S URGICAL T ECHNIQUE FOR USE WITH

®
P. F. C. S IGMA ™ K NEE S YSTEMS

Primary Cruciate-Retaining &

Cruciate-Substituting Procedure

SPECIALIST ®
INSTRUMENTS
CRUCIATE-RETAINING PROSTHESIS DESIGNED BY

RICHARD D. SCOTT, MD THOMAS S. THORNHILL, MD

Professor of Orthopaedic Surgery, John B. and Buckminster Brown Professor of Orthopaedics,
Harvard Medical School Harvard Medical School

Orthopaedic Surgeon, New England Baptist Orthopaedist-in-chief

Hospital and Brigham and Women’s Hospital Brigham and Women’s Hospital

Boston, Mass. Boston, Mass.

CRUCIATE-SUBSTITUTING PROSTHESIS DESIGNED BY

CHITRANJAN S. RANAWAT, MD

Clinical Professor of Orthopaedic Surgery

Cornell University Medical College

Chairman, Department of Orthopaedic Surgery

Ranawat Orthopaedic Center
Lenox Hill Hospital
New York, N.Y.
CONTENTS

Introduction 1

Primary Cruciate-Retaining Procedure 4

Primary Cruciate-Substituting Procedure 41

Appendix I: Ligamentous Balance in Total Knee Arthroplasty 81

Appendix II: The External Femoral Alignment System 90

Appendix III: Intramedullary Alignment Device 91

Appendix IV: Extramedullary Tibial Alignment Device

with Proximal Fixation Spike 96

Appendix V: Femoral and Tibial Insert Compatibility Charts 99

Appendix IV, Surgical Technique, edited by William L. Healy, MD, Chairman,

Department of Orthopaedic Surgery, Lahey Hitchcock Medical Center, Burlington, Mass.
SPECIALIST 2 TECHNIQUE
®

INTRODUCTION
Total knee replacement is performed on a range The P.F.C.® Total Knee Systems were designed
of patients, of all ages, with various pathologies as comprehensive approaches allowing intraop-
and anatomical anomalies. As no single arthro- erative transition from PCL retention to PCL
plastic approach is appropriate for every knee, substitution. The major difference in the design
the surgeon must be prepared, as the situation for the two prostheses is the incorporation of an
indicates, to preserve or substitute for the intercondylar post in the PCL substituting tibial
posterior cruciate ligament. PCL sacrifice is insert and its corresponding intercondylar
indicated in patients with severe deformity, receptacle in the femoral component, to com-
pronounced flexion contracture and in the pensate for the stabilizing restraint of the PCL.
greater number of revision cases. Most primary They were also designed to provide greater
and some relatively uncomplicated revision restraint in cases of revision surgery, and to
cases are suitable for cruciate-sparing proce- meet the most demanding clinical and institu-
dures. Where the ligament is to be preserved, tional requirements.
it is essential that its balance in flexion be
confirmed. A single integrated set of instruments, the
Specialist® 2 Instruments, was designed to
make fully accurate bone resection and to
accommodate most surgical techniques
and contingencies.

1
CRITERIA FOR SUCCESSFUL TKR BALANCING THE KNEE
Appropriate Sizing of Components The appropriate level of prosthetic constraint is
This is attained through critical approximation determined through preoperative evaluation
of the A/P dimension of the femoral compo- subject to intraoperative confirmation. Where
nent to the lateral femoral profile. Undersizing soft-tissue constraint is identified, the system is
will create looseness in flexion and possible designed to effectively address it.
notching of the femoral cortex. Oversizing will
create tightness in flexion and increased excur- Primary Cruciate-Retaining TKR
sion of the quadriceps mechanism. employs a posteriorly lipped insert, designed
for situations where the PCL is functionally
Accurate Component Alignment intact. Where there is tightness in the PCL, a
This is accomplished by resection of the distal posterior cruciate recession is indicated (see
femur in the appropriate degree of valgus as Appendix I).
determined by preoperative evaluation, and
resection of the proximal tibia at 90˚ to its Primary Cruciate-Supplementing TKR
longitudinal axis. uses a curved insert with improved contact area
to supplement the PCL where the ligament has
Soft-Tissue Balance sufficient functional laxity to accommodate the
This is realized through the careful sequential greater conformity.
release of medial constraining elements in
varus deformity and lateral structures Primary Cruciate-Substituting TKR
in valgus. incorporates a central polyethylene eminence in
the tibial insert to perform the function of an
Accurate Patellar Tracking absent PCL. The corresponding femoral compo-
This is effected through accurate positioning nent uses A/P cuts and chamfers identical to
of the femoral and tibial components, precise those of the PCL-retaining component, allowing
resurfacing of the patella, careful trial evalua- ready transition without revision of the pre-
tion and, where indicated, lateral retinacular pared implantation site.
release.
Revision TKR
Dependable Cement Fixation The geometry of the tibial insert allows for
This is achieved through controlled technique substitution of the PCL and/or MCL in revision
that ensures the establishment of comprehen- and complex primary situations. The selection
sive bone/cement/prosthesis interlock. of modular tibial and femoral stems and wedges
will accommodate virtually any revision con-
sideration. The system offers three levels of
constraint to meet the varied requirements of
revision cases: stabilized, constrained or TC3.

2
PREOPERATIVE PLANNING INSTRUMENTATION RATIONALE
Full-length extremity roentgenograms are Specialist 2 instrumentation was designed to
obtained and the mechanical and anatomic axes address the requirements of all total-knee
identified. Where the intramedullary alignment replacement procedures, to fully assure precise
system is selected, the angle of the anatomic and dependable resection of the recipient bone
and mechanical axes indicates the appropriate and to serve a variety of surgical options. The
angle to be used in conjunction with the intra- instruments can be customized to meet any spe-
medullary rod and the femoral locating device, cial requirements of the individual surgeon.
thereby assuring that the distal femoral cut will
be perpendicular to the mechanical axis. It is Preparation may be initiated at either the femur
helpful to draw the femoral and tibial resection or the tibia. The instruments may be employed
lines on the film as an intraoperative reference. with either the intra- or extramedullary align-
ment approach. Bone resection is made at the
Radiographic templates are overlaid on the appropriate level as determined through a cali-
films to estimate the appropriate size of the brated stylus assembly. A selection is offered of
prosthesis. The femoral component is sized on slotted and surface-cutting blocks. Spacer blocks
the lateral view. The A/P size is critical to the are provided for extension and flexion gap eval-
restoration of normal kinematics and quadri- uation. Patellar instrumentation is available for
ceps function. compatible preparation of either resurfaced or
inset patellar implants.

3
PRIMARY CRUCIATE-RETAINING PROCEDURE

RICHARD D. SCOTT, MD

Professor of Orthopaedic Surgery,

Harvard Medical School

Orthopaedic Surgeon, New England Baptist

Hospital and Brigham and Women’s Hospital

Boston, Mass.

THOMAS S. THORNHILL, MD

John B. and Buckminster Brown Professor of Orthopaedics,

Harvard Medical School

Orthopaedist-in-chief
Brigham and Women’s Hospital

Boston, Mass.

4
THE SURGICAL APPROACH

The skin incision is longitudinal and, where The joint is entered through a medial para-
possible, straight. It is initiated proximally from patellar capsular approach, extended proximally
the midshaft of the femur and carried over the to the inferior margin of the rectus femoris
medial third of the patella to the medial margin and distally to the medial margin of the tibial
of the tibial tubercle. tubercle.

N.B. Where indicated, the subvastus or the lateral approach may be used.

5
EXPOSURE

Exposure and preliminary balance must be

based on the patient’s preoperative deformity
and soft-tissue stability. The following is for
mild varus deformity.

N.B. See Appendix I for discussion of soft-tissue

balance.

With the knee in extension, the patella is

everted laterally. The medial tibial periosteum
is elevated and a narrow 90˚ Hohmann retrac-
tor positioned subperiosteally around the
medial border of the medial condyle. Residual
periosteum is dissected posteromedially to the
level of the insertion of the semimembranosus.
The knee is flexed and a partial meniscectomy
performed. Any residual ACL is excised.

With the knee in 90˚ of flexion,

the tibia is externally rotated
with posteromedial dissection,
bringing its medial condyle
clear of the femur. Medial
meniscectomy is completed,
and attention directed to the
lateral side.

6
A 90˚ Hohmann retractor is positioned
between the everted patella and the distolat-
eral femur, exposing the lateral patellofem-
oral ligament, which is incised with
electrocautery.

The retractor is repositioned at the

interval of the iliotibial tract and the
tibial attachment of the capsule.
The capsule is dissected free from the
infrapatellar fat pad and a lateral
meniscectomy is performed. The lat-
eral inferior genicular artery is coagu-
lated. The insertion of the iliotibial
tract is identified and the capsule dis-
sected from the lateral tibial condyle.
The retractor is repositioned against
the lateral tibial condyle.

7
ENTERING THE MEDULLARY CANAL

The medullary canal is entered at the midline

of the femoral trochlea 7–10 mm anterior to the
origin of the PCL to a depth of about 5–7 cm
using a 5/16" drill.

Care is taken that the drill avoids the cortices.

It is helpful to palpate the distal femoral shaft
as the drill is advanced. The drill hole may be
biased anteromedially to facilitate unobstructed
passage of the long intramedullary rod to the
diaphyseal isthmus, if indicated by pre-
operative X-rays

8
THE INTRAMEDULLARY ROD

With the handle assembled onto the long

intramedullary rod, the rod is introduced
slowly into the canal to the level of the isthmus
to confirm unobstructed passage. The rod is
fluted to relieve intramedullary pressure and
permit the release of bone matter, avoiding
embolization. It is subsequently withdrawn.

THE FEMORAL LOCATING DEVICE

The valgus angle with the appropriate

Right/Left designation, as indicated on the pre-
operative films, is set and locked into place on
the front of the locating device. The angle can
be set from 0 degrees to 9 degrees in one degree
increments.

With the rod repositioned in the medullary

canal, the handle is removed and the locating
device is placed over the rod.

9
THE EXTERNAL ALIGNMENT SYSTEM

A radiopaque marker is positioned over the

ipsilateral hip, parallel and immediately distal
to the inguinal ligament. An A/P roentgeno-
gram indicates which of four markers most
closely approximates the rotational center.

At surgery, the femoral-head locating strip is

aligned with the markers. A target screw is
introduced into the position overlying the rota-
tional center. Draping is such that the screw is
readily palpated as the coxal reference point.

The alignment tower is assembled onto

the femoral locating device. The align-
ment rod is passed through the hole and
advanced to the hip. Where the rod fails
to align with the coxal reference point,
a different angle is selected.

N.B. Where indicated, as in femoral deform-

ity, 0˚ is selected and a short intramedullary
rod is substituted. See Appendix II.

10
ROTATIONAL CORRECTION

Orientation is initially determined with refer-

ence to the posterior femoral condyles, subject
to subsequent correction at the A/P resection.
The calibrated outrigger is centered at the
femoral trochlea, placing it in slight external
rotation and exposing a greater amount of
medial condyle.

Alternatively, it may be externally rotated until

perpendicular to the mechanical axis of the tibia
in 90˚ of flexion.

The femoral locating device is tapped into

position at the more prominent condyle
(usually the medial).

N.B. It is essential that firm contact be established

at the subchondral level of the condyle, clear of any
residual peripheral osteophytes.

11
THE DISTAL FEMORAL CUTTING BLOCK

The cutting block is assembled onto the cali- The base block is slotted; however, if used
brated outrigger by depressing the button without the slot and the resection is initiated
located on the right proximal end. The resection from the top of the block, 4 mm is added to the
of the more prominent condyle, inclusive of resection level. For example, if 9 mm is the
residual cartilage, will correspond to the distal desired resection level, add 4 mm to this and
dimension of the femoral prosthesis. set the block at 13 mm and cut from the surface
Where the femoral locating device rests of the block. Note the top of the block is
on eburnated bone, resection is engraved “4 mm offset.”
2 mm less than the distal
dimension of the femoral
prosthesis to allow for
absent cartilage and to
avoid elevation of the
joint line.

The scale for the numbers on the outrigger is The outrigger and cutting block is lowered onto
even on the left and odd on the right. The the anterior cortex by depressing the button on
number corresponding to the appropriate resec- the left-hand side of the locating device. Either
tion level is aligned with the inscribed line in 1/8" drill bits or Steinmann pins are
the center of the window of the distal femoral introduced through the holes desig-
cutting block. nated zero and enclosed in ■ ’s. They
are advanced into the anterior cortex.

Note: For PFC Sigma Femoral components,

the following distal resection is recommended:
Sizes 1.5 through 5 — 9 mm distal resection.
Size 6 — 10 mm distal resection.

12
THE DISTAL FEMORAL CUT

on the calibrated outrigger.

aa
The locating device and intramedullary rod are disengaged from the cut-
ting block by depressing the right button on the cutting block. The holes
on the block are designated -2, 0, and +2, indicating in millimeters the
amount of bone resection each will yield supplemental to that indicated

The oscillating saw blade is positioned through the slot, or, where applic-
able, the blade is positioned flush to the top cutting surface of the block.
The condyles are resected and the surface checked for accuracy.
a 13
THE FEMORAL SIZING GUIDE

The guide is seated flush and centered on the

prepared distal femoral surface. The stylus is
allowed to move freely within the guide and
moved proximal to the articular surface.

The stylus is passed over the anterior cortex

immediately proximal to the articular surface.
At the appropriate level where the stylus is not
impeded, turn the stylus locking knob clock-
wise until tight to fix its position.

14
ROTATIONAL ALIGNMENT

The sizing guide skids are positioned against the

posterior condyles. This determines rotational
alignment. Where either condyle is deficient, the
guide is rotated such that it lies perpendicular to
the mechanical axis of the tibia.

N.B. Alternatively, the tibia may be prepared first,

wherein the A/P femoral cuts are based on the relation-
ship of the condyles to the prepared tibial surface.

Where the appropriate position of the stylus is

determined, secure the stylus arm in position by
tightening the arm clockwise. The actual
size of the femur is indicated on the ver-
tical shaft of the stylus arm.

The Posterior Reference

Femoral Sizing Guide
This sizing guide will position
the femoral A/P chamfer cut-
ting block such that A
8 mm will be resected
from the posterior
condyles, corresponding to
the posterior condyle thick-
The Anterior Reference
ness of the prosthesis.
Femoral Sizing Guide
Inherent in using the poste-
rior reference is the fact that This sizing guide will position the femoral
additional bone, resulting from A/P chamfer cutting block such that the
femurs being in-between whole sizes, anterior flange of the prosthesis will generally fit
may be resected from the anterior aspect flush with the anterior cortex of the femur. When
of the distal femur. The preoperative the sizing device indicates a whole size, 8 mm
condition of the knee joint can aid the will be resected from the posterior
selection of the appropriately sized condyles, corresponding to the posterior
implant. Selecting a small size condyle thickness of the prosthesis.
femoral component may result Consequently, using the anterior reference
in notching of the femur on femurs that are in-between whole sizes
and may be avoided may result in additional bone
by moving the drill being resected from the posterior
guide the appropriate condyles of the femur. The preop-
amount anterior to the indi- erative condition of the knee joint
cated smaller size using the can aid the selection of the appropriately
mm scale on the upper left sized implant. Care must be taken to
portion of the frame. (A) balance the flexion and extension gaps.

15
Where the guide is pinned in neutral rotation using
the posterior holes, it will position the A/P cutting
block such that 8 mm will be resected from the pos-
terior condyle, corresponding to the posterior
dimension of the prosthesis.

Where, as in most cases, the tibia is resected at

90º to its mechanical axis, the femoral component is
positioned in ~3º of external rotation to produce
flexion-gap symmetry. Accordingly, the lateral pos-
terior and medial anterior holes are selected, yield-
ing 8 mm lateral and 10–11 mm medial resection.
The cutting block thus positioned will yield
a cut in 3º of external rotation, enhancing patellar
tracking and promoting flexion-gap symmetry. It
will reduce soft-tissue release for tight medial flex-
ion gap and allow commensurate rotation of the
tibial component. Neutral

Occasionally, more than 3º of external rotation is

indicated for flexion-gap symmetry. Following
removal of peripheral osteophytes, with 90º of flex-
ion and the collateral ligaments tensed with lami-
nar spreaders, the external tibial alignment device
is positioned with its upper platform raised to the
level of the holes made through the drill guide,
which should lie parallel to the platform. Where
more external rotation is indicated, the medial hole
is repositioned anteriorly. In valgus deformity with
lateral condylar hypoplasia, the lateral hole is repo-
sitioned posteriorly.

3º External Rotation

16
aa a
ANTERIOR, POSTERIOR AND CHAMFER CUTS

The drill guide is removed and the correspond-

ing A/P chamfer cutting block selected. Assem-
ble the removable handles by depressing the
button and inserting the handle into the recep-
tacle and turning until locked into position.
The A/P chamfer cutting block is seated into
the drill holes and flush to the prepared sur-
face. The anterior, posterior and chamfer cuts
are performed with an oscillating saw.

SLOTTED A/P CHAMFER

CUTTING BLOCKS
Extend the anterior and posterior plates to
create slots on the block. Insert the blade of the
oscillating saw (a 1.19 mm saw blade is recom-
mended) to the femur and make the anterior
and posterior cuts. The anterior chamfer cut is
made through the posterior slot and the poste-
rior chamfer cut is made through the anterior
slot. Care is taken that the posterior cruciate
and collateral ligaments be protected.

SURFACE A/P CHAMFER

CUTTING BLOCKS
With the anterior and posterior plates in their
retracted position, make the anterior and poste-
rior cuts. The anterior chamfer cut is made
through the posterior slot and the posterior
chamfer cut is made through the anterior slot.
Care is taken that the posterior cruciate and col-
lateral ligaments be protected.

17
 a
The chamfers are made through the slotted A/P block.

Alternatively, a separate chamfer block can

be used to guide the anterior and posterior
a
chamfer resections.

18
TIBIAL ALIGNMENT

The knee is placed

in maximal flexion
with the tibia dis-
tracted anteriorly
and stabilized.

The upper cutting platform is assembled and

secured onto the proximal uprod of the tibial
alignment device. A 0,̊ 3˚or 5˚ cutting block can
be chosen.

The malleolar clamp

of the tibial align-
ment device is
positioned immedi-
ately proximal to
the malleoli. The
platform is raised
to the level of the
condyles.

19
THE UPPER PLATFORM

The upper platform is aligned with the medial

third of the tibial tubercle and the medial
margin of the lateral intercondylar eminence
with the extremities of the cutting surface
against the anterior cortex.

The exact level of resection will vary according

to patient anatomy. As the mediolateral transverse
plane of the tibial plateau is usually 3˚ from the
perpendicular and the projected cut is perpendicu-
lar to the anatomic axis, more bone is typically
removed from the lateral condyle.

20
THE TIBIAL STYLUS

The stylus determines the exact level of

resection.

The outrigger of the stylus is marked non-slotted

and slotted at either end. When the tibial resec-
tion is performed from the surface of the block,
choose the non-slotted end of the outrigger; con-
versely, when the resection is performed through
the slots, choose the slotted end of the outrigger.
There is a 4 mm difference between the top sur-
face and the slot.

The cylinder foot is inserted into the slot of the

cutting block and adjusted to the appropriate
level. It is calibrated in 2 mm increments, indicat-
ing the amount of bone and residual cartilage to
be resected.

A level of 8 mm or 10 mm is suggested where

resection is based on the less involved condyle.
The block is adjusted such that the stylus rests on
the center of the condyle and the cutting block is
secured by the large anterior setscrew.

The level of 0
is selected where
resection is based
on the more
involved condyle and does not
result in excessive contralateral
resection. The cutting block is secured
by the large anterior setscrew.

N.B. Where this indicates greater than 10 mm

of resection from the contralateral condyle, a
higher level is indicated. The deficiency is aug-
mented with cement, bone graft or a modular
wedge, as the situation dictates.

21
LOWER ALIGNMENT

The lower assembly is translated anteroposteri-

orly to align it parallel to the tibial axis. Where
posterior slope is desired, the assembly is
advanced anteriorly, or, alternatively, a sloped
block is used (see page 18). Up to 5˚ of slope is
generally appropriate (5 mm advancement will
produce approximately 1˚ additional slope).
There are scribe marks at 1 cm for reference.

Mediolateral alignment is approximately paral-

lel to the tibial axis, but as the lateral malleolus
is more prominent, bisecting the transmalleolar
axis will prejudice the cut into varus. The
midline of the tibia is approximately 3 mm
medial to the transaxial midline. The lower
assembly is translated medially to the palpable
anterior crest of the tibia, usually to the second
vertical mark. There are scribe marks at 3 and
6 mm for reference. Where the platform is
medially displaced, adjustment is made at the
lower assembly.

22
THE TIBIAL ALIGNMENT

The distal portion of the long arm of the tibial Lateral alignment is similarly confirmed.
alignment device should align with the center
of the talus. N.B. Where indicated, varus/valgus corrections are made
by sliding the distal portion of the tibial alignment to the
appropriate location.
a 23
a
SECURING THE PLATFORM AND TIBIAL RESECTION

Steinmann pins or 1/8" drill bits are intro-

duced through the central holes into the tibia
stopping well short of the posterior cortex. The
tibial alignment device can either be removed
by first unlocking the cutting block, or left in
place for additional stability.
a
24
An entry slot is cut with
a narrow oscillating saw
into the intercondylar
eminence anterior to the
attachment of the PCL and
an osteotome positioned to
shield the ligament.

Resection is made either through the

slot or on the top surface depending
upon the stylus reference used. A
1.19 mm saw blade is recommended
when cutting through the slots.
PATELLAR RESURFACING

It is important that the sagittal dimension and accurate tracking be main-

tained and that adequate bone stock be preserved. Problems arise
from inadequate or oblique resection resulting in greater thickness
0
10 to the complex, asymmetric positioning of the implant, subse-
quent patellar tilt and implant wear.
20
30

It is important that sufficient soft tissue be freed at

40

the prepatellar bursa to position the calipers at the

50

anterior cortex.
60
70
80
90
110 100

The greatest sagittal dimension is at the median

ridge. The normal range is 20–30 mm. The
dimension is established and an amount corre-
sponding to the size of the selected implant
subtracted. The remainder equals the target
dimension following resection. Where the
patella is small, a minimal residual dimension
of 12 mm should be maintained.

EXAMPLE: (for a 38 mm wide dome or oval/

dome patella) From a patella 25 mm thick,
9 mm of articular surface is resected, yielding
16 mm of residual bone to accommodate the
9 mm thick implant.

The template is selected that most adequately

covers the articular surface without overhang.
The handle is positioned on the medial side
of the everted patella. Where bone is deficient
The amount of appropriate bone resection, as
on the lateral side, the next smaller size is
indicated on the template, is noted.
selected, but positioned slightly to the medial
side to enhance patellar tracking.
Patellar Size Resection
32 mm 8 mm
35 mm 8.5 mm
38 mm 9 mm
41 mm 11.5 mm

25
THE PATELLAR CUTTING GUIDE

Synovial tissue is cleared to the level of the

insertions of the quadriceps mechanism and the
patellar ligament.

The prongs of the knurled fork are adjusted to

the predetermined dimension of residual
patella as indicated on the calibrated column.

The leg is placed in exten-

sion, the cutting guide
positioned with the prongs
of the fork deep to the
prepatellar bursa and
against the anterior patel-
lar cortex with the serrated
jaws at the superior and
inferior margins of the articular surface. The
switch is placed to the LOCK position and the
jaws closed to firmly engage the patella.

26
RESECTION AND DRILLING

a a
Alternatively, the saw blade is inserted into the
well of the cutting surface of either of the jaws.
The insert is lifted and the blade thereby con-
fined within the slot created, ensuring that the
cut will remain flush to the cutting surface. A
1.19 mm saw blade is recommended.

The previously selected template is positioned

onto the cut surface with the handle positioned
on the medial side of the everted patella, such
that two drill holes lie at the medial side, one at
the lateral. The template is firmly engaged to
the resected surface and the holes fashioned
with the appropriate drill bit.
Resection is performed with an oscillating saw,
maintaining the blade flush to the cutting sur-
face. The guide is subsequently removed and
the residual dimension checked with calipers,
laterally, medially, proximally and distally. All
measurements should be equivalent. Asymme-
try is addressed with the saw or a bone rasp.

27
 a
THE TRIAL TIBIAL COMPONENT

The knee is placed in maximal flexion, the tibia

subluxed anteriorly with the tibial retractor. The
tibial tray is selected which provides the greatest
coverage of the prepared surface but precludes
overhang anterior to the midcoronal plane.

The tibial tray alignment handle is connected to

the tibial tray trial by retracting the knob, insert-
ing the two pins into the anterior portion of the
tray trial, indexing the handle to the left and
releasing the knob.

The matching color-coded plastic trial is selected

and inserted into the tray.
a
28
THE TRIAL FEMORAL COMPONENT

a a
Assemble the quick connect slaphammer onto the femoral inserter.
With the knee in full flexion, the femoral trial is assembled to the
femoral inserter and positioned onto the prepared surface. The leading
edges are advanced equally, parallel to the distal femoral cut,
preserving its precisely prepared configuration.

Where there is a tendency for the trial to rock posteriorly (into flexion),
the most common cause is upward sloping or failure to resect adequately
at the anterior aspect. Less commonly, the posterior condyles have been
under-resected. The A/P chamfer cutting block
is repositioned onto the distal surface and the
deficient cut appropriately revised.

29
TRIAL REDUCTION

With all trial prostheses in place, the knee is care-

fully and fully extended, noting medial and lateral
stability and overall alignment in the A/P and
M/L plane. Where there is any indication of insta-
bility, the next greater size tibial insert is substi-
tuted and reduction repeated. The insert that gives
the greatest stability in flexion and extension and
allows full extension is selected. Where there is a
tendency for lateral subluxation or patellar tilt in
the absence of medial patellar influence (thumb
pressure), lateral retinacular release is indicated.

Rotational alignment of the tibial tray is adjusted

with the knee in full extension, using the align-
ment handle to rotate the tray and trial insert into
congruency with the femoral trial.

The appropriate position

is marked with electro-
cautery on the anterior
tibial cortex.

30
OVERALL ALIGNMENT

The tibial alignment handle is assembled to the

trial tibial tray and the two parts of the align-
ment rod to the handle.

Where static alignment is correct, the rod

will bisect the mechanical axis at the hip, knee
and ankle.

31
PLATEAU PREPARATION

a
a
With the knee in full flexion and the tibia sub-

a
luxed anteriorly, the trial tibial tray is assem-
bled to the alignment handle and placed onto
the resected tibial surface. Care is taken that
proper rotational alignment with the electro-
cautery marks be established.

The tray is secured with two short fixation pins

inserted through the holes designated ■ .
a
32
P.F.C.® CRUCIFORM KEEL TRAY PREPARATION

Remove the alignment handle from the tray trial and assemble the appro-
priately sized cruciform keel punch guide to the tray trial.

Assemble the appropriately sized non-cemented keel punch onto the slap-
hammer and insert the punch through the guide and impact until the
shoulder of the punch is in contact with the guide. The stem punch is sub-
sequently freed, taking care that the punch configuration be preserved.

Where the cemented tray is to be implanted, the

appropriately sized cemented tray stem punch is
subsequently positioned through the guide and
impacted until the shoulder of the punch is in con-
tact with the guide. The cemented stem punch is
subsequently freed, taking care that the punch con-
figuration be preserved.

33
P.F.C.® MODULAR TRAY & UHMWPE* TIBIA PREPARATION

Select the appropriate punch guide, drill bushing, drill and modular keel
punch system. Remove the alignment handle from the tray trial and as-
semble the appropriately sized modular tray punch guide to the tray trial.

Seat the appropriately sized drill bushing into the modular tray
punch guide.

The matching drill is fully advanced through the drill bushing

into the cancellous bone.

The appropriately sized modular tray keel punch is subse-

quently positioned through the guide and impacted until the
shoulder of the punch is in contact with the guide. The modu-
lar tray keel punch is subsequently freed, taking care that the
punch configuration be preserved.

*UHMWPE (ALL-POLY)

34
THE FEMORAL LUG DRILL

Mediolateral positioning of the femoral trial component is confirmed

and receptacles prepared for the implant lugs by advancing the
femoral drill through the appropriate holes.

35
a
36
a
IMPLANTING THE COMPONENTS

THE TIBIAL COMPONENT

The entire site is thoroughly cleansed with pul-
satile lavage. Methylmethacrylate cement is pre-
pared and applied by syringe or digital pressure
in its low viscous state to assure maximal pene-
tration into the trabecular bone.

The universal handle is assembled onto the uni-

versal tibial tray inserter and assembled onto
the tibial tray. The tray is carefully inserted,
avoiding malrotation. When it is fully seated, sev-
eral mallet blows are delivered to the top of the
universal handle. The nylon tibial tray impactor
may be used to further impact the tibial tray.
a
UHMWPE TIBIAL COMPONENT
Alternatively, when implanting an all-UHMWPE
tibial component, place the component in
appropriate orientation and impact the flat cen-
tral proximal portion of the component with
the nylon tibial tray impactor. Excess cement is
removed from the periphery of the tibial
plateau, and a final impaction is performed to
ensure complete seating of the component.

As the cement polymerizes, a trial component

is positioned on the prepared femur. The knee
is placed in full extension to maintain pressure
at the bone/tibial implant interface. Slight val-
gus stress is maintained to ensure that the tibial
implant not tilt into varus. When the cement
has set, the knee is placed in flexion and the
trial femoral component removed. All extruded
cement is carefully removed with special atten-
tion to the posterior compartment.
a 37
THE FEMORAL COMPONENT
The entry hole at the medullary canal is plugged with cancellous bone.
All surfaces are thoroughly cleansed with pulsatile lavage. Cement is
applied to the bone at the anterior, anterior chamfer and distal surfaces
and to the inner surface of the component at the posterior chamfer and
posterior condylar recesses. Care is taken to avoid the articular surface
of the implant. The implant is assembled onto the femoral inserter. Care
is taken that it be correctly oriented. The leading
edges are advanced equally, paral-
lel to the distal surface and protect-
ing the carefully configured
surfaces, until the lugs are
fully engaged.

The inserter is subse-

quently released and seat-
ing completed with the
femoral impactor and a
mallet. All extruded
cement is cleared with a
scalpel and curette.

38
THE PATELLAR COMPONENT
The patellar implant may be cemented at the over the articular surface of the implant and the
surgeon’s convenience with either of the other metal backing plate against the anterior cortex,
components. The cut surface is thoroughly avoiding skin entrapment. When snug, the han-
cleansed with pulsatile lavage. Cement is dles are closed and held by the ratchet until
applied to the surface and the component polymerization is complete. Excessive compres-
inserted. sion is avoided as it can fracture osteopenic
bone. All extruded cement is removed with a
The patellar clamp is designed to fully seat and curette. To release the clamp, place the locking
stabilize the implant as the cement polymerizes. knob in the unlocked position and squeeze the
It is positioned with the silicon O-ring centered handles together to release the pawl.

39
THE TIBIAL INSERT
The trial insert is removed and the perma-
nent insert introduced into the implanted
tibial tray and seated posteriorly, its
anterior margin resting on the lip.

The anterior margin is tapped with a nylon mallet,

deflecting it past the lip of the tray into position.
Seating is confirmed by circumferential inspection.

Alternatively, the permanent insert may be

inserted at any convenient time during the
cementing procedure.

When a curved insert topography is utilized and

the flexion gap is snug, it may be difficult to
extract a trial insert and introduce the permanent
one. In such a case, the permanent insert should
be implanted prior to cementing the femoral
component.

CLOSURE
The tourniquet is released and bleeding controlled
by electrocautery. A closed-wound suction drain
is placed in the suprapatellar pouch and brought
out through the lateral retinaculum. The fat pad,
quadriceps mechanism, patella tendon, and medial
retinaculum are reapproximated with interrupted
sutures.

The knee is put through a range of motion from

full extension to full flexion to confirm patellar
tracking and the integrity of the capsular closing.
The final flexion against gravity is noted for post-
operative rehabilitation.

Subcutaneous tissue is reapproximated and the

skin closed with sutures or staples.

40
CRUCIATE SUBSTITUTING PROCEDURE

CHITRANJAN S. RANAWAT, MD

Clinical Professor of Orthopaedic Surgery

Cornell University Medical College

Chairman, Department of Orthopaedic Surgery

Ranawat Orthopaedic Center
Lenox Hill Hospital
New York, N.Y.

41
THE SURGICAL APPROACH

The extremity is appropriately prepared and The incision is developed at the deep fascial
draped. A tourniquet is applied and, following level to the tendon of the rectus femoris and the
application of an Esmarch bandage, inflated. patellar tendon. Undermining of the bilateral
skin flaps is avoided. The tendon of the rectus
A long straight incision is initiated 12 cm proxi- femoris is incised and the incision carried
mal to the superior margin of the patella and an 2–3 mm medial to the medial margin of the
equivalent distance distal to its inferior margin. patella, the patellar tendon and, subperios-
Reducing, thereby, the degree of skin retraction teally, 5 cm distal to the superior margin of the
and lowering the risk of subsequent adipose tis- tibial tubercle.
sue necrosis.

42
EXPOSURE

The patella is everted laterally and the knee

placed in full flexion. The cruciate ligaments
and the menisci are excised (see Appendix I,
pages 81– 89). Where indicated, preliminary
soft-tissue release is performed. Where the knee
is tight and in varus, a curved osteotome is
passed along the medial tibial border posterior
to the midcoronal plane to release the menis-
cotibial ligament and promote anterior subluxa-
tion of the tibia.

N.B. For discussion of soft-tissue balancing, see Appendix I.

43
 TIBIAL ALIGNMENT

The knee is placed

in maximal flexion
with the tibia dis-
tracted anteriorly
and stabilized.

The malleolar clamp

of the tibial align-
ment device is posi-
tioned immediately
proximal to the
malleoli. The plat-
form is raised to the
level of the condyles.

44
THE UPPER PLATFORM

The upper platform is aligned with the medial

third of the tibial tubercle and the medial
margin of the lateral intercondylar eminence
with the extremities of the cutting surface
against the anterior cortex.

The exact level of resection will vary according

to patient anatomy. As the mediolateral transverse
plane of the tibial plateau is usually 3˚ from the
perpendicular and the projected cut is perpendicu-
lar to the anatomic axis, more bone is typically
removed from the lateral condyle.

45
THE TIBIAL STYLUS

The stylus determines the exact level of

resection.

The outrigger of the stylus is marked non-slotted

and slotted at either end. When the tibial resec-
tion is performed from the surface of the block,
choose the non-slotted end of the outrigger; con-
versely, when the resection is performed through
the slots, choose the slotted end of the outrigger.
There is a 4 mm difference between the top sur-
face and the slot.

The cylinder foot is inserted into the slot of the

cutting block and adjusted to the appropriate
level. It is calibrated in 2 mm increments, indicat-
ing the amount of bone and residual cartilage to
be resected.

A level of 8 mm or 10 mm is suggested where

resection is based on the less involved condyle.
The block is adjusted such that the stylus rests on
the center of the condyle and the cutting block is
secured by the large anterior setscrew.

The level of 0
is selected where
resection is based
on the more
involved condyle and does not
result in excessive contralateral
resection. The cutting block is secured
by the large anterior setscrew.

N.B. Where this indicates greater than 10 mm

of resection from the contralateral condyle, a
higher level is indicated. The deficiency is aug-
mented with cement, bone graft or a modular
wedge, as the situation dictates.

46
LOWER ALIGNMENT

The lower assembly is translated anteroposteri-

orly to align it parallel to the tibial axis. Where
posterior slope is desired, the assembly is
advanced anteriorly, or, alternatively, a sloped
block is used (see page 18). Up to 5˚ of slope is
generally appropriate (5 mm advancement will
produce approximately 1˚ additional slope).
There are scribe marks at 1 cm for reference.

Mediolateral alignment is approximately paral-

lel to the tibial axis, but as the lateral malleolus
is more prominent, bisecting the transmalleolar
axis will prejudice the cut into varus. The
midline of the tibia is approximately 3 mm
medial to the transaxial midline. The lower
assembly is translated medially to the palpable
anterior crest of the tibia, usually to the second
vertical mark. There are scribe marks at 3 and
6 mm for reference. Where the platform is
medially displaced, adjustment is made at the
lower assembly.

47
THE TIBIAL ALIGNMENT

The distal portion of the long arm of the tibial Lateral alignment is similarly confirmed.
alignment device should align with the center
of the talus. N.B. Where indicated, varus/valgus corrections are made
by sliding the distal portion of the tibial alignment to the
appropriate location.

48
 a
SECURING THE PLATFORM AND TIBIAL RESECTION

Steinmann pins or 1/8" drill bits are intro-

duced through the central holes into the tibia
stopping well short of the posterior cortex. The
tibial alignment device can either be removed
by first unlocking the cutting block, or left in
place for additional stability.
a Resection is made either through the
slot or on the top surface depending
upon the stylus reference used. A
1.19 mm saw blade is recommended
when cutting through the slots.

49
ENTERING THE MEDULLARY CANAL

The medullary canal is entered at the midline

of the femoral trochlea 7–10 mm anterior to the
origin of the PCL to a depth of about 5–7 cm
using a 5/16" drill.

Care is taken that the drill avoid the cortices.

It is helpful to palpate the distal femoral shaft
as the drill is advanced. The drill hole may be
biased anteromedially to facilitate unobstructed
passage of the long intramedullary rod to the
diaphyseal isthmus, if indicated by pre-
operative X-rays.

50
THE INTRAMEDULLARY ROD

With the handle assembled onto the long

intramedullary rod, the rod is introduced
slowly into the canal to the level of the isthmus
to confirm unobstructed passage. The rod is
fluted to relieve intramedullary pressure and
permit the release of bone matter, avoiding
embolization. It is subsequently withdrawn.

THE FEMORAL LOCATING DEVICE

The valgus angle with the appropriate

Right/Left designation, as indicated on the pre-
operative films, is set and locked into place on
the front of the locating device. The angle can
be set from 0 degrees to 9 degrees in one degree
increments.

With the rod repositioned in the medullary

canal, the handle is removed and the locating
device is placed over the rod.

51
THE EXTERNAL ALIGNMENT SYSTEM

A radiopaque marker is positioned over the

ipsilateral hip, parallel and immediately distal
to the inguinal ligament. An A/P roentgeno-
gram indicates which of four markers most
closely approximates the rotational center.

At surgery, the femoral-head locating strip is

aligned with the markers. A target screw is
introduced into the position overlying the rota-
tional center. Draping is such that the screw is
readily palpated as the coxal reference point.

The alignment tower is assembled onto

the femoral locating device. The align-
ment rod is passed through the hole and
advanced to the hip. Where the rod fails
to align with the coxal reference point,
a different angle is selected.

N.B. Where indicated, as in femoral deform-

ity, 0˚ is selected and a short intramedullary
rod is substituted. See Appendix II.

52
ROTATIONAL CORRECTION

Orientation is initially determined with refer-

ence to the posterior femoral condyles, subject
to subsequent correction at the A/P resection.
The calibrated outrigger is centered at the
femoral trochlea, placing it in slight external
rotation and exposing a greater amount of
medial condyle.

Alternatively, it may be externally rotated until

perpendicular to the mechanical axis of the tibia
in 90˚ of flexion.

The femoral locating device is tapped into

position at the more prominent condyle
(usually the medial).

N.B. It is essential that firm contact be established

at the subchondral level of the condyle, clear of any
residual peripheral osteophytes.

53
THE DISTAL FEMORAL CUTTING BLOCK

The cutting block is assembled onto the cali- The base block is slotted; however, if used
brated outrigger by depressing the button without the slot and the resection is initiated
located on the right proximal end. The resection from the top of the block, 4 mm is added to the
of the more prominent condyle, inclusive of resection level. For example, if 9 mm is the
residual cartilage, will correspond to the distal desired resection level, add 4 mm to this and
dimension of the femoral prosthesis. set the block at 13 mm and cut from the surface
Where the femoral locating device rests of the block. Note the top of the block is
on eburnated bone, resection is engraved “4 mm offset.”
2 mm less than the distal
dimension of the femoral
prosthesis to allow for
absent cartilage and to
avoid elevation of the
joint line.

The scale for the numbers on the outrigger The outrigger and cutting block is lowered onto
is even on the left and odd on the right. The the anterior cortex by depressing the button on
number corresponding to the appropriate the left-hand side of the locating device. Either
resection level is aligned with the inscribed 1/8" drill bits or Steinmann pins are
line in the center of the window of the distal introduced through the holes desig-
femoral cutting block. nated zero and enclosed in ■ ’s. They
are advanced into the anterior cortex.

54
THE DISTAL FEMORAL CUT

on the calibrated outrigger.

aa
The locating device and intramedullary rod are disengaged from the cut-
ting block by depressing the right button on the cutting block. The holes
on the block are designated -2, 0, and +2, indicating in millimeters the
amount of bone resection each will yield supplemental to that indicated

The oscillating saw blade is positioned through the slot, or, where applic-
able, the blade is positioned flush to the top cutting surface of the block.
The condyles are resected and the surface checked for accuracy.
a 55
EVALUATING THE EXTENSION GAP

The knee is placed in full extension and lamina

spreaders applied medially and laterally. The
extension gap must be rectangular in configura-
tion. Where it is trapezoidal, the bilateral soft
Medial
tissue must be balanced (see Appendix I). Bone
tightness
cuts are not altered.

Balanced

A set of spacer blocks measures the gap and indicates

the appropriate thickness of the tibial insert, subject
to reevaluation at trial reduction.

When using blocks to assess flexion and extension

gaps, a 1 mm shim should be used for the extension
gap and the spacer is removed when assessing the
flexion gap. This will compensate for the 1 mm differ-
ence between the distal and posterior resection levels.

56
SIZING THE FEMORAL COMPONENT

Careful preoperative planning, including the

application of templates to lateral radiographs,
is critical to the sizing of the femoral compo-
nent. Priority is given to reestablishment of the
A/P dimension, as this will restore normal
kinematics and quadriceps function. Undersiz-
ing will cause looseness in flexion and possible
notching of the anterior femoral cortex. Over-
sizing will create tightness in flexion and
increased tension in the quadriceps mechanism.
Where a stabilizing or constraining insert is
used, a matched size relationship between the
components must be maintained.

ASSEMBLING THE FEMORAL A/P CUTTING BLOCK

The appropriate
rod is selected
and assembled to
the femoral A/P
cutting block, the
appropriate
RIGHT/LEFT desig-
nation to the ante-
rior. The pins are
retracted.

N.B. Alternatively, the femoral sizing guide is used

to position and size the component (see pages 14-
16). With positioning established, any appropriate
A/P cutting block may be used.

57
POSITIONING THE CUTTING BLOCK

The rod is introduced into the prepared

intramedullary hole until the cutting block is
seated flush to the cut distal surface.

The foot of the stylus assem-

bly is fully seated in its
receptacle on the anterior
surface of the block such that
it reads 0.

The cutting block is adjusted

posteriorly until the stylus
(slotted arm) is in contact with
the anterior femoral cortex.

ROTATIONAL ADJUSTMENT

Rotation is determined with the knee in 90° of

flexion and the block positioned such that its
posterior surface is parallel to
the resected tibial plateau, creat-
ing the desired rectangular flex-
ion gap.

The retractable pins are subse-

quently tapped into the distal
a
femur.

58
a
EVALUATING THE FLEXION GAP

Lamina spreaders are positioned bilaterally

between the resected proximal tibial surface
and the posterior surface of the block.
Tension is applied.

Medial
tightness

N.B. Further ligamentous release is not recom-

mended at this stage.

Balanced

59
 a
a
ANTERIOR AND POSTERIOR FEMORAL CUTS

The anterior and posterior cuts are made

with the blade of the oscillating saw held flush
against the respective surfaces. The
cuts are checked for accuracy
and the cutting block removed.

Alternatively, the slotted A/P cham-

fer block may be substituted for the cut-
ting block, positioned into the distal
bilateral holes. A 1.19 mm saw blade
is recommended.

a
a
a
60
The chamfer cuts can be made through
the slotted A/P block at this time.

Alternatively, a separate chamfer block

can be used to guide the anterior and
posterior chamfer resections.
MEASURING FLEXION GAP

Spacer blocks are used to

measure the gap at 90° of

a
flexion. When using blocks
to assess flexion and exten-
sion gaps, a 1 mm shim
should be used for the exten-
sion gap and removed when
assessing the flexion gap.
This will compensate for the
1 mm difference between the
distal and posterior resection
levels.

Where further distal femoral

resection is required to estab-
lish equivalent flexion and
extension gaps, the Stein-
mann pins are returned to
their original position in the
anterior femoral cortex and
the distal femoral cutting
block repositioned using the
holes designated +2 and +4
as indicated.

The long alignment rod

should pass through the cen-
ter of the talus and lie paral-
lel to the lateral tibial axis.
a
61
THE FEMORAL NOTCH CUT

a
Place the trial femoral component onto the prepared
femur and position it such that the lateral flange of the
trial component meets the lateral margin of the femur.
Overhang of the flange is avoided where possible.

With electrocautery, mark the medial/lateral location of

the trial with lines drawn on the distal femur within
each border of the intercondylar notch.
a
62
THE FEMORAL NOTCH GUIDE

The appropriate femoral notch guide is applied

a
to the distal femur, seated flush upon the cut
anterior and distal surfaces. It is centered about
the two lines, previously made, within the
intercondylar notch.

Where the posterior margins of the guide fail

to align with the cut posterior condyles,
the cuts are accordingly revised.

Steinmann pins are introduced in the sequence

displayed: anterior (1), contralateral distal (2),
anterior (3) and distal (4).

a a
The notch is created with
an oscillating saw and an
osteotome.

A 1/2" x 1.19 mm blade is

recommended.

63
Alternatively, the femoral notch/chamfer
guide may be employed for the notch and
chamfer cuts.

M/L size of implant is at the arrows

indicated below. The mediolateral positioning
of the guide is confirmed.
a
64
a
a
Steinmann pins are introduced in the sequence displayed:
anterior (1), contralateral distal (2), anterior (3) and distal (4).

aa The notch is created with bilateral

and superior transverse cuts, as
described above. A 1/2" x 1.19 mm
saw blade is recommended.

The chamfers are fashioned with the oscillating saw using the
appropriate slots. A 1.19 mm saw blade is recommended.

65
PATELLAR RESURFACING

It is important that the sagittal dimension and accurate tracking be main-

tained and that adequate bone stock be preserved. Problems arise
from inadequate or oblique resection resulting in greater thickness
0
10 to the complex, asymmetric positioning of the implant, subse-
quent patellar tilt and implant wear.
20
30

It is important that sufficient soft tissue be freed at

40

the prepatellar bursa to position the calipers at the

50

anterior cortex.
60
70
80
90
110 100

The greatest sagittal dimension is at the median

ridge. The normal range is 20–30 mm. The
dimension is established and an amount corre-
sponding to the size of the selected implant
subtracted. The remainder equals the target
dimension following resection. Where the
patella is small, a minimal residual dimension
of 12 mm should be maintained.

EXAMPLE: (for a 38 mm wide dome or oval/

dome patella) From a patella 25 mm thick,
9 mm of articular surface is resected, yielding
16 mm of residual bone to accommodate the
9 mm thick implant.

The template is selected that most adequately

covers the articular surface without overhang.
The handle is positioned on the medial side
of the everted patella. Where bone is deficient
The amount of appropriate bone resection, as
on the lateral side, the next smaller size is
indicated on the template, is noted.
selected, but positioned slightly medial
to enhance patellar tracking.
Patellar Size Resection
32 mm 8 mm
35 mm 8.5 mm
38 mm 9 mm
41 mm 11.5 mm

66
THE PATELLAR CUTTING GUIDE

Synovial tissue is cleared to the level of the

insertions of the quadriceps mechanism and the
patellar ligament.

The prongs of the knurled fork are adjusted to

the predetermined dimension of residual
patella as indicated on the calibrated column.

The leg is placed in exten-

sion, the cutting guide
positioned with the prongs
of the fork deep to the
prepatellar bursa and
against the anterior patel-
lar cortex with the serrated
jaws at the superior and
inferior margins of the articular surface. The
switch is placed to the LOCK position and the
jaws closed to firmly engage the patella.

67
RESECTION AND DRILLING

a a
Alternatively, the saw blade is inserted into the
well of the cutting surface of either of the jaws.
The insert is lifted and the blade thereby con-
fined within the slot created, ensuring that the
cut will remain flush to the cutting surface. A
1.19 mm saw blade is recommended.

The previously selected template is positioned

onto the cut surface with the handle positioned
on the medial side of the everted patella, such
that two drill holes lie at the medial side, one at
the lateral. The template is firmly engaged to
the resected surface and the holes fashioned
with the appropriate drill bit.

68
Resection is performed with an oscillating saw,
maintaining the blade flush to the cutting sur-
face. The guide is subsequently removed and
the residual dimension checked with calipers,
laterally, medially, proximally and distally. All
measurements should be equivalent. Asymme-
try is addressed with the saw or a bone rasp.
 a
THE TRIAL TIBIAL COMPONENT

With the knee in maximal flexion, the tibia is

subluxed anteriorly with the tibial retractor.

The tibial tray is selected which provides the

greatest coverage of the prepared surface with-
out overhang anterior to the midcoronal plane.

The appropriate color-coded nylon trial is

inserted into the tray.
a 69
THE TRIAL FEMORAL COMPONENT

a
70
➀

➂
THE FEMORAL COMPONENT BOX
ASSEMBLY

a
1) Place the two outrigger tabs of the box trial into
the recesses of the posterior condyles.

2) Insert the two anterior tabs into the recesses of

the anterior flange.

3) Turn the angled screw, located in the side of the

box, until tight.

Note: Do not overtighten the screw or attempt to

remove the screw from the box trial as this will
result in damage to the box trial attachment.

The femoral trial is positioned on the prepared dis-

tal femur and the accuracy of the cuts is evaluated.

Where the component tends to rotate posteriorly

(rocking into flexure) the A/P cuts may require
adjustment. Where there is lateral rocking, the
depth of the notch is inadequate.

All appropriate modifications are made at this time.

TRIAL REDUCTION

With all trial prostheses in place, the knee is care-

fully and fully extended, noting medial and lateral
stability and overall alignment in the A/P and
M/L plane. Where there is any indication of insta-
bility, the next greater size tibial insert is substi-
tuted and reduction repeated. The insert that gives
the greatest stability in flexion and extension and
allows full extension is selected. Where there is a
tendency for lateral subluxation or patellar tilt in
the absence of medial patellar influence (thumb
pressure), lateral retinacular release is indicated.

Rotational alignment of the tibial tray is adjusted

with the knee in full extension, using the align-
ment handle to rotate the tray and trial insert into
congruency with the femoral trial.

The appropriate position

is marked with electro-
cautery on the anterior
tibial cortex.

71
OVERALL ALIGNMENT

The tibial alignment handle is assembled to the

trial tibial tray and the two parts of the align-
ment rod to the handle.

Where static alignment is correct, the rod

will bisect the mechanical axis at the hip, knee
and ankle.

72
PLATEAU PREPARATION

a
a
With the knee in full flexion and the tibia sub-

a
luxed anteriorly, the trial tibial tray is assem-
bled to the alignment handle and placed onto
the resected tibial surface. Care is taken that
proper rotational alignment with the electro-
cautery marks be established.

The tray is secured with two short fixation pins

inserted through the holes designated ■ .
a 73
P.F.C.® CRUCIFORM KEEL TRAY PREPARATION

Remove the alignment handle from the tray trial and assemble the appro-
priately sized cruciform keel punch guide to the tray trial.

Assemble the appropriately sized non-cemented keel punch onto the slap-
hammer and insert the punch through the guide and impact until the
shoulder of the punch is in contact with the guide. The stem punch is sub-
sequently freed, taking care that the punch configuration be preserved.

Where the cemented tray is to be implanted, the

appropriately sized cemented tray stem punch is
subsequently positioned through the guide and
impacted until the shoulder of the punch is in con-
tact with the guide. The cemented stem punch is
subsequently freed, taking care that the punch con-
figuration be preserved.

74
P.F.C.® MODULAR TRAY & UHMWPE* TIBIA PREPARATION

Select the appropriate punch guide, drill bushing, drill and modular keel
punch system. Remove the alignment handle from the tray trial and as-
semble the appropriately sized modular tray punch guide to the tray trial.

Seat the appropriately sized drill bushing into the modular tray
punch guide.

The matching drill is fully advanced through the drill bushing

into the cancellous bone.

The appropriately sized modular tray keel punch is subse-

quently positioned through the guide and impacted until the
shoulder of the punch is in contact with the guide. The modu-
lar tray keel punch is subsequently freed, taking care that the
punch configuration be preserved.

*UHMWPE (ALL-POLY)

75
a
76
a
IMPLANTING THE COMPONENTS

THE TIBIAL COMPONENT

The entire site is thoroughly cleansed with pul-
satile lavage. Methylmethacrylate cement is pre-
pared and applied by syringe or digital pressure
in its low viscous state to assure maximal pene-
tration into the trabecular bone.

The universal handle is assembled onto the uni-

versal tibial tray inserter and assembled onto
the tibial tray. The tray is carefully inserted,
avoiding malrotation. When it is fully seated, sev-
eral mallet blows are delivered to the top of the
universal handle. The nylon tibial tray impactor
may be used to further impact the tibial tray.
a
UHMWPE STABILIZED TIBIAL
COMPONENT
Alternatively, when implanting an all-UHMWPE
tibial component, place the component in
appropriate orientation and impact the flat cen-
tral proximal portion of the component with
the nylon tibial tray impactor. Excess cement is
removed from the periphery of the tibial
plateau, and a final impaction is performed to
ensure complete seating of the component.

As the cement polymerizes, a trial component

is positioned on the prepared femur. The knee
is placed in full extension to maintain pressure
at the bone/tibial implant interface. Slight val-
gus stress is maintained to ensure that the tibial
implant not tilt into varus. When the cement
has set, the knee is placed in flexion and the
trial femoral component removed. All extruded
cement is carefully removed with special atten-
tion to the posterior compartment.
a 77
THE FEMORAL COMPONENT
The entry hole at the medullary canal is plugged with cancellous bone.
All surfaces are thoroughly cleansed with pulsatile lavage. Cement is
applied to the bone at the anterior, anterior chamfer and distal surfaces
and to the inner surface of the component at the posterior chamfer and
posterior condylar recesses. Care is taken to avoid the articular surface
of the implant. The implant is assembled onto the femoral inserter.
Care is taken that it be correctly oriented. The leading
edges are advanced equally, parallel to
the distal surface and protecting the
carefully configured surfaces, until
the lugs are fully engaged.

The inserter is subse-

quently released and seat-
ing completed with the
femoral impactor and a
mallet. All extruded
cement is cleared with a
scalpel and curette.

78
THE PATELLAR COMPONENT
The patellar implant may be cemented at the over the articular surface of the implant and the
surgeon’s convenience with either of the other metal backing plate against the anterior cortex,
components. The cut surface is thoroughly avoiding skin entrapment. When snug, the han-
cleansed with pulsatile lavage. Cement is dles are closed and held by the ratchet until
applied to the surface and the component polymerization is complete. Excessive compres-
inserted. sion is avoided as it can fracture osteopenic
bone. All extruded cement is removed with a
The patellar clamp is designed to fully seat and curette. To release the clamp, place the locking
stabilize the implant as the cement polymerizes. knob in the unlocked position and squeeze the
It is positioned with the silicon O-ring centered handles together to release the pawl.

79
THE TIBIAL INSERT
The trial insert is removed and the perma-
nent insert introduced into the implanted
tibial tray and seated posteriorly, its
anterior margin resting on the lip.

The anterior margin is tapped with a nylon mallet,

deflecting it past the lip of the tray into position.
Seating is confirmed by circumferential inspection.

Alternatively, the permanent insert may be

inserted at any convenient time during the
cementing procedure.

When a curved insert topography is utilized and

the flexion gap is snug, it may be difficult to
extract a trial insert and introduce the permanent
one. In such a case, the permanent insert should
be implanted prior to cementing the femoral
component.

CLOSURE
The tourniquet is released and bleeding controlled
by electrocautery. A closed-wound suction drain
is placed in the suprapatellar pouch and brought
out through the lateral retinaculum. The fat pad,
quadriceps mechanism, patella tendon and medial
retinaculum are reapproximated with interrupted
sutures.

The knee is put through a range of motion from

full extension to full flexion to confirm patellar
tracking and the integrity of the capsular closing.
The final flexion against gravity is noted for post-
operative rehabilitation.

Subcutaneous tissue is reapproximated and the

skin closed with sutures or staples.

80
 LIGAMENTOUS BALANCE IN TOTAL KNEE ARTHROPLASTY
I

The suggested sequence of ligamentous release

P P E N D I X

• Balance is established by eliminating soft-

to correct varus or valgus deformity and tissue contractures, not by modifying the
quadriceps-mechanism imbalance is described. bone cuts.
There is no general agreement on the order;
there is on the principles. • Final correction is established at trial
reduction.
• Preliminary soft-tissue release is performed at
the start of surgery, based upon preoperative
evaluation.
A

MEDIAL LIGAMENTOUS RELEASE FOR FIXED VARUS DEFORMITY

Following removal of
peripheral osteophytes, the
medial meniscus (1) and
the meniscotibial ligament
(2) are excised. In rheuma-
toid arthritis and minimal
deformity, this is often
sufficient.

81
 a
Where further release is indicated, the posterior
expansion of the deep medial collateral liga-
ment is released from its tibial attachment (3)
using a curved osteotome.

Where still further release is indicated, the

medial tibia is denuded subperiosteally (4).

Where, following trial reduction, further

release is indicated, the superficial portion of
the medial collateral ligament is released
from its tibial attachment (5). Generally, this
is indicated only in severe deformity associ-
ated with significant flexion contracture.
a
82
a
LATERAL LIGAMENTOUS RELEASE FOR FIXED VALGUS DEFORMITY

Following removal of peripheral osteophytes,

initial release comprises medial meniscectomy
(1) and release of the iliotibial band from its tib-
ial insertion (2). A lateral quadriceps retinacular
release is indicated where there is poor patellar
tracking at trial reduction.
a Lateral retinacular release is performed on the
internal surface in the longitudinal plane. Care
is taken that the lateral superior genicular
artery be protected; it is isolated at the inter-
muscular septum as it penetrates the retinacu-
lum superficially, retracted proximally as the
retinacular incision is carried to the level of the
joint-line, distally as the incision is extended
superiorly to the intermuscular septum (3).

Where indicated, further release is effected by

extending the distal terminus of the incision
transversely to the lateral margin of the patellar
tendon (4) and posteriorly to the lateral collat-
eral ligament.

83
 a
a
Where still further release is indicated, the
lateral collateral ligament and popliteus tendon
are released from the femoral epicondyle and
allowed to slide posteriorly (5).

Where further release is indicated, the posterior

cruciate ligament is evaluated and, where nec-
essary, sacrificed (6).

a
N.B. Priority of steps 5 and 6 is a matter
of preference.
a
84
Where balance requires still further release,
dissection is extended posteriorly, freeing
the intermuscular septum (7) and the lateral
head of the gastrocnemius (8).

Care is taken that the posterolateral

neurovascular structures be preserved
and that the insertion of the biceps
femoris, which overlies the common
peroneal nerve, remains intact.
BALANCING THE POSTERIOR CRUCIATE LIGAMENT

In cruciate-retaining total-knee replacement, there

are three indicators for PCL tightness identified at
trial reduction: limited flexion with excessive
femoral rollback, anterior lift-off of the tibial tray
and palpable ligamentous tension in flexion.

Possible causes include residual posterior/

posteromedial osteophytes and loose bodies
such as meniscal segments. It is essential
during initial exposure that all peripheral pos-
terior osteophytes be cleared, that the menisci
be completely removed and that the attach-
ments of the PCL be defined.

Problems commonly arise from failure to clear

the posterior horns of the menisci, including the
posterior meniscofemoral ligament, and failure
to identify synovial adhesions.

85
Where the surgeon elects to increase the poste- PCL recession is possible at either the tibial or
rior slope, it should not exceed a total of 7˚, as femoral attachments, but as the anterior and
excessive posterior slope will complicate liga- posterior fibers at the femoral attachment differ
mentous balance in flexion and extension. It is in tension in transition from extension to flexion
preferable, therefore, that the PCL be recessed. and as compromising this attachment increases
the likelihood of evulsion, preliminary recession
at the tibial attachment is recommended.

The diagram below shows the changes in PCL

tension throughout range of motion.

In extension, the bulk of the PCL is relaxed and only the posterior band is tight.
In flexion, the bulk of the PCL becomes tight and the small posterior band is loose.

86
The tibial attachment is elevated subper-
iosteally along the entire proximal margin such
that the ligament is allowed to recede incre-
mentally until flexion tension in trial reduction
is satisfactory with normal patellar tracking.

Where tightness persists, further release is indi-

cated, which may be performed at the femoral
attachment. This can produce laxity; to lessen
the likelihood, a supplemental curved compo-
nent is introduced. The knee is placed in 90˚ of
flexion and the tensed fibers incrementally
freed from the femoral attachment with sharp
dissection until the supplemental component is
accepted without anterior lift-off of the tray.

N.B. Residual posterior osteophytes or undetected

bone fragments can impinge upon the components
and promote lift-off.

87
BALANCING FLEXION AND EXTENSION GAPS

Where the joint line is maintained, flexion and RESIDUAL FLEXION CONTRACTURE
extension gaps are usually found to be bal-
anced at trial reduction, but where there is pre- Where there is restriction in extension but not
operative deformity and contracture, imbalance in flexion, additional bone is removed from the
may be present. distal femur. This affects the extension gap but
not the flexion gap. Where contracture persists
following appropriate retinacular release
and removal of posterior osteophytes and scar
tissue, depending on severity, removal of an
additional 2–4 mm of distal femur is indicated.

The Steinmann pins are returned to their origi-

nal position in the anterior femur and the distal
femoral cutting block returned to the pins using
the holes designated +2 as the degree of con-
tracture indicates. The distal cut is accordingly
revised.

Chamfers are subsequently revised to maintain

the correct configuration; anterior and posterior
cuts are not. This affects ligamentous tension in
extension but not in flexion.

88
RESIDUAL TIGHTNESS IN FLEXION
AND EXTENSION

A thinner tibial insert or additional tibial resec-

tion is indicated, as either will affect flexion and
extension gaps. Where resection is selected, it is
recommended that 2 mm of proximal tibia be
removed. The Steinmann pins are returned to
their drill holes in the anterior tibial cortex and
the cutting block repositioned on the pins,
using the holes designated +2. The cut is
accordingly revised.

RESIDUAL TIGHTNESS IN FLEXION ONLY

Where such is the case, excessive PCL tension is indi-
cated, and the PCL should be recessed. Recession is
effected as described above. Residual posterior osteo-
phytes, soft tissue, and loose bodies may be factors
and must be addressed. In the rare case where ten-
sion persists following appropriate correction, 5˚ of
additional posterior slope may be indicated. The pins
are returned to the anterior cortex and the 5˚ cutting
block positioned using the holes designated ■. Final
slope should not exceed 7˚.

Alternatively, tightness in flexion may be addressed

by downsizing the femoral component, provided
anterior femoral notching be avoided. The pins are
returned to the distal femoral surface, the designated
cutting block positioned, and the cuts revised. As
additional posterior condyle is resected, flexion gap
is increased.

N.B. For discussion of soft-tissue balancing, see above.

89
II
THE EXTERNAL FEMORAL ALIGNMENT SYSTEM
P P E N D I X

In patients with femoral deformity or with total hip replacement, the

intramedullary alignment system is not appropriate. The short
intramedullary rod coupled to the femoral locating device (set at 0˚),
tower and alignment rod are employed. The femoral head is identified
preoperatively, radiopaque markers positioned parallel and just distal
to the inguinal ligament. An A/P radiograph identifies the marker
which approximates the center of the hip.

At surgery, the femoral head locating device is taped over the

A

radiopaque markers, the large-headed screw introduced into the hole

over the identified marker. Draping is such that the screw is readily
palpated as the coxal reference point.

With the rod repositioned in the

medullary canal, the handle is
removed and the locating device is
placed over the rod.

The tower is assembled to the

locating device, the alignment rod
introduced through
the hole and advanced to
the hip. Resection is as
previously described.

90
III
INTRAMEDULLARY ALIGNMENT DEVICE

PREOPERATIVE PLANNING
P P E N D I X

Where the Specialist® 2 Intramedullary Tibial

Alignment System is to be used, it is essential
that the appropriate point of entry on the tibial
plateau be accurately determined. In most
cases, this point will be centered on the tibial
spine in both the medial/lateral and anterior/
posterior aspect. In some cases, it may be
slightly eccentric.
A

Using full-length extremity radiograms, lines

are constructed along the central axis of the tibia
on the A/P view by determining mid-points of
the diameter of the tibia in the diaphysis at least
10 centimeters apart. A line defined by these
two points is extended proximally to the knee
joint and distally to the ankle joint. The point of
intersection with the tibial plateau determines
the point of entry in the medial lateral plane.
This line should pass at or near the center of the
ankle joint. If it does not, it is usually because of
excessive tibial bowing. In this circumstance, it
is preferable to use an external tibial alignment
system.

In the lateral view, a point is defined at the

mid-point of the tibial plateau and another
point defined at the mid-point of the isthmus.
The line defined by these two points will define
the appropriate placement of the intramedul-
lary tibial alignment rod in the lateral plane.

These lines are projected to the tibial plateau;

their intersection determines the appropriate
point of entry.

N.B. The entry point for the intramedullary align-

ment rod is a critical starting point for accurate
alignment of the intramedullary tibial alignment sys-
tem. Selected correctly, neutral alignment in the
anteroposterior and lateral planes is easily achieved.

91
ENTERING THE MEDULLARY CANAL

The knee is flexed maximally, the tibial retractor

inserted over the posterior cruciate ligament and
the tibia subluxed anteriorly. All soft tissue is
cleared from the intercondylar area. The tibial spine
is resected to the highest level of the least affected
tibial condyle. Entrance to the medullary canal is
facilitated with a 5/16" step drill bit which makes a
pilot hole to assure accuracy.

The intramedullary rod is passed down into the

medullary canal until the isthmus is firmly engaged.

92
a THE I.M. TIBIAL ALIGNMENT GUIDE

ASSEMBLING THE GUIDE

As a posterior slope is usually desired, a 3˚ or a
5˚ posteriorly sloped cutting block is selected.

a
POSITIONING THE GUIDE
The handle is removed and the I.M. tibial alignment guide is positioned
on the I.M. rod. The I.M. guide should sit flush to the resected tibial spine.

It is suggested the level of resection be set at 8 or 10 mm. This is accom-

plished with use of the stylus, set at the appropriate resection level (see
footnote), positioned in the center of the condyle of the least affected side.

Alternatively, to use the reference scale on the front of the outrigger to

measure the resection level, the scale as indicated is relative to cutting
through the slot. To adjust for cutting on the surface of the block, add
4 mm to the front scale. For example, when cutting on top of the slotted
block and an 8 mm resection is desired, set the outrigger for 12 mm and
proceed to cut on the surface of the block. Note, the top of the cutting
block is engraved 4 mm offset.

N.B. For a full explanation of the stylus, refer to page 21 of this manual.

93
ROTATIONAL ALIGNMENT

When the level of resection has been determined, the alignment tower,
tibial side, is inserted into the tibial cutting block and rotated such that the
center of the block is aligned with the medial third of the tibial tubercle.

The long alignment rod is passed through the appropriate hole to the
ankle. It should align with the center of the talus. Lateral alignment is
similarly confirmed.

94
a
a SECURING THE CUTTING BLOCK

TIBIAL RESECTION
Steinmann pins or 1/8" drill bits are introduced
through the central holes, marked with a ■, into
the tibia stopping well short of the posterior cor-
tex. The intramedullary alignment device is
removed from the cutting block and the I.M. rod
is subsequently removed.

N.B. Where indicated, varus/valgus corrections are

made by removing one of the pins and allowing the
block to pivot on the other. The pin is subsequently
repositioned through a more peripheral hole.

An entry slot is cut with a nar-

row oscillating saw into the
intercondylar eminence anterior
to the attachment of the PCL and
an osteotome positioned to shield the ligament.

Resection is made either through the slot or on

the top surface depending upon the stylus refer-
ence used. A 1.19 mm saw blade is recommended
when cutting through the slots.

95
IV
P P E N D I X

a
A
EXTRAMEDULLARY TIBIAL ALIGNMENT DEVICE
WITH PROXIMAL FIXATION SPIKE

The knee is placed in maximum flexion with the

tibia distracted anteriorly and stabilized. The malleo-
lar clamp of the tibial alignment device is positioned
proximal to the malleoli. With the appropriate
transverse tibial cutting guide attached to the
tibial alignment device, the proximal spike is
placed in the center of the tibial eminence and seated
to the depth of the shortest, or anterior, spike. The
cutting block is advanced posteriorly to the proximal
tibia and the head containing the spikes is tightened.

The lower assembly is

translated anteroposteriorly
to align it parallel to the tibial
axis. Where posterior slope is
desired, the assembly is advanced anteri-
orly, or, alternatively, a sloped block is used
(see page 18). Up to 5˚ of slope is generally
appropriate (5 mm advancement will produce
approximately 1˚ additional slope). There are
scribe marks at 1 cm for reference.

96
Adjustable Head

Set Knob

Mediolateral alignment is approximately parallel to the

tibial axis, but as the lateral malleolus is more promi-
nent, bisecting the transmalleolar axis will prejudice the
cut into varus. The midline of the tibia is approximately
3 mm medial to the transaxial midline. The lower
assembly is translated medially to the palpable anterior
crest of the tibia, usually to the second vertical mark.
There are scribe marks at 3 and 6 mm for reference.
Where the platform is medially displaced, adjustment is
made at the lower assembly.
a
Appropriate rotation is established and the
shorter spike is seated in the proximal tibia,
securing the medial/lateral, anteroposterior,
and rotational positions. With the set knob of
the adjustable head free, slide the cutting block
forward until contact with the anterior tibia
is established. Tighten the set knob. The cylin-
der foot of the stylus is inserted into the slot
of the cutting block and adjusted to the
appropriate level. A level of 8 mm or 10 mm
is suggested where resection is based on the
less involved condyle.

a a
A level of 0 mm or 2 mm is selected where
resection is based on the more involved
condyle and does not result in excessive
contralateral resection. The block is adjusted
such that the stylus rests on the center of the
condyle and the block is secured by the large
lateral knob.

97
Steinmann pins or 1/8" drill bits are intro-
duced through the central holes into the tibia,
stopping well short of the posterior cortex.
The cutting block is unlocked, the black lat-
eral knob loosened and the set knob securing
the head loosened. The uprod is pulled and
disengaged from the cutting block. Connect
the quick connect slap hammer to the head
and disengage the spikes from the proximal
tibia. The tibial alignment device is removed
and the appropriate resection performed.

a
Appendix IV, Extramedullary Tibial Alignment Device
with Proximal Fixation Spike Surgical Technique,
edited by William L. Healy, MD, Chairman,
Department of Orthopaedic Surgery, Lahey Hitchcock
Medical Center, Burlington, Mass.

98
a
 CRUCIATE RETAINING—
V

FEMORAL AND TIBIAL INSERT COMPATIBILITY

P E N D I X

CR FEMORAL COMPONENT
SIZE 1.5 SIZE 2 SIZE 2.5 SIZE 3 SIZE 4 SIZE 5 SIZE 6
53AP/57ML 56AP/60ML 59AP/63ML 61AP/66ML 65AP/71ML 69AP/73ML 74AP/78ML

TIBIAL INSERTS
SIZE 1.5
41AP/61ML PLI ■ ■ ■
AP

CVD, CVD+XLK ■ ■
SIZE 2
43AP/64ML PLI ■ ■ ■ ■ ■
CVD, CVD+XLK ■ ■ ■ ■
SIZE 2.5
45AP/67ML PLI ■ ■ ■ ■ ■
CVD, CVD+XLK ■ ■ ■
SIZE 3
47AP/71ML PLI ■ ■ ■ ■ ■
CVD, CVD+XLK ■ ■ ■ ■
SIZE 4
51AP/76ML PLI ■ ■ ■ ■ ■ ■
CVD, CVD+XLK ■ ■ ■
SIZE 5
55AP/83ML PLI ■ ■ ■ ■
CVD, CVD+XLK ■ ■ ■
SIZE 6
59AP/89ML PLI ■ ■ ■
CVD, CVD+XLK ■ ■

POSTERIOR LIPPED
8, 10, 12.5, 15, 17.5, 20 (mm)

CURVED
8, 10, 12.5, 15, 17.5, 20 (mm)

CURVED PLUS XLK

8, 10, 12.5, 15, 17.5, 20 (mm)

99
CRUCIATE SUBSTITUTING PRIMARY AND REVISION—
FEMORAL AND TIBIAL INSERT COMPATIBILITY

CS TC3 FEMORAL COMPONENTS

SIZE 1.5 SIZE 2 SIZE 2.5 SIZE 3 SIZE 4 SIZE 5 SIZE 6
53AP/57ML 56AP/60ML 59AP/63ML 61AP/66ML 65AP/71ML 69AP/73ML 74AP/78ML

CS TC3 CS TC3 CS TC3 CS TC3 CS TC3 CS TC3 CS TC3

TIBIAL INSERTS
SIZE 1.5
41AP/61ML PS SP ■ ■ ■ ■
TC3 ■ ■
SIZE 2
43AP/64ML PS SP ■ ■ ■ ■ ■ ■ ■ ■
TC3 ■ ■ ■ ■
SIZE 2.5
45AP/67ML PS SP ■ ■ ■ ■ ■ ■
TC3 ■ ■ ■
SIZE 3
47AP/71ML PS SP ■ ■ ■ ■ ■ ■ ■ ■
TC3 ■ ■ ■ ■
SIZE 4
51AP/76ML PS SP ■ ■ ■ ■ ■ ■
TC3 ■ ■ ■
SIZE 5
55AP/83ML PS SP ■ ■ ■ ■ ■
TC3 ■ ■
SIZE 6
59AP/89ML PS SP ■ ■ ■

PS POSTERIOR STABILIZED
8, 10, 12.5, 15, 17.5, 20, 22.5, 25 (mm)

SP STABILIZED PLUS
10, 12.5, 15, 17.5, 20, 22.5, 25, 30 (mm)

TC3 TC3
10, 12.5, 15, 17.5, 20, 22.5, 25, 30 (mm)

100
NOTES
NOTES
 LCS® Complete™ – P.F.C.® Sigma™ RP Mobile Bearing Total Knee System
Important:
This essential product information sheet does not include all of the information necessary for selection and use of a device. Please see full labeling for all
necessary information.

Indications
Cemented Use:
The LCS® Complete™ – P.F.C.® Sigma™ RP Mobile Bearing Total Knee System is indicated for cemented use in cases of osteoarthritis and rheumatoid
arthritis. The RPF insert and femoral component are indicated where a higher than normal degree of post-operative flexion is required. The rotating
platform prosthesis and modular revision components are indicated for revision of failed knee prostheses.

Uncemented Use:
The porous coated Keeled and Non-Keeled M.B.T.™ (Mobile Bearing Tibial) Tray configurations of the LCS Total Knee System are indicated for
noncemented use in skeletally mature individuals undergoing primary surgery for reconstructing knees damaged as a result of noninflammatory
degenerative joint disease (NIDJD) or either of its composite diagnoses of osteoarthritis and post-traumatic arthritis pathologies. The Rotating Plat-
form device configuration is indicated for use in knees whose anterior and posterior cruciate ligaments are absent or are in such condition as to justify
their sacrifice. The P.F.C. Sigma RP Curved bearings when used with the P.F.C. Sigma Cruciate Retaining Femoral Component can be used in
posterior cruciate ligament retaining procedures.

Contraindications:
The use of the LCS Complete – P.F.C. Sigma RP Mobile Bearing Total Knee System is contraindicated in:
• the presence of osteomyelitis, pyrogenic infection or other overt infection of the knee joint;
• patients with any active infection at sites such as the genitourinary tract, pulmonary system, skin or any other site. Should a patient have any
infection prior to implantation, the foci of the infection must be treated prior to, during and after implantation.
• patients with loss of musculature or neuromuscular compromise leading to loss of function in the involved limb or in whom the requirements
for its use would affect recommended rehabilitation procedures.
• patients with severe osteoporosis or other metabolic bone diseases of the knee.
• patients with any of the following conditions:
• lesions of the supporting bone structures (e.g. aneurysmal or simple bone cysts, giant cell tumor or any malignant tumor),
• systemic and metabolic disorders leading to progressive deterioration of solid bone support,
• the presence of severe instability secondary to advanced loss of osteochondral structure or the absence of collateral ligament integrity, fixed
deformities greater than 60° of flexion, 45° of genu varus or valgus,
• known drug or alcohol addiction,
• skeletally immature individuals and the presence of allergic reaction to implant metals or polyethylene are also contraindications for the non-
cemented, porous coated, M.B.T. and LCS Complete – P.F.C. Sigma RP Mobile Bearing device configurations, and for the cemented use of
all device configurations of the LCS Complete – P.F.C. Sigma RP Mobile Bearing Total Knee System.

Contraindications for use without cement:

Noncemented use of the Porous Coated Keeled or Non-Keeled M.B.T. Tray device configurations is contraindicated in patients with sufficient loss in
quantity or quality of bone stock (as determined on X-ray) such that successful noncemented fixation is unlikely. Additional contraindications may
become apparent at the time of surgery. These include:
• vascular deficiency at the bone site;
• inadequate bone stock to assure both a firm press fit and close apposition of the cut bone surfaces to the prosthesis;
• the inability to make bone cuts so as to assure both correct component position and intimate apposition of bone and prosthetic surfaces;
• inadequate bone quality (e.g. severe osteoporosis) and lack of stability of the implanted components.

In the presence of any of the above conditions the components should be fixed with cement.

Warnings and Precautions:

Components labeled for “Cemented Use Only” are to be implanted only with bone cement. The following conditions tend to adversely affect knee replace-
ment implants: excessive patient weight, high levels of patient activity, likelihood of falls, poor bone stock, metabolic disorders, disabilities of other joints.
The P.F.C. stem extensions can only be used with M.B.T. revision trays and LCS Complete Revision and Modular femoral components.

Adverse Events:
The following are the most frequent adverse events after knee arthroplasty: change in position of the components, loosening, bending, cracking,
fracture, deformation or wear of one or more of the components, infection, tissue reaction to implant materials or wear debris; pain, dislocation, sub-
luxation, flexion contracture, decreased range of motion, lengthening or shortening of leg caused by improper positioning, looseness or wear of compo-
nents; fractures of the femur or tibia.

For more information about DePuy products, visit our web site at www.jnjgateway.com.

DePuy Orthopaedics, Inc. DePuy International Ltd

700 Orthopaedic Drive St Anthony's Road
Warsaw, IN 46581-0988 Leeds LS11 8DT
USA England
Tel: +1 (800) 366 8143 Tel: +44 (113) 387 7800
Fax: +1 (574) 267 7196 Fax: +44 (113) 387 7890

2M0206 Printed in USA.

SP2-007 (Rev. 6) ©1998 DePuy Orthopaedics. All rights reserved.