1. Pre-Operative Planning Skin Incision and Arthrotomy

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2 Stage of Operation 1. Pre-Operative Planning Skin Incision and Arthrotomy Femoral valgus angle confirmation Distal Femur Cutting Proximal Tibial Cutting Establish External Rotation Angle A/P Size Measurement A/P and Chamfer Cutting Posterior Stabilized Femoral preparation Tibia preparation Patella preparation Trial reduction Implantation Instruments Index

3 Pre-Operative Planning Use the U2 Radiographic templates overlay on the A-P radiographs to evaluate the angle between the anatomic axis and the mechanical axis. That can assist in use to assure the intramedullary alignment guide posited and to evaluate the implant size. Skin Incision and Arthrotomy The skin incision can be performed in various ways according to the surgeon s preference. Here demonstrates a typical mini incision fashion, which starts from the superomedial aspect of the patella, runs along the medial boarder of the patella and ends at the superior aspect of the tibial tuberosity. The manners of arthrotomy are also at the surgeon s disposal. Here shows the mini-midvastus approach, which is considered as an less invasive dissection while provides excellent exposure. Preliminary medial/ lateral capsular release, trimming off the marginal osteophytes and excision of cruciate ligaments and part of the menici all contribute to development of the operation field. With the knee flexed at 90 degrees, both distal femoral condyles can be exposed readily as being ready for starting the distal femur cutting. -1

4 Femoral valgus angle confirmation In preparing the femur, make sure the osteophytes on both sides of distal femoral condyle are removed after resecting the patient s anterior cruciate ligament. Use the starter to make a pilot hole. This hole is located slightly medial to the center of the intercondylar notch, approximately 5 to 7 mm to the origin of posterior cruciate ligament. Then, use the 8 mm Twist Drill to create an opening in the femoral canal. Standard for Adjustable Angle After removal of the drill, button up the T-handle to the Alignment rod and inserted into the femoral canal. With T-handle removed, insert the Femoral Intramedullary Alignment Guide onto the Femoral IM Rod and advance the guide close contact with the distal femoral condyle(s). Adjust the Femoral Intramedullary Alignment Guide to the desired valgus angle ( range: 0-11 ). With the guide position in a neutral rotation, fix the femoral interamedullary alignment guide with a 3.2 mm Steinmann Pin. Option for Fixed Angle After removal of the drill, then insert the femoral interamedullary alignment guides which have difference degree from 5 to 9 for convenience to obtain a central position that parallels with the femoral axis. Fix the femoral interamedullary alignment guide with spike when we confirm the ideal position. The rail track" design of Distal Femoral Cutting Guide can eliminate obstruction from the surrounding soft tissue. -2

5 Distal Femur Cutting Standard for Adjustable Angle Attach the Distal Femoral Cutting Guide to the Femoral IM Alignment Guide. Use two 3.2 mm Twist Drills to fix the Distal Femoral Cutting Guide. Then remove the Femoral IM Alignment Guide and the Femoral IM Rod. Resect distal femur along the slot of the Distal Femoral Cutting Guide with a 1.27 mm saw blade (mark a cutting amount of 9 mm). Option for Fixed Angle Insert the distal femoral alignment guide upper the femoral interamedullary alignment guide and attach the distal femoral cutting guide. Use two 3.2 mm twist drills to fix the distal femoral cutting guide. Then remove the femoral interamedullary alignment guide and distal femoral alignment guide. Resect distal femur along the slot of the distal femoral cutting guide with a 1.27 mm saw blade (mark a cutting amount of 9 mm). The Distal Femoral Cutting Guide is smaller size and provide in semiflexion position cutting. -3

6 Proximal Tibial Cutting Attach the Tibial Cutting Jig to the Tibial EM Alignment Guide. Fix the distal elastic clip of the Tibial EM Alignment Guide at the ankle joint around the supramalleolar area. The proximal end of the guide is transfixed with a short pin to center of the tibial plateau. After confirming the position of the Tibial Cutting Jig, fix it by two 3.2 mm Twist Drills. Nail with Spike in fixation pin hole for extra fixation, preventing any loosening due to blade vibration during the resection. Then release the clamp ring and remove the Tibial EM Alignment Guide. Resection of the tibia plateau is performed utilizing a 1.27 mm saw blade. Prior to resection, if the surgeon needs to increase or decrease the tibial resection thickness that can be use the +2 or-2 hole to reposition the Tibial Cutting Jig. -4

7 Establish External Rotation Angle Place the External Rotation Guide flush against the resected distal femur and the two feet rested flat against the posterior distal femoral condyles. Then create two fixation pin holes with a 3.2 mm Twist Drill. A/P Size Measurement Nail the Femoral Sizer in predrilled fixation pin holes and its stylus touching a proper position on the anterior femoral cortex to estimate the femoral component s size of implant. A/P and Chamfer Cutting Insert the chosen Femoral A/P Chamfer Cutting Guide in predrilled fixation pin holes. Nail the spike in the side holes of Femoral A/P Chamfer Cutting Guide to enhance the stability during resection. Then use a saw blade of 1.27 mm to complete four resection procedures accordingly. -5

8 Posterior Stabilized Femoral Component Preparation PS Femoral Notch Guide Positioning Assemble the Cr Femoral Trial to the Femoral Driver. Introduce the Trial in an aligned fashion onto the femur. Carefully advance the Trial with a mallet. The Femoral Impactor may also be used for seating. Check the Trial for flush contact with the femur. Once confirmed, femoral and tibial trialing may be conducted in a standard fashion. Engage the PS Cutting Jig Drill Guide onto the CR Femoral Trial, leaving a 3.2 mm Twist Drill in place to position the PS Notch Cutting Guide. Remove the Femoral Trial and position the PS Notch Cutting Guide, onto the two drills. Additional Pins are now used to secure the Guide in position. Insert the PS Reamer first into the anterior guide slot in the Ps Notch Guide. Advance the PS Reamer under drill power until it is seated flush with the Guide. The PS Reamer is then inserted in the same manner into the posterior guide slot. A visual clearance of complete bone removal is advised. The PS Housing Punch is now inserted into both the anterior and posterior Guide slot to complete all bone removal. The PS Housing Impactor is now inserted to verify complete clearance of bone. Tibial Preparation Initial Tibial Baseplate Trial Insertion Select the Tibial Baseplate Trial that best provides maximum coverage of the proximal tibia. Once selected, attach the Tibial Trial Handle to the Tibial Baseplate Trial and reposition this assembly onto the tibia. Attach the Tibial Trial Handle to the Tibial Baseplate Trial and insert the Alignment Rod into the Tibial Trial Handle to further evaluate the proper position. Determination of Final Tibial Baseplate Location and Tibial Stem Space Creation The Tibial Punch Handle and appropriate size Tibial Punch are then assembled. This assembly is then carefully impacted into the stem hole. Once completed, the Tibial Punch and Tibial Punch Handle are removed. -6

9 Patellar Preparation Inset Type Patellar Component In using the inset type patellar component, attach the selected diameter Patellar Clamp Ring and the Anterior Patellar Clamp Head to the Clamp. Position the Ring, aligning the center of the Ring with the center mark previously created. The anterior-posterior direction of the Clamp is accessed and then clamped securely into position. Place the corresponding diameter Depth Sleeve onto the Ring, align the keyway slots, and completely seat. The Patellar Reamer and the Reamer Stopper are loosely assembled and positioned into the Ring to establish the depth of advancement of the Reamer. Allow the Reamer to contact the patellar surface. The Stopper is allowed to slide into contact with the face of the Depth Sleeve. The Stopper is then securely tightened with the Screw driver. The Depth Sleeve and Reamer are now removed for center hole drilling. -7

10 The Patellar Drill Guide is now positioned into the Ring and the Patellar Drill is fully inserted to create the center peg hole. Once drilling is completed, the Reamer is reintroduced into the Ring for creation of the inset patellar bed. Under power, carefully advance the Reamer and Stopper assembly into the patellar bone until the Stopper contacts the Ring. NOTE: The Reamer and Stopper will create a recess depth equal to the thickness of the selected diameter implant. In addressing a small patella, care should be taken to retain at least 8 mm of patellar bed thickness. In some patients, it may be necessary to adjust the Patellar Reamer Stopper manually. The patellar Resection Clamp is now removed and the INSET Patellar Trial is positioned into the prepared bone bed. The peripheral bone shoulder surrounding the INSET patellar trial is accessed, and may be trimmed to achieve a smooth blending of the implant periphery to the boney shoulder. A thickness measurement of the implant/bone couple may be performed to assure the original patellar A-P thickness has been recreated. Trial evaluation is conducted in a standard fashion. -8

11 Onset Type Patellar Component Evert the patellar and remove excessive osteophytes. With a Caliper, measure and record the thickness of the patella. NOTE: In planning the resection thickness, it is recommended to retain a 10 mm minimal thickness of retained patella bone to support the implant structure. The Onset Cutting Guide Jaws are mounted onto the Patellar Clamp along with the Feeler Index corresponding to the thickness of the intended implant diameter. The Clamp is then introduced onto the patella and the Feeler Index is held in contact with the posterior patellar surface. The A-P direction of the Clamp is evaluated. The Clamp is then stably clamped into position. A.050" thick saw blade is carefully guided through the slots for the resection. Once the resection is complete, the Patellar Clamp is removed from the bone and the Onset Cutting Guide Jaws are removed from the Clamp. The Tri-Peg Modular Drill Guide and Anterior Patellar Clamp Ring are mounted onto the Clamp, and the assembly is then repositioned onto the patella to perform the tri-peg drilling. (As an alternative, the hand-held Patellar Drill Guide may be used.) The Tri-Peg holes are now drilled with the collared Peg Drill. The Onset Patellar Trial may now be positioned, assessing the contact and stability of the bone/implant couple. A thickness measurement of the implant/bone couple may be erformed to assure the original patellar A-P thickness has been re-established. Trialing is performed in a standard fashion. -9

12 Final Trial Reduction With the selected femoral, tibial and patellar Trials in position, a final trial assessment is performed. The joint is thoroughly examined, the trials are then removed and the bone is prepared for final implantation. Implant Fixation All Implants are indicated for cemented fixation. To impact the Tibial Baseplate, it is recommended to carefully introduce and align the stem of the implant into the prepared stem hole. The implant may be positioned by hand or by using the Tibial Baseplate Driver. Once the Tibial Baseplate is advanced sufficiently, the Tibal Baseplate Impactor may then be used to complete seating of the implant. To impact the Femoral Implant, the Femoral Implant Driver is assembled onto the Femoral Implant. Carefully align the femoral implant with the distal femur to assure correct advancement and seating of the implant. The Femoral Impactor may also be used for seating if desired. The Patellar Implant is first seated by hand, carefully aligning the implant peg(s) with the prepared bone bed. The Patellar Clamp is equipped with the Cement Clamp Adaptor and the Anterior Compression Head. This assembly is then used to fully seat the cemented implant in a standard fashion. Femoral Tibial trialing may now be performed again if desired. Prior to insertion of the final Tibial Insert, place the knee in a flexed position and be sure to adequately retract soft tissues to allow proper visualization of the Tibial Base peripheral locking detail. It is recommended to initially introduce the Tibial Insert by hand onto the Tibial Base. Once initial engagement with the locking detail is verified, the grooved Tibial Insert Impactor may be used to fully seat the Insert. All areas of the assembly are then visually assessed for complete seating and locking detail engagement. -10

13 MISTKA Instruments Index Standard : Adjustable Angle Femoral IM alignment guide Option : Fixed Angle Femoral IM alignment guide, 5, right Femoral IM alignment guide, 7, right Femoral IM alignment guide, 9, right Femoral IM alignment guide, 5, left Femoral IM alignment guide, 7, left Femoral IM alignment guide, 9, left Distal femoral alignment guide Distal femoral cutting guide

14 External Rotation guide, 3 9mm Femoral sizer,posterior ref Femoral A/P chamfer cutting guide, # Femoral A/P chamfer cutting guide, # Femoral A/P chamfer cutting guide, # Femoral A/P chamfer cutting guide, # Femoral A/P chamfer cutting guide, # Femoral A/P chamfer cutting guide, # Chamfer guide extractor

15 Tibial EM alignment guide Tibial cutting jig, open slot, 0, Right Tibial cutting jig, open slot, 0, Left U2 MIS Knee Case

16 Each Step We Care Contact Us Taiwan United Orthopedic Corporation 12F, No.80, Sec.1, Chenggong Rd., Yonghe Dist., New Taipei City 23452, Taiwan Tel: Fax: China United Medical Instrument Co., Ltd. Room 402, Building 7, No.697, Ling Shi Road, ShangHai , China Tel: Fax: Japan United Biomech Japan Inc. Ginyo Bldg 4th floor, Kitasaiwai, Nishi-Ku Yokohama City, Kanagawa, , Japan Tel: Fax: USA UOC USA Inc. 20, Fairbanks, Suite 173, Irvine 92618, CA Tel: Fax: EU Representative mdi Europa GmbH Langenhagener Strasse 71, Langenhagen 30855, Germany Tel: Fax: Europe UOC (Suisse) SA Avenue Général Guisan 60A, Pully 1009, Switzerland Tel: Fax: UOC (France) 21, Rue de la Ravinelle, Nancy 54000, France Tel: Fax: Copyright 2017 United Orthopedic Corp. All rights reserved. UOC-UM-UN Rev.0 SEP. 2017