KRI M-O-M knee reconstruction implant surgical technique Femorotibial M-O-M coupling

Transcription

1 knee reconstruction implant surgical technique Femorotibial M-O-M coupling

2

3 knee reconstruction implant surgical technique Femorotibial M-O-M coupling MUTARS was developed in co-operation with Prof. Dr. W. Winkelmann (former director) and Prof. Dr. G. Gosheger (director), Clinic and Polyclinic for General Orthopedics and Tumororthopedics at the University Hospital of Münster, Germany. MUTARS has been in successful clinical use since Table of Contents Table of Contents...1 Information About the Silver Coating...2 System overview...3 Surgical technique...5 Implants...21 Instruments...25 Nota Bene: 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 note: MUTARS, implavit and implatan are registered trademarks of implantcast GmbH. The use and copy of the content of this brochure are only allowed with prior permit given by the implantcast GmbH. 1

4 The Silver coating Early and late infections represent the most severe complications of tumour arthroplastic treatments. Although local and systemic antibiotic treatments are considered, the scientific literature reports of infection rates from 5 to 35 percent. Reasons for these high rates are, for example, the long surgery time, the large incisions and the immunosupression due to chemo therapy and radio therapy as well as the increasing resistance of the bacteria against antibiotic drugs. The anti-infective effect of silver ions has been known for centuries i.e. the disinfection of potable water is based on this principle. This special property of silver is used for the silver coated components of MUTARS to build an intelligent protection against bacteria. Created by Brownian motion of the electrons of the silver coating, silver ions emerge on the prosthetic surface binding to electronegative groups of proteins, enzymes and the DNA of the bacteria. Until now only non-articulating surfaces and surfaces without direct bony contact are coated with silver. In the catalogue information of this brochure you can find the supplement *S indicating which MUTARS components are available in a silver coated version. The eight digit REF number receives an addition after the last digit (e.g S). It is not permitted to flush the wound with antiseptics that contain Iodine or heavy metals (such as Betaisodona ) Iodine and Silver form insoluble salt complexes not only with the silver ions that are released postoperatively but also with the silver layer of the implant that will be covered with an insoluble silveriodine (AgI) film. This will destroy the anti-adhesive protective layer irreversibly. Iodine or heavy metal based antiseptics may not be used at any time. Alternatively solutions containing H 2 O 2 (like Lavasept, Prontosan or similar) can be used. The silver coating can be destroyed in its function by two factors: large amounts of albumin from seroma or hematoma can bind larger amounts of silver (1 mol Albumin inactivates 3 moles Silver ions). This should be minimized by using an attachment tube. In the instance that an infection is known pre-operatively, antibiotics like Vancomycin can be mixed with the bone cement. The intramedullary stems are not silver coated and cemented components are preferred in case of a septic revision. The TiN coating for allergy prophylaxis As the metallic components of total knee replacements, the articulating metallic parts of the MUTARS system are made of casted CoCrMo alloy. In the late 70 s and 80 s of the last century, some of the Cobalt Chromium implants had a small Nickel content to add strength to the implant. Nickel is the primary cause for metal sensitivity, although some patients have shown to be hypersensitive to other metals such as Cobalt and Chromium. The use of titanium components can t solve this problem, because the wear of the articulating polyethylene inlays will increase and so the survival time of the prosthesis is reduced. Since the end of the 1990 s TiN (Titanium Nitride coating) has been successfully applied to protect the body against metal ions that could cause allergic reactions. The metal ion release of TiN coated or TiNbN coated implants is reduced down to 10%. 1 In order to prevent allergic reactions, certain parts of the prosthesis may be supplied with a ceramic coating (TiN). Since almost all components of the tumor system consist of titanium alloy, this only concerns those components, which are made of a cast CoCr alloy (CoCrMo). The REF-numbers of the TiN coated implants have the suffix N after the last digit (e.g N). *S: For anti-infective treatment, silver coated implants are available. *N: For anti-allergic treatment, TiN coated implants are available. 1 Metal Ion Release from Non-Coated and Ceramic Coated Femoral Knee Components: Boil test 240h in NaCl-solution nach FMZ PhysWerk VA 97350, University Würzburg (D) (On File) 2

5 System Overview RS stem ø14-20mm cementless ø12-18mm cemented KRI for locking mechanism 75mm M-O-M locking mechanism 15mm 50mm PE-inlay tibial plateau m-o-m small, standard, large cemented stem for tibial plateau length: 120, mm ø12-18mm cementless ø11-15mm cemented tibial spacer 25, 35, 50 mm (bicondylar) 5,10,15,20 mm (unicondylar) Note: Please notice that the amount of implants and instruments send with an individual shipment may differ from the information in the catalogue information of this brochure. Please make sure, during the preoperatively planning, that all necessary implants and instruments are available for the surgery. 3

6

7 Distal femoral resection Resect the amount of 75mm of the distal femoral condyles. If the upper part of the KRI shall be inserted in the medullary cavity a resection can be minimized to 50mm (see page 1). Remove the menisci. Tibial bone preparation Open the tibial medullary cavity with the universal drill 6 mm (fig. 1a and 1b). The drilling should be orientated to open the center of the medullary cavity (eminentia intercondylaris: ventral 1/3, dorsal 2/3). figure 1a and 1b Enlarge the opening of the medullary cavity with rigid drills (fig. 2a and 2b). To choose the correct reamer size for the use of a cementless tibial stem consult table 1, for the use of a cemented tibial stem consult table 2. Table 1: cementless implantation Tibial stem 12 mm drill 11 mm Tibial stem 14 mm drill 13 mm Tibial stem 16 mm drill 15 mm Tibial stem 18 mm drill 17 mm figure 2a and 2b 1 Table 2: cemented implantation Tibial stem 11 mm drill 13 mm Tibial stem 13 mm drill 15 mm Tibial stem 15 mm drill 17 mm Tibial stem 17 mm drill 17 mm To ascertain adequate depth is met, the drills have depth marks (120 mm for 120 mm stems, 160 mm for 160 mm stems and 200 mm for 200 mm stems) corresponding with the tibial stem length (fig. 2a and 2b). The last drill used is left in the tibial canal. 5

8 The tibia resection block1 0 is attached to the intramedullary tibial alignment guide2 and the cutting block is placed over the tibial drill that was left in the intramedullary canal. Adjust the rotational alignment and lock the alignment guide by inpacting the two spikes into the tibial surface. Mount the tibial resection stylus3 onto the resection block. 2 figure 3a 1 3 For the primary procedure make sure the 15 mm tip is resting on the highest point of the higher plateau, mainly the lateral side of the joint. Using this technique the 2 mm tip 4 faces from the bone (fig. 3b). 4 figure 3b Please insert the fixation pins in the marked level to fix the block to the bone. Remove the tibial resection stylus. If necessary please use the 3,2mm drill to predrill the holes. Make sure that enough bone (app. 15mm) is cut from the tibia (fig. 4). 5 figure 4 6

9 Double check the resection angle and height by using the resection check (fig. 5). figure 5 Mount the saw capture onto the resection block. Use the ACS saw blade to resect the bone. Prevent damaging of the intramedullary drill. If necessary please remove the drill before resectioning (fig. 6). figure 6 Please check the quality of the cut. Make sure that the cut is totally flat and remove the resection block. The resected tibia is checked and the reamer guide with the tibial centering guide is slid over the tibial reamer in place. (fig. 7). The mark MEDIAL should be placed on the medial side. figure 7 7

10 The right mediolateral alignment should be established and the tibial reamer guide is fixed with two pins (fig. 8a). The tibia reamer guide and the intramedullary tibial reamer are now removed. Use of tibial spacer 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. figure 8a figure 8b Combine the tibial reamer and the T- handle and ream carefully until the reamer is stopped by the chimney of the reamer (fig. 9a and 9b). It is strongly recommended not to use power tools for the reaming. figure 9a figure 9b 8

11 The tibial fin 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. Remove all instruments. figure 11a figure 11b 9

12 Preparation of the distal femur Drill the femoral medullary cavity using a flexible medullary reamer 3mm smaller than the diameter of the preoperatively chosen cementless RS-stem (fig. 12). Connect the slide hammer with the broach which is of the same size as the chosen cementless stem (fig. 13). For cemented use prepare the cavity with a reamer which is 1mm smaller than the cemented RS stem (fig. 12). Connect the slide hammer with the broach which is one size larger than the chosen stem (fig. 13). figure 12 Prepare the medullary cavity with the RS broach. The mark 50mm shows the joint line of the prosthesis. If an extension piece of 25mm has been planned refer to the 75mm mark of the broach (fig. 14). 50mm figure 13 figure 14 10

13 Trial reduction Connect the RS stem with the KRI through the taper connection (fig. 15a). Consider the curvation mark on the stem and the KRI to meet the correct femoral alignment. (If a 25mm extension piece shall be used, please add it between the stem and the KRI) (fig. 15a). Do not insert the screw for trialing, this allows an easy readjustment of the femoral rotation afterwards. Impact the components into the femoral bone using the impactor (fig. 15b). figure 15a and 15b If the stem should be implanted separately please connect the stem to the impactor and impact the stem (fig 16a). Please mount the KRI and the optional extension sleeve onto the stem (fig. 16b). For a minimized bone resection the proximal part of the KRI component can be inserted into the distal femoral bone (fig. 17). figure 17 figure 16a and 16b 11

14 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. 18). 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. 18). figure 18 The tibial trial and stem can be inserted using the tibial impactor (fig. 19a and 19b). figure 19a figure 19b The corresponding trial inlay is now placed on the tibial trial implant (fig. 20a), using the PE-inlay setting instrument (fig. 20b). Perform a trial reduction to assure that the correct femoral rotation is achieved and the joint line is restored in the correct height (fig. 21). Remark Please notice that a coupling of the joint components is not possible at this stage when using the trial components. At a later stage the joint stability can be checked using the final implant components and the locking mechanism. figure 20a figure 20b figure 21 12

15 Remove the trial inlay. Screw the slide hammer into the tapered hole of the trial plateau and remove the trial components (fig. 22a and 22b). figure 22a figure 22b Tibial component assembly Attach the selected tibial stem onto the cone of the tibia component and connect the two parts with the screws provided. A torque wrench 3.5 mm hex screw driver (fig. 24) should be used. Any tibial spacers should be added in the same way (fig. 23). figure 23 13

16 Impact the tibial components with the tibial impactor (fig. 24a and 24b). After cement hardening, insert the PE- Inlay in the tibial joint. Insert the inlay from behind, move it forward towards the anterior locking rim and push down upon the posterior part until it is locked securely (fig. 25a). Consider using the impactor for PE-Inlay (fig. 25b). Although trial inserts are available, it is recommended to insert the final PE-inlay at this time in order to reduce the surgery time. figure 24a figure 24b figure 25a figure 25b 14

17 Implantation of the femoral components Connect the KRI and the RS stem in the correct rotational alignment. Insert the 25mm bar screw (fig. 26a) (50mm bar screw if an extension piece is used) and lock it with the swing wrench and the counter instrument (fig. 26b). figure 26a and 26b Insert and lock the safety screw in the same way (fig. 27a and 27b). figure 27a and 27b 15

18 Assemble the MUTARS locking mechanism and the special MUTARS instrument for locking mechanism. Therefore turn the attachment part of the lock by 110 degrees until it rests in the sleeve of the locking instrument (fig. 28a). figure 28a Insert the lock into the intracondular notch of the femoral joint (fig. 28b). j figure 28b Use the socket wrench to turn the locking instrument and the lock clockwise by 180 degrees (fig. 29). figure 29 16

19 The lock is correctly positioned when the attachment part falls out of the sleeve of the locking instrument (fig. 30a). Remove the locking instrument. 1 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. 30b). figure 30a figure 30b The coupling mechanism should be fully engaged and placed in the correct rotational position. The screw hole (1) (fig. 30a) should be placed turned forward to enable locking (fig. 30b). The positioner is inserted into the screw hole of the short stem of the coupling mechanism (fig. 31 and 32). figure 31 figure 33 figure 32 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. 33). Be sure that the locking bolt is fully engaged into the tibia component (fig. 34). figure 34 17

20 A hexagonal torque wrench 3.5 mm hex screw driver is used to screw in the Multilock security screw and to tighten the locking bolt (fig. 35a and 35b). figure 35a figure 35b The implantation of the implant is now concluded. Stability and range of motion should be performed in flexion (fig. 36a) and extension (fig. 36b). figure 36a figure 36b 18

21 Removal of an implant In case a tibia component should be removed the Multilock security screw and the locking bolt should be removed ventrally using the torque wrench 3,5mm hex screw driver. The locking instrument is then used to remove the locking mechanism from the femoral component.. figure 37a The femoral component can now be removed using the slide hammer and the special extractor (fig. 37a and 37b). The tibial extractor is now attached to the slide hammer and placed into the screw hole of the tibial component (fig. 37a). figure 37b The attachment is secured using the rod with the small chain (fig. 37b). The tibial component is now removed using the slide hammer (fig. 37c). figure 37c 19

22

23 IMPLANTS *S: For anti-infective treatment, silver coated implants are available. *N: For anti-allergic treatment, TiN coated implants are available. RS stem cementless mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ /150 mm /150 mm /150 mm /150 mm /200 mm /200 mm* /200 mm* /200 mm* /250 mm /250 mm* /250 mm* *marked length 200 and 250 mm with locking screw holes RS stem cemented *N mat.: implavit ; CoCrMo-casting alloy according to DIN ISO 5832/ /150 mm /150 mm /150 mm /150 mm /200 mm /200 mm /200 mm /200 mm RS extension piece *S mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ mm RS extension piece mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ mm KRI M-O-M *N mat.: implavit ; CoCrMo-casting alloy according to DIN ISO 5832/ right left 21

24 IMPLANTS MUTARS PE-inlay mat.: UHMWPE according to DIN ISO 5834/ small standard large MUTARS locking mechanism m-o-m incl. screw mat.: implavit ; CoCrMo-casting alloy according to DIN ISO 5832/4 screw: TiAl6V4 according to DIN ISO 5832/ MUTARS patellar component, cemented Mat.: UHMW-PE acc. to DIN ISO 5834/ Intramedullary plug Mat.: UHMW-PE acc. to DIN ISO 5834/ small large MUTARS tibial spacer, unicondylar *S Mat.: implatan ; TiAl 6 V 4 nach DIN ISO 5832/ mm rl/lm mm rl/lm mm rl/lm mm rl/lm mm ll/rm mm ll/rm mm ll/rm mm ll/rm. MUTARS tibial spacer small *S Mat.: implatan ; TiAl 6 V 4 acc. todin ISO 5832/ mm small right/left mm small left mm small left mm small right mm small right MUTARS screw for tibial spacer M-O- M Mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ for 5mm spacers for mm spacers 22

25 IMPLANTS screw for KRI mat.: implatan ; TiAl 6 V 4 according to DIN ISO 5832/ M 8 x 25 mm M 8 x 50 mm MUTARS tibial plateau m-o-m *S cemented mat.: implavit ; CoCrMo-casting alloy nach DIN ISO 5832/ small standard large MUTARS screws for tibial plateau m-o-m (2 pcs) mat.: implatan ; TiAl 6 V 4 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 *N mat.: implavit ; CoCrMo-casting alloy according 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 23

26

27 INSTRUMENTS MUTARS KRI instrument tray MUTARS RS instrument container MUTARS RS instrument container MUTARS modular tibia instrument container I MUTARS modular tibia instrument container II

28 INSTRUMENTS MUTARS rigid drills MUTARS tibia modular trialcontainer

29 INSTRUMENTS 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 /120 mm /120 mm /120 mm /160 mm /160 mm /160 mm /200 mm /200 mm /200 mm KRI M-O-M trial implant rechts links trial locking mechanism

30 INSTRUMENTS MUTARS tibial impactor MUTARS femoral impactor MUTARS RS broach /150mm /150mm /150mm /150mm /200mm /200mm /200mm /200mm MUTARS slide hammer for RS MUTARS RS stem impactor MUTARS RS broach handle MUTARS RS stem extractor adapter MUTARS RS guide rod MUTARS RS socket wrench SW MUTARS RS reamer for metaphyseal part MUTARS extractor device

31 INSTRUMENTS MUTARS socket wrench MUTARS swing wrench handle for intramedullary plug MUTARS tibial drill MUTARS tibial drill sleeve MUTARS tibial extractor m-o-m MUTARS RS extractor for KRI for locking mechanism MUTARS femoral extractor for femoral component MUTARS locking instrument for femoral component setting instrument for locking mechanism MUTARS positioner for locking mechanism

32 INSTRUMENTS hexagon screw driver 3,5mm torque wrench ¼ adapter Zimmer/ Jakobs 7Nm ZJ hexagon screw driver angled 3,5 mm MUTARS impactor for PE Inlay MUTARS patella drill MUTARS tibial centering guide MUTARS tibial reamer tibial resection block ,2 mm fixation pins (4 pcs.) Tibia stylus 2/15 mm ic T-handle Tibial reamer guide

33 INSTRUMENTS MUTARS Tibial fin punch saw capture 1, resection check I/M tibial alignment guide MUTARS universal drill 6 mm Pin inserter Pin extractor MUTARS patella clamp MUTARS patella drill guide ic adapter male A/O, ic cannulated drill 126x3,2 mm (2 pcs.) rigid drill mm mm mm mm mm mm mm mm mm 31

34 INSTRUMENTS KRI trial screw mm mm MUTARS KRI disassembly instrument MUTARS counter instrument KRI M-O-M ACS Tibial drill

35

36 Your local distributor: implantcast GmbH Lüneburger Schanze 26 D Buxtehude Germany phone: fax: internet: MUTM3OPE *+E1ICMUTM3OPE++* *+$$E1IC *