner PE margin. To remove these inserts, use an arched chisel to first lever the ceramic insert up out of the polyethylene and then the polyethylene out of the metal shell. 18

21 Removing a BICON-PLUS shell First expose the implanted cup shell and remove the insert. Open the sectors with the sector closing module. Remove any bone that has grown into the sectors. Manually insert the suitable spring piece and turn without axial pressure until the cams engage in the sector openings. To check that the spring piece and the shell are flush, run a finger over the margin of the cup. Connect the jolly rod with the spring piece and push the matching clamp rod through the jolly rod, twist into position and tighten until the cup is clamped in place. Please note Clamp rod size 01/0 is not secured in the jolly rod. This means that the clamp rod can fall out of the jolly rod if it is not connected with the spring piece. Fit the ratchet from the standard instrument set. An attempt can now be made to remove the cup from the acetabulum by turning it counterclockwise. Please note It may not be possible to remove a well osteointegrated cup using the procedure mentioned above. In this case the surgeon should attempt to separate the cup from the inside with a diamond chisel or reamer, for example, and then remove the individual pieces from the bone with forceps from the inside. 19

22 The BICON-PLUS cup as a revision implant The BICON-PLUS Standard and BICON-PLUS Porous cup duo is also suitable for cup revisions. After removing the loosened cup, any cement residue or granulation tissue has to be carefully removed. The acetabulum is then prepared step by step with the cup reamers. Larger uncontained defects are then filled with autologous or allograft bone. The bone chips can be modeled slightly with the reamers. The bone chips are for filling defects only and not for anchoring the cup shell. Anchoring should be achieved in pre-existing and living bone. The Standard or Porous cup shell is inserted as described in the surgical technique. After implanting the cup shell, additional cancellous bone packing may also be undertaken through the open sectors. Important If the anterior acetabular rim is missing there is an increased risk of injury to the femoral artery or vein during insertion of the shell. For successful revision with the screw cup, the bony ring of the acetabulum has to be utilized. For this, cups of adequate size are chosen and placed slightly more laterally than otherwise in order to achieve stable contact of the implant with the bony ring. Medialization with smaller cups must be avoided in these cases. With 9 sizes, a wide choice is available, even in the larger implant size range. To make it easier to produce the original stem-cup geometry in revision surgery it is advisable to use the previously mentioned cup trial system. When repositioning with the complete trial system which comprises trial insert, trial ball head and trial stem, the ideal combination can be investigated to determine whether a standard, antiluxation or constraint insert is preferable. A trial can be carried out to ascertain if a ball head size 28, 32 or 36 mm can be selected, or how the required neck length can be combined with a standard or lateralizing stem to result in an implant secured against luxation while preserving leg length. If in doubt, the definitive decision can be left until the final trial reposition. 20

23 Sterilization Implants All the implants described in this Surgical Technique are sterile when they are delivered by the manufacturer. Resterilization is not allowed. Instruments System components and instruments are not sterile when they are delivered. Before use they must be cleaned by the usual methods in accordance with internal hospital regulations and sterilized in an autoclave in accordance with the legal regulations and guidelines applicable in the relevant country. (For detailed information please refer to leaflet Lit. No ). The correct settings are given in the instructions for use issued by the autoclave manufacturer. Instrument manufacturers and suppliers accept no responsibility for sterilization of products by the customer. Combination options cup/inserts Cups /37 0/40 1/43 2/46 3/49 4/52 5/56 6/59 7/63 8/68 9/72 PE XLPE PE Constraint BIOLOX delta

24 Implants Cups BICON-PLUS Standard cup, cementless (Ti-shell) Art. No. SAP No. Size Ø mm mm mm mm mm mm mm Ø Special sizes: mm mm mm mm BICON-PLUS Porous cup, cementless (Ti-shell) Art. No. SAP No. Size Ø mm mm mm mm mm mm mm Ø Special sizes: mm mm mm mm 22

25 Inserts Note All cup inserts may be used only in combination with the appropriate cup systems approved by Smith & Nephew Orthopaedics AG. PE-insert standard Art. No. SAP No. Size Ø mm mm mm mm mm mm mm mm mm mm mm mm Special sizes: mm mm PE-insert antiluxation Art. No. SAP No. Size Ø mm mm mm mm mm mm mm mm mm mm mm mm Special sizes: mm mm 23

26 XLPE -insert standard Art. No. SAP No. Size Ø mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Special sizes: mm mm mm mm XLPE -insert antiluxation Art. No. SAP No. Size Ø mm mm mm mm mm mm mm mm mm mm mm mm Special sizes: mm 24

27 PE-insert constraint Art. No. SAP No. Size Ø mm mm mm mm mm mm mm mm mm mm mm mm mm 25

28 Ceramic/polyethylene-insert for ceramic-ceramic pairing (BIOLOX delta) Insert standard Art. No. SAP No. Size Ø mm mm Art. No. SAP No. Size Ø mm mm mm mm mm Note BIOLOX Delta Ceramic Inserts may only be combined with BIOLOX Forte/ Delta Ceramic Ball heads. Any Smith & Nephew ball head from the BIOLOX Delta/Forte family may be combined with any Smith & Nephew ceramic insert from the BIOLOX Family, providing the correct head or calotte diameter. Other components not authorized by Smith & Nephew Orthopaedics are not permissible. 26

29 Ball heads OXINIUM ball heads Art. No. SAP No. Ø Cone Neck length mm 12/14 S/ mm 12/14 M/ mm 12/14 L/ mm 12/14 XS/ mm 12/14 S/ mm 12/14 M/ mm 12/14 L/ mm 12/14 XL/ mm 12/14 XS/ mm 12/14 S/ mm 12/14 M/ mm 12/14 L/ mm 12/14 XL/ mm 12/14 S/ mm 12/14 M/ mm 12/14 L/ mm 12/14 XL/+12 Ceramic Ball Heads, BIOLOX delta Art. No. SAP No. Ø Cone Neck length mm 12/14 S mm 12/14 M mm 12/14 L mm 12/14 S mm 12/14 M mm 12/14 L mm 12/14 XL mm 12/14 S mm 12/14 M mm 12/14 L mm 12/14 XL 27

30 Instruments Case Basic Instruments 1/2 Art No./SAP No / Art. No. SAP No. Description Optional Case Basic Instruments 1/ Easy Tray Lid Inlay Base Module with Handle Sector Closing Module 01/0 ~~ Sector Closing Module Impactor Head for Insert 22 ~~ Impactor Head for Insert Impactor Head for Insert Impactor Head for Insert Measuring Hook Inlay Extractor with Screw ~ Screw for Inlay Extractor (Replacement) ~ Jolly Rod Clamp Rod, sizes Clamp Rod, sizes Spring Piece, size 01 ~~ Spring Piece, size 0 ~~ Spring Piece, size Spring Piece, size Spring Piece, size Spring Piece, size Spring Piece, size Spring Piece, size Spring Piece, size Spring Piece, size 8 ~~~ Spring Piece, size 9 ~~~ Centering Sleeve Ti-Cap XLPE ~ Punch Ti-Cap XLPE, size 1 9 ~ Punch Ti-Cap XLPE, size 01+0 ~ Optional Instrument Sets: xx BICON-PLUS up-grade Set 01+0 xxx BICON-PLUS up-grade Set

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32 Case Basic Instruments 2/2 Art No./SAP No / Art. No. SAP No. Description Optional Case Basic Instruments 2/ Easy Tray Lid Ratchet Handle with Support Plate Drive Shaft Reamer - AO Reamer with Cross, sizes Reamer with Cross, sizes Medialization Reamer with Cross Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes Reamer with Cross, sizes 8 68 ~~~ Reamer with Cross, sizes 9 72 ~~~ Optional Instrument Sets: xxx BICON-PLUS up-grade Set

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34 Case Trial Instruments 1/2 Art No./SAP No / Art. No. SAP No. Description Optional Case Trial Instruments 1/ Easy Tray Lid Trial Insert Standard 1/ Trial Insert Standard 2/ Trial Insert Standard 3/ Trial Insert Standard 4/ Trial Insert Standard 5/ Trial Insert Standard 6/ Trial Insert Standard 2/ Trial Insert Standard 3/ Trial Insert Standard 4/ Trial Insert Standard 5/ Trial Insert Standard 6/ Trial Insert Standard 7/ Trial Insert Standard 3/ Trial Insert Standard 4/ Trial Insert Standard 5/ Trial Insert Standard 6/ Trial Insert Standard 7/ Trial Insert Standard 8/36 ~~~ Trial Insert Standard 9/36 ~~~ Trial Insert Antilux 1/ Trial Insert Antilux 2/ Trial Insert Antilux 3/ Trial Insert Antilux 4/ Trial Insert Antilux 5/ Trial Insert Antilux 6/ Trial Insert Antilux 2/ Trial Insert Antilux 3/ Trial Insert Antilux 4/ Trial Insert Antilux 5/ Trial Insert Antilux 6/ Trial Insert Antilux 7/32 Optional Instrument Sets: xxx BICON-PLUS up-grade Set

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36 Case Trial Instruments 2/2 Art No./SAP No / Art. No. SAP No. Description Case Trial Instruments 2/ Easy Tray Lid Turning and Setting Instrument Universal Turning and Setting Instrument Standard Turning and Setting Instrument Standard Turning and Setting Instrument Standard Turning and Setting Instrument Antilux Turning and Setting Instrument Antilux 32 34

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38 Set Inserters Art No./SAP No / Art. No. SAP No. Description Optional Case Setting Modules Easy Tray Lid Inserter PE Standard 22 ~~ Inserter PE Antilux 22 ~~ Inserter PE Standard Inserter PE Antilux Inserter PE Standard 2/ Inserter PE Antilux 2/ Inserter PE Standard 3-9/ Inserter PE Antilux 3-9/ Inserter PE Standard 3-4/ Inserter PE Standard 5-9/ Inserter CER/CER 28/ Inserter CER/CER Centering Module 01 ~~ Centering Module 0 ~~ Centering Module Centering Module Centering Module Centering Module Centering Module Centering Module Centering Module Centering Module 8 ~~~ Centering Module 9 ~~~ J Centering Module Adapter Optional instruments Art. No. SAP No. Description Optional Drive Shaft Reamer Stryker Curved Reamer Shaft Positioning Instrument Optional Instrument Sets: xx BICON-PLUS up-grade Set 01+0 xxx BICON-PLUS up-grade Set

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40 Manufacturer Smith & Nephew Orthopaedics AG Oberneuhofstrasse 10d 6340 Baar Switzerland OXINIUM is a registered trademark from Smith & Nephew Inc., CE0086. BIOLOX delta, BIOLOX forte and BIOLOX OPTION are registered trademarks from CeramTec GmbH, Germany, CE0123. Trademark of Smith & Nephew en V4 (2179) Ed. 05/