Revision Knee System Surgical Technique

Transcription

1 Revision Knee System Surgical Technique

2

3 Revision Knee System Surgical Technique MUTARS was developed in cooperation with Prof. Dr. W. Winkelmann and Prof. Dr. G. Gosheger, Clinic and Polyclinic for General Orthopedics, University Hospital Münster, Germany. MUTARS is clinically in use since Table of Contents System overview...2 Surgical Technique...3 Removal of an implant...21 Implants...23 Instruments...26 Note: The described surgical technique is the suggested treatment for the uncomplicated procedure. In the final analysis the preferred treatment is that which addresses the needs of the individual patient. Copyright: MUTARS, Aida, Cepthar, CCI, ACS, DiaLoc, EcoFit, Load Shift, implavit and implatan are registered trademarks of implantcast GmbH. The use and copy of the content of this brochure are only allowed with prior written permission of implantcast GmbH.

4 Component overview Revision stem for femoral components Length 160, 200 and 240 mm mm cementless mm cemented Femoral spacer 5 und 10 mm (distal) 10 mm (posterior-distal) Femoral component Size 3-5 Cementless and cemented versions Tibial plateau m-o-m small, standard, large cemented Tibial spacer 25, 35, 50 mm (bicondylar) 5,10,15,20 mm (unicondyar) Tibial stem Length 120, 160 and 200 mm mm cementless mm cemented Note: Consignment shipments may differ in composition of implants and instruments from what is shown in this brochure. In a preoperative planning the instruments and implants needed should be established and ordered accordingly. 2

5 Surgical Approach With the knee slightly flexed a straight mid-line incision is made over the patella, through the retinaculum, capsule and synovium. Alternatively, in case of neutral or varus deformity, a medial parapatellar, or in case of a valgus deformity a lateral parapatellar incision can be selected Also surgical scars from previous procedures should be taken into consideration, when selecting the surgical approach. The patella is inverted and the periostal structures are released medially resp. laterally. To improve the access, a preliminary resection of the patella could be considered. All components of the implant to be revised are removed. Intramedullary tibial alignment The medullary canal of the tibia is drilled with a 9mm drill (fig. 1). The preparation should be in the centre of the medullary canal (at the eminentia intercondylaris: ventral 1/3, dorsal 2/3). The canal is reamed progressively with 2 mm increments until the diameter and length, that have been established preoperatively, are met (see table 1 and 2). The point of the latest used reamer should make cortical contact. figure 1 Table 1: cementless implantation Tibial stem 12mm Reamer 11mm Tibial stem 14mm Reamer 13mm Tibial stem 16mm Reamer 15mm Tibial stem 18mm Reamer 17mm 3

6 Table 2: cemented implantation Tibial stem 11mm Reamer 13mm Tibial stem 13mm Reamer 15mm Tibial stem 15mm Reamer 17mm 1 To ascertain adequate depth is met, the reamers have depth marks (120mm for 120mm stems, 160mm for 160mm stems and 200mm for 200mm stems) corresponding with the tibial stem length (fig. 2). The last reamer used is left in the tibial canal. figure 2 The tibia resection block 0 is attached to the intramedullary tibia alignment guide, and the cutting block is placed over the tibial reamer that was left in the intramedullary canal. The stylus or depth gauge (1) is attached to the tibia cutting block and lowered with the adjustment cylinder (2) until the tip (3) of the stylus reaches the deepest point of the most effected part of the tibia plateau. (Fig.4).The 2 mm tip is used standard. In case of a major medial defect the 10mm tip of the stylus can be used to determine the level of resection on the lateral part of the tibial plateau. The tibial cutting block is attached to the bone using two 3.2 mm pins in the marked pin holes (Fig. 3). The stylus is now removed. If in a later stage the level of resection is too high, the cutting block can be repositioned over the pins accurately in a lower position (fig. 4). 1 figure 3 3 Remark In a primary case a minimum of If 15mm has to be resected from the tibia. 4 figure 4 2 4

7 The intramedullary alignment guide is removed using the slide hammer (fig. 5) figure 5 The anticpated resection level is checked using the resection check (fig. 6). figure 6 The saw capture is placed on the tibial resection guide. The proximal tibia is resected using an ACS saw blade or a saw blade with 1,47 mm thickness. Care should be taken not to hit the intramedullary reamer. The soft tissues should be protected from the saw blade (fig. 7). figure 7 5

8 Genu revision total knee system The resected tibia is checked and the reamer guide with the tibial centering guide is slid over the tibial reamer in place. (fig. 8a). The mark MEDIAL should be placed on the medial side The joint line can be restored using tibial spacers or bone grafts. If necessary, additional bone should be resected to accommodate the trial tibial spacer. The trial tibial spacer is clicked under the tibial reamer guide. (fig. 8b). The height of the spacer should correspond with the one fixed at the preoperative assessment. The right mediolateral alignment should be established and the tibial reamer guide is fixed with two pins (fig. 8b). The tibia reamer guide and the intramedullary tibial reamer are now removed. figure 8a figure 8b The tibial reamer is attached to the Thandle and the tibia is reamed manually (fig. 9a) until the plate of the reamer is stopped by the tibial reamer guide (fig 9b). It is strongly recommended not to use a power tool at this stage. figure 9a 6 figure 9b

9 The tibia punch is used to continue the tibial preparation. The punch should be punched down until it is stopped by the tibial reamer guide (fig. 10a and 10b). figure 10a figure 10b In case of sclerotic bone the tibial drill can be used. A drill sleeve is placed inside the tibia reamer guide to accommodate this drill. The drill sleeve is placed medially and the canal is drilled. After turning the sleeve 180, the lateral side is to be drilled. figure 11a figure 11b 7

10 Femoral preparation The femoral intramedullary canal is reamed using the 9 mm intramedullary initiator drill (fig.12a). The canal is reamed progressively with 2 mm increments till the diameter and length that have been established preoperatively are met (tabel 3 and 4). The drilling depth should be such that the marking(1) is at the level of the distal femoral bone (fig. 12b). figure 12a figure 12b 1 table 3: cementless Implantation Femoral Stem 12mm Reamer 11mm Femoral Stem 14mm Reamer 13mm Femoral Stem 16mm Reamer 15mm Femoral Stem 18mm Reamer 17mm 2 table 4: cemented Implantation Femoral Stem 11mm Reamer 13mm Femoral Stem 13mm Reamer 15mm Femoral Stem 15mm Reamer 17mm Femoral Stem 17mm Reamer 18mm The size of the femoral implant is determined by measuring the lateral condyle with the femoral sizing template. The outside of the template corresponds with the outer surface of the femoral component. The interior flange of the femoral temple should be held in the same plane as the anterior cortex (fig. 13). figure 13 The alignment stylus is attached to the A/P femoral resection block of the corresponding size. The AP cutting block is slid over the femoral intramedullary reamer that was left in place and the anterior stylus is attached to the A/P resection block. The stylus is slid beneath the quadriceps muscle anteriorly onto the periosteum of the femur. The stylus should be flush and parallel to the longitudinal axis of the femur (fig. 14) figure 14 8

11 The A/P femoral resection block is placed between the epicondyles. The A/P block should be placed parallel to the resected posterior femoral condyle. Now the A/P cutting block can be attached to the bone using two 3,2 mm pins (fig. 15). figure 15 The saw capture is attached to the A/P cutting block. The level of resection can be checked using the resection check to prevent notching the anterior femoral cortex. If necessary the A/P cutting block can be replaced by one size larger. figure 16a figure 16b Anterior femoral resection With the saw capture in place and the anterior condyle is resected using an ACS Sawblade or a saw blade with 1,47mm thickness. Posterior femoral resection The saw capture is now placed on the posterior side and the posterior femoral condyle is resected (fig. 17). figure 17 9

12 Distal Femoral Resection 2 Select the distal femoral cutting block (1) with a valgus angle of 6 and attach it to the femoral alignment guide (2). The femoral alignment guide and the distal femoral cutting block are now attached to the A/P cutting block (fig. 18a). 1 The distal femoral cutting block should now be adjusted for a minimal amount of bone to be resected. The resection check can be used to check the anticipated resection level (fig. 18b). figure 18a The reamer can be left in the intramedullary canal to stabilize the system. The distal femoral resection block should lie flush on the resected anterior femur (3). The distal femoral resection block can now be fixed at the anterior femur using two 3,2 mm pins (4) (fig. 19a). Remark To resect bone for the use of the femoral spacer please shift the distal cutting block bei 5mm and resect the affected distal condyle (fig. 19b). 3 figure 18b 4 figure 19a figure 19b 10

13 figure 20a The saw capture is attached to the distal femoral cutting block, the anticipated resection level is checked again and the distal femur is resected (fig. 20a and 20b). Care should be taken not to hit the intramedullary reamer in place. If necessary, the reamer can be removed for this step. After resection the distal femoral cutting block can be removed. figure 20b Femoral Preparation In case the reamer was removed in the previous step, it should now be resinserted. Regardless of the stem diameter selected to be implanted, at this stage always the 18 mm sleeves for the long stem revision and femoral drill should be placed in the femoral reamer guide of the appropriate size. This femoral reamer guide is placed on the distal femur (fig. 21). Care should be taken to set the sleeve in such a way that the marking LEFT can be read when preparing the implantation of a left knee or RIGHT when preparing a right knee. The femoral reamer guide should lie flush with both resected planes and can now be fixed using two 3,2 mm pins or drills (fig. 22). figure 21 figure 22a and 22b The 18 mm femoral drill sleeve and the reamer can now be removed. The 18mm guide for the stem revision should be left in place. Remark In case huge bone defects should be filled by the use of femoral spacers, the magnetic distance adapters (5mm and 10mm) may be added to the reamer guide to achive proper seating of the guide (fig. 22a and 22b). 11

14 Insert two fixation pins to fix the guide to the bone (fig. 23). Remove the 18mm reamer and the sleeve and the drill sleeve but leave the long stem reamer guide 18mm in place. To prepare sufficient space for the connecting cone 1 between femoral component and the stem extension (fig. 24a) the 18 mm intramedullary reamer should be used and advanced to a depth, so that appr. 1 cm of the cutting part still sticks out (fig. 24a and 24c). figure 23 1cm 1 1 figure 24b figure 24a The guides for the stem revision and the reamer are removed and the guide for the femoral reamer is now placed in the femoral reamer guide (fig. 25). figure 24c figure 25 12

15 The reamer should be advanced until it engages the stop of the reamer guide (fig. 26a and 26b). figure 26a figure 26b Use the narrow ACS Saw blade with 1,47 mm thickness to cut the anterior and posterior chamfer. The Cuts are performed through the slots (fig. 27 and fig. 28). figure 27 figure 28 figure 29 The osteotome is to be used to prepare the anterior femoral notch (fig. 29). Femoral and tibial preparation is now completed (fig. 30). figure 30 13

16 Use of Trial Implants To check all resections performed, the tibial and femoral trial implants are used. Screw the trial stem under the tibial trial of the selected size (fig. 31). The stem is medialized and care should be taken to place the trial stem into the correct medio-lateral position. If necessary a trial spacer can be clicked under the trial tibial implant (fig. 31). figure 31 The tibial trial and stem can be inserted using the tibial impactor (fig. 32a and 32b). figure 32a The corresponding trial inlay is now placed on the tibial trial implant (fig. 33a), using the PE-inlay setting instrument (fig. 33b). figure 32b figure 33a figure 33b 14

17 The trial stem is screwed onto the femoral trial implant of the selected size When femoral spacers should be used please click the trial spacer into the femoral trial (fig. 34). figure 34 Bone preparation for femoral spacer figure 35a To perform additional bone preparation for femoral spacers please impact the trial component without trial spacers using the impactor (fig. 35a). Use the narrow ACS sawblade to cut through the slots of the trial and cut bone for distal and/or posterior spacers (5mm or 10mm) (fig. 35b). Impact the trial components onto the femur with the help of the femoral impactor (fig. 35a and 35b). figure 35b Because each diameter and length of stem is represented by just one trial, if necessary, the stem should be replaced by a shorter one. A trial reduction is performed to check the level of the joint line in flexion (fig. 36a) and extension (fig.36b). figure 36a and 36b Attention: Neither the coupling of the femoral and tibial components nor the test for joint stability is envisioned at this stage. If the desired position is met, the tibial and femoral trial components can be removed using the slide hammer (fig. 37a and 37b). figure 37a figure 37b 15

18 The trial PE-inlay is removed and the distal part of the slide hammer is screwed into the thread of the tibial trial and the tibial trial is hammered out (fig. 38). figure 38 Tibial component assembly Attach the selected tibial stem onto the cone of the tibia component and connect the two parts with the screws provided. The torque wrench 3.5 mm hex screw driver (fig. 39) should be used. Any tibial shims or spacers should be added in the same way (fig. 39). figure 39 The assembled tibial component is inserted using the tibial impactor (fig. 40a and 40b). figure 40a figure 40b 16

19 The corresponding PE-inlay is now placed on the tibial component using the tibial setting instrument (fig. 41). Care should be taken to fully seat the inlay into the tibial component. figure 41 Assembly of the femoral component The femoral stem of the appropriate length and diameter is selected and placed on the assembling block. The cone of the femoral component is placed into the trunnion of the stem and the stem and the femoral component are assembled using the femoral impactor (fig. 42a). figure 42a and 42b Lock the femoral spacers by a screw into the femoral component and secure the assembly by the use of the torque wrench 3,5mm (fig. 42b). Implantation of the femoral component figure 43a The assembled femoral component is inserted using the femoral impactor (fig. 43a and 43b). figure 43b 17

20 To adjust or to remove the femoral component a special screw-in extractor for the slide hammer should be used (fig. 44a and 44b). The impactor can be removed once the femoral component is placed in a satisfactory way. figure 44a figure 44b Coupling of the femoral and tibial components The coupling and the locking instrument are assembled. The coupling of the locking mechanism is turned 110 until it is fully engaged in the sleeve (fig. 45). figure 45 The locking mechanism is placed in the intracondylar hole of the femoral component. The positioner is used to turn the locking instrument 180 clock wise (fig. 46a and 46b). The locking mechanism is placed correctly, when the short stem falls freely from the instrument. The locking instrument can now be removed. figure 46a 18 figure 46b

21 The coupling mechanism m-o-m is now attached to the femoral component. The instrument to insert the mechanism into the tibia component is now placed in the hole of the coupling and the mechanism is guided into the hole of the tibial plateau (fig. 47a). figure 47a figure 47b 1 The coupling mechanism should be fully engaged and placed in the correct rotational position. The screw hole (1) (fig. 47b) should be placed forward-turned to enable locking. figure 48a The positioner is inserted into the screw hole of the short stem of the coupling mechanism (fig. 48a and 48b). figure 48b figure 49a The coupling mechanism is held in place with the setting instrument while removing the positioner. Then the locking bolt is fixed with the torque wrench 3,5 mm hex screw driver into the tibial component (fig. 49a). Be sure that the locking bolt is fully engaged into the tibia component (fig. 49b). figure 49b 19

22 The torque wrench hex screw driver is used to screw in the Multilock security screw and to tighten the locking bolt (fig. 50a and 50b). figure 50a The implantation of the GenuX knee replacement is now concluded. Stability and range of motion is to be tested (fig. 51a and fig. 51b). figure 50b figure 51a figure 51b 20

23 Removal of an implant In case a tibia component should be removed the Multilock security screw and the locking bolt should be removed from ventrally using the torque wrench 3,5mm hex screw driver. figure 52a The locking instrument is then used to remove the locking mechanism from the femoral component. figure 52b The femoral component can now be removed using the slide hammer and the special extractor (fig. 52a and 52b). The tibial extractor is now attached to the slide hammer and placed into the screw hole of the tibial component (fig. 53a). figure 53a The attachment is secured using the rod with the small chain (fig. 53b). figure 53b The tibial component is now removed using the slide hammer (fig. 53c). figure 53c 21

24

25 IMPLANTS MUTARS revision stem for femoral component cementless mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ /160 mm /160 mm /160 mm /160 mm /200 mm /200 mm /200 mm /200 mm /240 mm /240 mm /240 mm /240 mm MUTARS revision stem for femoral component cemented mat.: implavit ; CoCrMo-casting alloy according to DIN ISO 5832/ /160 mm /160 mm /160 mm /160 mm /200 mm /200 mm /200 mm /200 mm /240 mm /240 mm /240 mm /240 mm MUTARS GenuX femoral component cemented mat.: implavit ; CoCrMo-casting alloy according to DIN ISO 5832/ right size left size right size left size right size left size 5 MUTARS GenuXfemoral component cementless mat.: implavit ; CoCrMo-casting alloy According to DIN ISO 5832/ right size left size right size left size right size left size 5 23

26 IMPLANTS MUTARS PE-inlay mat.: UHMWPE according to DIN ISO 5834/ small standard large MUTARS tibial plateau m-o-m cemented mat.: implavit ; CoCrMo-casting alloy acc.to DIN ISO 5832/ small standard large MUTARS screws for tibial plateau m-o-m (2 pcs) mat.: implatan ; TiAl 6 V 4 acc. to DIN ISO 5832/ MUTARS locking mechanism m-o-m incl. screw mat.: implavit ; CoCrMo-forged alloy according to DIN ISO 5832/12 screw: TiAl6V4 according to DIN ISO 5832/ MUTARS tibial stem, cementless mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ x 120 mm x 120 mm x 120 mm x 120 mm x 160 mm x 160 mm x 160 mm x 160 mm x 200 mm x 200 mm x 200 mm x 200 mm MUTARS tibial stem, cemented mat.: implavit ; CoCrMo-casting alloy acc. to DIN ISO 5832/ x 120 mm x 120 mm x 120 mm x 160 mm x 160 mm x 160 mm x 200 mm x 200 mm x 200 mm 24

27 IMPLANTS MUTARS Tibial spacer unicondylar, small mat.: implatan ; TiAl 6 V 4 acc.to DIN ISO 5832/ mm right/lat. left/med mm right/lat. left/med mm right/lat. left/med mm right/lat. left/med mm left/lat. right/med mm left/lat. right/med mm left/lat. right/med mm left/lat. right/med. MUTARS Tibial spacer, small mat.: implatan ; TiAl 6 V 4 acc. to DIN ISO 5832/ mm small right/left mm small left mm small left mm small right mm small right MUTARS Screw for Tibial spacer mat.: implatan ; TiAl 6 V 4 acc. to DIN ISO 5832/ für 5mm Spacer für 10-50mm Spacer MUTARS Femoral spacer mat.: implatan ; TiAl 6 V 4 acc. to DIN ISO 5832/ ll/rm distal size 3 10mm rl/lm ll/rm distal size 3 5mm rl/lm ll/rm distal size 4 10mm rl/lm ll/rm distal size 4 5mm rl/lm ll/rm distal size 5 10mm rl/lm ll/rm distal size 5 5mm rl/lm ll/rm L-Spacer size 3 10mm rl/lm ll/rm L-Spacer size 3 5mm rl/lm ll/rm L-Spacer size 4 10mm rl/lm ll/rm L-Spacer size 4 5mm rl/lm ll/rm L-Spacer size 5 10mm rl/lm ll/rm L-Spacer size 5 5mm rl/lm MUTARS screw for femoral spacer mat.: implatan ; TiAl 6 V 4 acc. to DIN ISO 5832/ MUTARS patella component cemented mat.: UHMW-PE acc. to DIN ISO 5834/

28 INSTRUMENTS MUTARS femoral joint instrument tray Größe MUTARS femoral joint instrument tray MUTARS modular tibia instrument tray I MUTARS modular tibia instrument tray II MUTARS modular tibia trial container MUTARS rigid drills

29 INSTRUMENTS MUTARS femoral trial right right right left left left MUTARS trial inlay standard small large MUTARS tibial trial m-o-m small standard large MUTARS tibial spacer trial mm small mm small mm small MUTARS tibial spacer trial mm rl lm mm ll rm mm rl lm mm ll rm mm rl lm mm ll rm mm rl lm mm ll rm MUTARS trial stem for femur/tibia /120 mm /120 mm /120 mm /160 mm /160 mm /160 mm /200 mm /200 mm /200 mm MUTARS Femoral spacer trial ll/rm L-Spacer size 3 10mm rl/lm ll/rm L-Spacer size 3 5mm rl/lm ll/rm L-Spacer size 4 10mm rl/lm ll/rm L-Spacer size 4 5mm rl/lm ll/rm L-Spacer size 5 10mm rl/lm ll/rm L-Spacer size 5 5mm rl/lm

30 INSTRUMENTS MUTARS Femoral spacer trial distal ll/rm size 3 10mm distal ll/rm size 3 5mm distal ll/rm size 4 10mm distal ll/rm size 4 5mm distal ll/rm size 5 10mm distal ll/rm size 5 5mm distal rl/lm size 3 10mm distal rl/lm size 3 5mm distal rl/lm size 4 10mm distal rl/lm size 4 5mm distal rl/lm size 5 10mm distal rl/lm size 5 5mm Distal femoral cutting block Femoral alignment guide Femoral alignment stylus MUTARS femoral box reamer Slide hammer Assembling block for stem Reamer Guide for long stem mm mm mm mm mm Reamer Sleeve mm mm mm mm MUTARS femoral extractor MUTARS femoral impactor Initiator drill 9 mm

31 INSTRUMENTS Osteotome Universal rasp MUTARS femoral reamer guide MUTARS femoral cutting block size size size 5 Femoral sizing guide / /6 Femoral resection guide size size size 5 MUTARS impactor for tibial joint Tibial cutting block I/M tibial guide / I/M tibial resection guide / Tibial reamer guide Fixation pins D:3,2 mm L: 77mm L: 97mm Primary alignment stylus 2/15 mm MUTARS tibial centralizer sleeve modular handle (4 pcs.)

32 INSTRUMENTS MUTARS setting instrument for PEinlay Hexagon screwdriver short 3,5 mm Saw capture 1,5 mm incl. handles Resection check MUTARS locking instrument for femoral component MUTARS tibial reamer Universal extractor Setting instrument for locking mechanism MUTARS positioner for locking mechanism MUTARS tibial punch hex driver 3,5mm Torque wrench ¼ adapter Zimmer/ Jakobs 7Nm ZJ Distance adapter magnetic mm mm modular mm 30

33 INSTRUMENTS MUTARS patellar drill MUTARS patellar drill guide MUTARS patellar clamp drill 126x3,2 mm pin inserter Pin extractor ic T-handle MUTARS intramedullary drill 310mm mm mm mm mm mm mm mm mm mm ic Adapter outside A/O, inside ic canulated MUTARS tibial drill MUTARS tibial drill sleeve MUTARS tibial extractor m-o-m

34

35

36 your local distributor: implantcast GmbH Lüneburger Schanze 26 D Buxtehude Germany phone: fax: internet: GENUXOPE *+E1ICGENUXOPE++* *+$$E1IC *