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™ Preservation™ Knee System surgical technique I N T E L L I G E N T O R T H O P A E D I C S Contents Ci™ System Connections 2 Borders of the Condyles 29 Ci™ System Set-up 4 Femoral Cortex Modelling 30 Start-up Procedure 5 Femoral Model Calculation and Verification 31 Ci™ Menu Buttons 6 Tibial Slope 32 Ci™ Procedure Set-up 8 Cartilage Defect Planning 33 Tibial & Femoral Array Positioning 10 Leg Extension 34 Tibial & Femoral Array Fixation 11 Desired Post-Operative Leg Alignment 34 Camera Side 11 Leg Flexion 35 Camera Alignment 12 Femoral Implant Planning 35 Incision & Exposure 13 Tibial Implant Planning 37 Registration 14 Motion Analysis 39 Calculating the Femoral Head Centre 15 Tibial Pin Insertion 40 Pointer Tips 16 Tibial Resection Navigation 41 Definition of the Malleoli 17 Tibial Resection 43 Definition of the Tibial Mechanical Axis 18 Tibial Resection Verification 44 Tibial Sizing 19 Check Extension Gap 45 Tibial A/P Direction 20 Check Flexion Gap 46 Tibial Modelling 21 Extension / Flexion Gap Adjustments 47 Tibial Plateau Modelling 22 Distal Femoral Resection 48 Tibial Model Calculation and Verification 23 Distal Femoral Resection Verification 50 Femoral Mechanical Axis 24 Tibial Template Navigation 51 Registration of Epicondyles 25 Tibial Template Preparation 52 Registration of the Anterior Cortex 26 Femoral Preparation 53 Epicondylar Axis 27 Tibial Component Trial and Verification 57 Femoral Condyle Modelling 28 Femoral Component Trial and Verification 58 1 Ci™ System Connections 3 2 5 1 4 Ci™ Unit Connections Connecting the Ci™ System 1. Power switch (on / off) 2. Power lead connection 3. Currency switch All cables are connected to a panel at the The power switch is positioned below the The standard 3 pin power lead connects The red ‘H-shape’ switch adjusts the rear of the Ci™ unit. All power cables and power socket. A green light indicates when to the power socket. power supply between 110 volts and 220 connectors are supplied with the system. the unit is switched on. volts. Make sure that the correct voltage is selected before switching on the system. 2 Power lead Camera cable Camera unit cable 1 Camera unit cable 2 Earth connection 4. Earth lead connection 5. Camera unit connection Important: The camera must be switched Please refer to the System User Guide The earth socket is identified by the The orange coloured camera cable plugs on at least 20 minutes prior to the start of (Art-No: 52543-03EN) for detailed standard yellow and green earth colours. into the camera unit socket (also marked the procedure. set-up instructions. The system must be earthed using the in orange). The cable pins are aligned cable supplied before switching on the before inserting the cable. The cable is system. removed by pulling smoothly and slowly to Connections on the camera unit should also be checked at this stage. avoid damaging the pins. 3 Ci™ System Set-up Ci™ Unit Surgeon Assistant Surgeon Assistant O.R. Nurse O.R. Nurse Ci™ Unit Camera Unit Camera Unit Option 2: Ci™ System next to surgeon Option 1: Ci™ System opposite surgeon Positioning the Ci™ System in the O.R. Ideally the infra-red camera unit has an If the Ci™ unit is positioned within the Please refer to the System User Guide The Ci™ unit should be positioned so that uninterrupted view of the tibial and femoral sterile field it must be covered using the (Art-No: 52543-03EN) for detailed the surgeon has a clear view of the screen. marker arrays throughout a full range of drape supplied. set-up instructions. The touch-screen should be within easy motion (flexion, extension and pivoting of reach of the surgeon or theatre assistant. the hip joint). The camera unit should be Unstable stands or tables should not be used for placement of the Ci™ unit. (see positioned between 1.5 and 2 metres ordering information for Ci™ unit trolley) away from the surgical site. 4 Start-up Procedure Figure 1 Figure 2 Figure 3 All cables must be fully connected before Once the power supply has been switched If the camera unit is not properly The start-up screens allow the user to switching on the system. on, the Ci™ software will automatically connected, no ‘beeps’ will be heard and configure network and video settings initialise (Figure 1). an error message will appear asking you if required (Figure 3). to restart the system (Figure 2). Two ‘beeps’ indicate that the camera unit A blank CD-R (not CD-RW) should be is properly connected. inserted into the Ci™ unit to allow any patient data to be stored. 5 Ci™ Menu Buttons 1. Status Field – red / orange / green Green: Normal tracking mode Yellow: Ci™ instrument not visible to camera Red: Ci™ instrument and / or navigation array not visible to camera for more than 3 seconds Pressing on this button brings up the camera field of view screen. This will show the position of all visible navigated instruments in the field of view. 2. Information Button Provides information on the application, version number, phone ’hotline’ numbers and www.iorthopaedics.com website 3. Zoom In Zooms in on the morphed bone model 4. Zoom Out Zooms out of the morphed bone model 5. Ligament Balancing Can be used at any time after the registration procedure is complete 6 6. 3D Model Allows the user to switch between hiding or displaying the 3D model, leaving only the ‘cloud’ of acquired points visible on screen. 7. Implant information Provides details on the implants and sizes. This may be used to confirm the selected implants after the implant planning stage. 8. Verification Button If, at any time the reference arrays are moved or knocked out of position, you can re-verify the accuracy of the bone model using the pointer. If the bone model is no longer accurate, the registration process will need to be repeated. (if only one array has been moved, the registration will only need to be repeated for that array). Use the next / back buttons to return to the appropriate point in the procedure. 9. Screenshot Button This allows the user to take manual screenshots at any stage of the procedure. Screenshots are stored within the system and can be written to a CD. The system will also take automatic screenshots at key stages during the procedure. 10. Close Button This closes the application. All information can then be stored on disk before continuing with a new procedure. The patient’s name and ID are stored as an HTML file with all information gathered during the procedure. 7 Ci™ Procedure Set-up On screen there are next and back buttons. In this surgical technique we use arrows to indicate movement to the next step. Arrow Key: Press ‘next’ to continue Press ‘back’ to return to the previous step Figure 4 Figure 5 The procedure is started by entering the The appropriate knee system software is patient’s name and ID, using the touch- selected from the choices displayed - screen keyboard (Figure 4). LCS® / P.F.C.® Sigma™ / P.F.C.® Sigma™ RP / This information will appear on the screen Preservation™ (Figure 5). and on each screenshot taken during the operation. 8 Figure 6 Figure 7 A choice of metal backed fixed bearing, The appropriate leg and the affected condyle all polyethylene fixed bearing or mobile are selected for the operation (Figure 7). bearing implants is displayed on screen (Figure 6). The desired implant is selected (as defined pre-operatively). Press ‘change’ to alter the selections on screen. 9 Tibial & Femoral Array Positioning Position of standard Ci™ tibial jig Schantz pin position Intended femoral array position Schantz pin position Intended tibial array position Figure 8 Figure 9 The arrays must be placed away from the Note: The position of the reference arrays Positioning of the tibial jig Positioning of the femoral array intended positions of both the femoral and must not be moved during the operation, The tibial jig / system handle assembly is The femoral array should be positioned tibial instruments to avoid any contact as this will lead to inaccurate information held in an approximate position on the away from the intended incision and during bone resection and drilling. It is being displayed, and possible cancellation tibial while a a mark is made to identify the should not influence soft tissue and important that the navigated system of the procedure. Please refer to the schantz pin position.Care should be taken ligament movement in extension and handle is attached to the tibial jig prior to Clinical User Guide (Art-No: 60901-11EN) to position the array clear of the tibial jig flexion (Figure 9). array fixation and that its position is noted. for further information on positioning and and any navigated instrument (Figure 8). fixation of the reference arrays. 10 Tibial & Femoral Array Fixation Camera Side Screw connector Flexible joint Fixation knob Cortical bone spikes Figure 10 Figure 11 A schantz pin is inserted into the drill and The tibial array is lowered onto the pin until The screw connector is tightened by hand The position of the camera in relation to introduced bicortically to the tibia. A soft it touches the surface of the leg and the until the array is stable. A wrench is used the patient is defined on the system tissue cover should be used on the spikes on the bottom of the array engage to fully secure the final position and angle (Figure 11). schantz screw to avoid any tissue with cortical bone. The array is angled so of the array. disruption. The reflective marker spheres that it does not interfere with the positioning Care should be taken if the patient has should now be attached to the tibial of the tibial jig and the navigated system osteoporotic bone, as over tightening of (T-shape) array. handle (Figure 10). the array may loosen the schantz pin. 11 Camera Alignment Red dots: Tibial array Yellow dots: Femoral array Purple dots: Ci™ pointer Blue dots: Additional Ci tools Grey dots: Unknown marker The status field lights indicate that all instruments are visible The camera field of view Green: Normal tracking mode Yellow: Ci™ instrument not visible to camera is indicated by the blue cone Red: Red circles: Tibial array Ci™ instrument and / or navigation array not visible to camera for more than 3 seconds Yellow circles: Femoral array Purple circles: Ci™ pointer Grey: Blue circles: Additional Ci tools Camera communication error during start-up Re-start the system Grey circles: Unknown marker Figure 12 The camera alignment window highlights Coloured dots represent the positions The status field lights indicate the visibility movement of the reference arrays and of the femoral and tibial reference arrays, of the arrays and instruments. instruments. These are displayed as and the Ci™ pointer. The camera displays can be accessed at different coloured dots and circles The circles show the position of the any time during the procedure by touching instruments in relation to the camera unit’s the status field lights. on-screen (Figures 12). field of view. 12 Incision & Exposure Figure 13 Figure 14 Depending on the location of the 2 cm distal to the joint line (Figure 13). The The deep menisco-tibial layer of the pad may also be excised to improve vision osteoarthrosis, an antero-medial or antero- joint capsule is entered with a parapatellar medial or lateral capsule should be and allow inspection of the opposite lateral skin incision is performed. The incision (Figure 14). Once the joint is carefully reflected to provide good access compartment. Two large rake retractors are incision should begin 1 cm proximal to the exposed a final assessment can be made to any tibial osteophytes and allow then introduced to maintain access at all superior border of the patella. It should of the extent of arthritic damage and the accurate wound closure. Any excess deep stages of the procedure. extend 6 - 10 cm distally along the edge of suitability of the joint for this procedure. synovium is excised to provide clear sight No ligament releases should be the patella and patella tendon, and end of the joint. If required, all or part of the fat performed as part of this procedure. 13 Registration It is vital that all osteophytes are removed from the entire medial or lateral edges of the femur and tibia Anatomic axis Mechanical axis Valgus angle Joint line Figure 15 Figure 16 In order to achieve medial / lateral (M/L) A retractor is used on the patella rim to Registration defines the mechanical axis existing 3D model created from an alignment and joint stability, it is vital that draw the patella into a central position. and important anatomical landmarks extensive database of healthy and arthritic all osteophytes are removed from the Any significant osteophytes on the edge of (Figure 16). This allows accurate knees. Tibial registration is performed first, entire medial or lateral edges of the femur the patella should also be excised. positioning and sizing of the intended followed by femoral registration. Each and tibia before registration takes place implants. A 3D model of the patient’s bone screen offers the option to re-perform the (Figure 15). anatomy is created and mapped onto an step if required. 14 Calculating the Femoral Head Centre An assistant may hold the pelvis in position during this step to ensure that an accurate calculation is made. Figure 17 Figure 18 Registration defines the mechanical axis Calculating the rotational centre of the The femur is pivoted using circular The system calculates the centre of the and important anatomical landmarks. This femoral head defines the proximal point of motions (Figure 17). The system femoral head to within 3 mm. This relates allows accurate positioning and sizing of the mechanical axis. It is important to calculates a series of points to determine to no more than a 0.5˚ deviation on the the intended implants. A customised 3D make sure that the patient’s pelvis is not the rotational centre and will automatically mechanical axis. If the centre of the model of the patient’s bone anatomy is moved excessively during registration proceed when the rotational centre has femoral head is not calculated correctly, created. Each screen offers the option to as this will lead to miscalculation by been calculated (Figure 18). a warning box will appear and the step re-perform the step if required. the system. is re-performed. 15 Pointer Tips The pointer is pivoted prior to a point being acquired Figure 19 1. To acquire points accurately, it is helpful Figure 20 2. To avoid acquiring unnecessary points 3. Make sure all three marker spheres on to refer to the screen as each point to hold the tip of the pointer with one before the pointer is positioned, it may the pointer are directed towards the is acquired. If the camera cannot see hand while pivoting the pointer with the be helpful to cover one of the marker camera unit when acquiring a point. the pointer, a deep sounding ‘beep’ will other. This will ensure that all of the spheres with a hand. This will effectively be heard, 4. When a point has been successfully points are registered on the bone, not ‘eliminate’ the pointer from the field away from the patient (Figure 19). of view (Figure 20). acquired, the system will emit an audible ‘beep’. This removes the need 5. If at any stage during the procedure the marker spheres become contaminated with blood or tissue, they may be gently 16 cleaned using lint-free cloth. Definition of the Malleoli Figure 21 Figure 22 The medial and lateral malleolus are Place the tip of the pointer to the medial Acquiring the malleoli defines the distal It is important that these points are defined using the Ci™ pointer. malleolus and pivot the pointer (Figure 21). point of the mechanical axis. acquired as accurately as possible as implant position and alignment are It is important not to move the tip of the The malleoli can usually be located by All single registration points for referenced to the hip / ankle axis and pointer from the bone. Once the system hand before acquiring the points. It is anatomical landmarks are acquired in the mechanical axis. has registered the medial malleolus, the important that draping or bandaging is the same way. lateral malleolus can be registered in the reduced to a minimum to enable the same way (Figure 22). malleoli to be located. 17 Definition of the Tibial Mechanical Axis Figure 23 Figure 24 The mechanical axis is defined by It is important that the point acquired The definition of the mechanical axis is the acquiring the posterior aspect of the ACL defines the mechanical axis, and not the basis for all further calculations and should tibial attachment point (Figure 23). tibial eminence. be acquired as accurately as possible. This is indicated by the arrow on screen (Figure 24). 18 Tibial Sizing Figure 25 Figure 26 The most medial or lateral point of the The points should be acquired at the The posterior point is required to assess A visual check should also be performed proximal tibia is acquired using the pointer, approximate level of resection. tibial component sizing. This point should during the tray navigation step. followed by the most anterior and posterior be acquired as accurately as possible. point on the affected compartment (Figures 25 & 26). 19 Tibial A/P Direction Figure 27 Figure 28 The pointer is placed on the tibia to The pointer is held in place for 2 seconds Note: incorrect registration of the tibial determine the A/P direction of the tibial to allow the system to calculate the A/P direction may lead to compound slope (Figure 27). If access to the centre of direction (Figure 28). slope phenomenon. the tibia is limited, the pointer can be placed to one side. 20 Tibial Modelling Points should be acquired around the rim, and as posteriorly as possible Figure 29 Figure 30 A fixed number of points along the anterior The pointer is placed on the tibia and The tip of the pointer should ‘paint’ the The sequence ends when enough points and medial or lateral tibia are acquired pivoted to begin the procedure. A ‘beep’ surface of the tibia. Points should be have been acquired. using the Ci pointer. These are used to will indicate when to begin moving the acquired mainly around the rim and extend define the bone model (Figure 29). pointer (Figure 30). as posteriorly as possible. Acquisitions further down the tibia are less important, but will add shape to the model. 21 Tibial Plateau Modelling Place the tip of the pointer in the centre of the plateau Figure 31 Figure 32 The Ci™ pointer should be placed in the The tip is moved in a circular motion across It may be helpful to apply varus or valgus The sequence ends when enough points centre of the medial or lateral tibial plateau the surface of the plateau (Figure 32). stress to the knee joint to allow greater have been acquired. (Figure 31). access to the tibial plateau. 22 Tibial Model Calculation and Verification The white areas The deviation from the tip represent acquired points of the pointer to the bone is represented in mm Figure 33 Following registration, the system adapts the tibial model (Figure 33). • White areas are parts of the model with Figure 34 • Brown areas are parts of the model where no points have been acquired. The maximum acceptable deviation is less Note: implant sizing is based on aquired than 2 mm. Acquired points will normally points only. The accuracy of the model show a deviation of less than 1 mm should be checked on the areas Verification of the model will only be responsible for implant sizing and accurate in white areas where points have position (medial or lateral boundary, been acquired (Figure 34). medial or lateral plateau). The accuracy of the model is checked by deviations no greater than 2 mm from holding the Ci™ pointer to the tibia. The the actual bone structure. exact deviation from the tip of the pointer to the model is displayed on the screen. 23 Femoral Mechanical Axis Figure 35 Figure 36 The registration of the femur is The pointer should be placed at the It is important that the mechanical axis automatically activated once the tibial anterior aspect of the femoral notch point point is acquired as accurately as possible. registration has been completed. as indicated on screen (Figures 35 & 36). 24 Registration of Epicondyles Figure 37 Figure 38 Acquisition of the most medial and lateral These points are required for the model epicondylar points may be made either morphing process and are not used in through the incision or on top of the skin implant alignment. (Figures 37 & 38). 25 Registration of the Anterior Cortex Figure 42 The anterior cortex is acquired using the This point helps to shape the final bone pointer. Ideally, the pointer should be model (Figures 39 & 40). Figure 43 placed on the deepest point on the anterior femoral cortex just above the superior border of the femero-patella articular surface. 26 Epicondylar Axis Figure 41 Figure 42 The pointer is placed on the distal The pointer can be positioned through the Note: this line does not have an condyles (below the patella) and held still incision and can be checked by feeling influence on the rotational alignment to allow the system to calculate the through the skin for contact. of the femoral component. epicondylar axis (Figures 41 & 42). Alternatively, it can be held on top of the incision and positioned against the condyles. 27 Femoral Condyle Modelling Points should be acquired as posteriorly as possible on the affected condyle Figure 43 Figure 44 A fixed number of points along the surface The tip of the pointer should ‘paint’ the If insufficient posterior points are acquired of the medial or lateral condyle are acquired surface of the condyles. Points should be the system will ask for the step to be re- using the Ci™ pointer (Figures 43 & 44). acquired as posteriorly as possible and performed. Acquisition should begin at the most along the distal part of the affected condyle. distal point. This allows the system to accurately calculate both the size and position of the intended implant. 28 Borders of the Condyles Figure 45 Figure 46 A fixed number of points along the border These points will act as a guide to help of the affected condyle are acquired using define the M/L and rotational alignment of the Ci™ pointer. It should move along the the implant. outer and inner edge of the condyle in one movement (Figures 45 & 46). 29 Femoral Cortex Modelling Figure 47 Figure 48 Multiple points on the affected side of the anterior femoral cortex are acquired using the Ci™ pointer (Figures 47 & 48). 30 Femoral Model Calculation and Verification The white areas The deviation from the tip represent acquired points of the pointer to the bone is represented in mm Figure 49 Following registration, the system adapts the femoral model (Figure 49). • White areas are parts of the model with Figure 50 • Brown areas are parts of the model where no points have been acquired. The maximum acceptable deviation is less Note: femoral implant sizing is based on than 2 mm. Acquired points will normally aquired points only. The accuracy of the show a deviation of less than 1 mm model should be checked on the areas Verification of the model will only be responsible for implant sizing and position. The accuracy of the model is checked by deviations no greater than 2 mm from holding the Ci™ pointer to the tibia. The the actual bone structure. exact deviation from the tip of the pointer accurate in white areas where points have been acquired (Figure 50). to the model is displayed on the screen. 31 Tibial Slope Figure 51 Figure 52 The navigated plane is attached to the After removal of the meniscus and with the After a couple of seconds or by pressing It may be helpful to remove the 3D model navigated tibial handle with the flat side leg in flexion, the instrument is placed on ‘next’ the system will measure the tibial and use the acquired points only as a facing down toward the tibia. the tibial plateau as posteriorly as slope angle and display this on screen reference to adjusting the slope manually. possible. The leg is placed in extension to (Figure 52). The tibial slope angle can be enable the instrument to be secured re-adjusted manually if required. Pressing between the tibia and femur (Figure 51). ‘next’ will accept the tibial slope angle. 32 Cartilage Defect Planning Figure 53 Figure 54 The next few steps allow the surgeon to The amount of cartilage to be removed Important: Care should be taken when Large cartilage defect assumptions assess the pre-disease leg alignment. should be assessed visually. The defect assessing the cartilage defect. The larger may produce a small distal resection amount (in mm) is entered into the system. the cartilage defect, the thinner the distal face. This may cause problems with Average defects range between 1 - 2 mm bone resection. Choosing a 2 mm or fixation of the femoral cutting block and in severe cases up to 3 mm (Figures 3 mm cartilage defect may cause later in the procedure. 53 & 54). problems in patient’s with sclerotic bone. 33 Leg Extension Desired Post-Operative Leg Alignment Figure 55 Figure 56 The leg is placed in full extension and held This is used to gauge the patient’s The leg is then placed in approximately When natural alignment is achieved in position to allow the system to register maximum extension range for the femoral 4 - 7 degrees of flexion. Varus / valgus (balanced medial and lateral tension) the maximum extension angle (Figure 55). planning steps. movement is applied to the joint and the position is stored on the system. ligament stress is assessed (Figure 56). 34 Leg Flexion Femoral Implant Planning Figure 57 Figure 58 The leg is placed in approximately The femoral implant size and position is Dark blue lines – proposed cutting plane Green line - Most anterior point of the tibia, 85˚ to 95˚ of flexion. A neutral position of displayed on screen (Figures 58-61). of the femur projected parallel to the mechanical axis of Button functions and screen information: Orange line - HKA line. the tibia should be achieved. No external femur. The anterior point of the femoral A/P or rotational force should be applied. component should always remain behind The position is stored on the system Blue arrows – allow repositioning of the Yellow line – proposed cutting plane of (Figure 57). femoral component the tibia 35 this line. Frontal / flexed view (top left) Lateral view (top right) Projected anterior point of the tibia Anterior / posterior Anterior / posterior translation translation Internal / external M/L Internal / external Flexion / extension Superior / inferior Flexion / extension rotation rranslation rotation rotation translation rotation Figure 59 Figure 60 The image can be zoomed in or out for Adjustment is limited to 10 degrees internal / better viewing using the Zoom function on external rotation, while changes to superior / the menu bar. inferior adjustment will automatically change the bone loss assumption. 36 Tibial Implant Planning Planning information (bottom right) The implant size function is used to change the size of the femoral component. After changing the size, the distal cut will be re-calculated, and the flexion gap adjusted. The system will only allow compatible sized components to be selected. The ‘freesize’ option can be used to manually change the implant size. However, if inappropriate implants are selected, the system will display a warning message relating to implant compatibility. The ‘proceed’ option will be removed at this stage to force the user to select compatible implants. Figure 61 Figure 62 When using the fine tune functions, the Tibial implant planning is conducted in the Frontal / flexed view (top left screen) acquired points are the main reference same manner as the femoral implant Superior / inferior and in varus / valgus for planning and implant placement. planning. Adjustments can be made to adjustments can be made to the tibial The 3D model only provides additional both the proposed femoral and tibial implant. If the tibial insert thickness is information and 3D orientation. implants at this stage (Figures 62 -66). increased, the resection level is automatically adjusted to ensure that leg alignment is not influenced. 37 Frontal / flexed view (top left) Lateral view (top right) Figure 63 Figure 64 Axial view (bottom left) Figure 65 Medial / lateral and rotational adjustments Axial view (bottom left screen) The yellow dot represents the centre of the The tibial position and the femoral position may also be made to the femoral The tibial implant position can be adjusted tibial component (top left screen) are optimised to allow the component at this stage. in A/P, M/L and internal / external rotation. contact point of the femoral component to The red dot represents the contact point of lay central on the tibial component. The image shows the virtual tracking of the Lateral view (top right screen) the femoral component in extension The orientation (red line) of the femur is femoral component on the tibia in extension. The posterior slope can be adjusted using The red line represents the internal / external approximately aligned to the direction of direction of the femoral implant in extension. the tibial component. the blue arrows. 38 Motion Analysis Planning Information (bottom right) The ‘implant size’ and ‘implant size’ buttons change the size of the tibial component and / or the insert. The tibial cut is re-calculated and the gaps adjusted accordingly. The system only allows compatible sized implants to be selected. The ‘freesize’ option can be used to change this manually. However, the system will only allow you to change the tibial component and insert size if a compatible femoral implant is also selected at the same time. Resets all Returns to the Accepts all adjustments previous step adjustments Figure 66 Figure 67 The planning screen displays the final tibial The virtual contact points are shown on The yellow dot represents the centre of the implant data. screen in real time through a full range of tibial implant. The large red dot represents motions (Figure 67). If adjustments need the current contact point of the femoral to be made to the plan shown on screen, implant. The smaller red dots show the the previous implant planning steps can recorded contact points between the be repeated. femoral and tibial components. 39 Tibial Pin Insertion Figure 68 Figure 69 The navigated system handle is attached If the shape of the tibia does not allow A slotted or non-slotted cutting option is Note: If the pin is moved too far from the to the tibial jig (Figure 68). The suggested fixation in the M/L position shown on selected on screen, depending on suggested screen position, M/L fixation position of the pin is shown on screen, the closest possible position preference (Figure 69). adjustment may be difficult. screen (Figure 69). The system handle should be used. When navigation is complete, the tibial jig allows the tibial jig and pre-fixation pin to is pinned in place. be accurately positioned on screen. 40 Tibial Resection Navigation Navigated L-cut block Tibial slope adjustment screw Figure 70 Figure 71 With the tibial jig pinned in place, the Make sure the tibial jig is placed against Step 1: The L-cut block is rotated until the Step 2: The tibial slope is adjusted by navigated handle is removed. The navigated the tibia throughout the following steps to navigated L-cut line (blue) is parallel to the turning the slope screw until the planned tibial jig array / L-cut block is attached to maintain a consistent reference for the fine planned L-cut line (yellow) (Figure 71). and actual resection planes are parallel the top of the tibial jig (Figure 70). adjustments on screen. Once in position, the screw is tightened to in the sagittal view. The slope may be ensure stable fixation. increased by up to 2˚ after pinning the jig to the bone. The slope cannot be decreased at this stage. 41 Final pin position M/L adjustment screw Resection height adjustment screw Second pin position Figure 72 Figure 73 Step 3: The tibial jig is rotated around the Step 4: The M/L-position of the L-cut is Step 5: Once the M/L, varus / valgus and Step 6: The height of the tibial cut is now initial pin to adjust the varus / valgus angle. adjusted by turning the M/L adjustment tibial slope are aligned, the tibial jig is adjusted by turning the vertical screw in screw. It is important that the varus / valgus secured in place below the cutting block the centre of the tibial jig. Adjustments to angle remains unchanged during M/L using one or two pins (Figure 72). the varus / valgus angle and tibial slope adjustment. can be made if required. The jig is secured in place with a final pin prior to resection (Figure 73). 42 Tibial Resection Figure 75 Figure 74 The L-cut is initiated along the L-cut guide. The transverse cut must be performed Care must be taken to avoid over avoid cutting into the unaffected condyle. The L-cut can be completed after removing according to the cutting option selected resecting the bone or weakening the The L-cut must not proceed past the the L-cut block (Figure 74). earlier (either slotted or non-slotted) ACL. During the transverse cut, the saw transverse cut as this may cause (Figure 75). blade must be kept as level as possible, tibial fracture. and the L-cut guide must be used to 43 Tibial Resection Verification Figure 76 The tibial resection is verified using the The resection may be repeated at this navigated plane, attached to the navigated stage if required. Figure 77 handle (Figures 76 & 77). 44 Check Extension Gap Figure 78 Figure 79 Figure 80 The distal femoral cutting block is attached The system will indicate which tibial and The cutting block is inserted into the to the non-navigated handle (Figure 78). femoral spacer blocks to attach to the extension gap and the joint is assessed for cutting block (Figure 79). stability and alignment is checked on screen (Figures 79 & 80). 45 Check Flexion Gap Figure 81 The cutting block is removed and the knee Note: Make sure the knee is stable in is placed in approximately 90˚ of flexion. extension. The flexion position allows for The femoral spacer is removed, and the slightly more laxity, which may help in cutting block is inserted into the flexion high flexion. Figure 82 gap. The joint is assessed for stability (Figures 81 & 82). 46 Extension / Flexion Gap Adjustments Tight in Extension / Flexion OK: • If the tibial slope is OK a small shave Loose in Extension / Flexion OK: of bone may be taken from the • Check the tibial slope and re-cut • Check the tibial slope and re-cut posterior condyle. if necessary. if necessary. • Alternatively, choose a thinner tibial insert • Reduce the bone loss assumption • Choose a thicker tibial insert and shave or re-cut the tibia, and increase the bone (i.e. a thinner bone loss shim may be a little off the posterior condyle to adjust loss assumption (i.e. a thicker bone loss used to move the femoral component the flexion gap. shim may be used to move the femoral slightly proximal) component slightly distal). • Alternatively, increase the bone loss assumption (i.e. a thicker bone loss Tight in Extension and Flexion: shim may be used to move the femoral Loose in Flexion / Extension OK: component slightly distal). • A thinner insert should be selected. • Check the tibial slope and re-cut • If a thinner insert is not available, re-cut if necessary. Loose in Extension and Flexion: the tibia and update the tibial cut with • Choose a thicker tibial insert and reduce • Use a thicker tibial insert. the navigated plane bone loss assumption. Reduce the bone loss assumption (i.e. a thinner bone loss Tight in Flexion / Extension OK: • Check the tibial slope and re-cut • Note: Be careful with using larger bone shim may be used to move the femoral loss shims to correct a loose extension component slightly proximal. The knee position as this could lead to a very thin should not be tight in flexion). resection level on the distal femur. If this if necessary. resection level is very thin, fixation of the femoral cutting block may be problematic later in the procedure. 47 Distal Femoral Resection Figure 83 Figure 84 The non-navigated system handle is The block and spacers are introduced into Two pins are used to fix the cutting block Important: There should be no gap attached to the distal femoral cutting the joint and the leg flexed to the angle as in place. between the distal cutting block and the block. The appropriate tibial and femoral indicated on the screen (2 planes parallel). surface of the femur. If a gap exists, the spacers are added to the cutting block as This ensures that the distal cut matches resection will not match the planned indicated on screen (Figure 84). the planned flexion / extension angle of the resection on the system. femoral component (Figures 83 & 84). 48 Figure 85 Figure 86 The system handle is removed and the To avoid capsular damage posteriorly, this Once the resected distal bone is removed, distal resection performed (Figure 85). cut should be completed with the distal any remaining soft tissue is cleared from femoral cutting block removed (Figure 86). the meniscal rim and posterior of the tibia. 49 Distal Femoral Resection Verification Figure 87 The femoral resection is verified using the The resection may be re-performed if navigated plane (Figure 87). required. The verified position is used to Figure 88 update the plan on the system (Figure 88). 50 Tibial Template Navigation Figure 89 The tibial template (as indicated on If good bone coverage cannot be screen) is attached to the navigated achieved, a new position can be chosen system handle and positioned on the or the template size can be changed. The Figure 90 • The yellow dot represents the centre of the tibial component. • The M/L and rotational position of the femoral component can be adjusted at this stage to improve • The red dot represents the contact point resected tibia using on screen navigation template is held in position for 3 seconds tracking alignment. of the femoral component in extension. (Figures 89 & 90). to update the system. The axial view is • The red line represents the internal / used to assess the component tracking external rotation of the femoral on screen. component in extension. 51 Tibial Template Preparation Figure 91 Figure 92 With all on screen adjustments made, A sagittal saw is used to pre-cut the keel the navigated handle is removed and slot. The tibial osteotome completes the the template is fixed in place with a keel preparation (Figure 92). Specialist® II pin and the navigated handle is removed (Figure 91). 52 Femoral Preparation When the blue and yellow dots are aligned, the M/L and rotational position of the block is correct. Figure 93 Figure 94 The femoral finishing block is attached to The block is placed flush to the distal The screen indicates if the block is sitting Rotational alignment and M/L position are the navigated system handle. femoral resection, with the foot held flush on the distal cut (Figure 94). navigated on screen. against the posterior condyle. It may help With correct alignment achieved, the block to adjust the angle of the leg to reduce the is pinned in place. tension in on the patella while positioning the block (Figure 93). 53 Figure 95 Figure 96 There are two pin holes on either side of The system handle is removed and the the block. The upper pin hole is angled, posterior resection and posterior chamfer and is used on the outer side of the cut are made using a Preservation™ saw condyle. The lower straight hole is used on blade (Figure 96). the side closest to the patella (Figure 95). 54 Figure 97 Figure 98 The femoral peg hole is made using the The femoral slot is completed with a burr. peg drill (Figure 97). In cases where hard or sclerotic bone is present the slot should be pre-cut with a saw blade (Figure 98). 55 Figure 99 Figure 100 The 3/8th hibs gouge is used to mark the The Preservation™ chisel is used to make anterior profile of the femoral component the anterior chamfer cut (Figure 100). (Figure 99). 56 Component Trial & Verification Figure 101 Figure 102 The trial components are used to ensure The tibial prosthesis is trialed first and The system will then display a report with that the knee is placed in the appropriate gently impacted into place using the planned and achieved measures. The position to facilitate implantation, prior to C-arm impactor. The tray and keel should appropriate tibial insert trial is inserted. inserting the final components. be fully seated on the tibia. The position of For all poly and fixed bearing tibial the three dimples in the trial are recorded implants the same modular trials are used with the pointer in the order as indicated (Figure 103). on screen (Figures 101 & 102). 57 Figure 103 Figure 104 Figure 105 The femoral prosthesis is attached to the The system will then display a report femoral introducer, introduced to the femur with planned and achieved measures and gently pushed into place using the (Figure 106). femoral impactor. The position of the three dimples in the trial are recorded with the pointer in the order indicated on screen (Figures 104 & 105). 58 Figure 107 Figure 108 The joint is checked for alignment The tracking of the components can also Final femoral preparation should be and stability in flexion and extension be checked (Figure 108). completed using current Preservation™ (Figure 107). instruments. 59 Figure 109 A CD-ROM is inserted to allow all planning The system will automatically save this On the close application screen, information, screenshots and therapy information on shut-down. The system press ‘finish’ to exit the Ci™ software reports to be recorded. shut-down begins after pressing the (Figure 109). ‘close’ button on the final screen. 60 I N T E L L I G E N T O R T H O P A E D I C S I N T E L L I G E N T O R T H O P A E D I C S This publication is not intended for distribution in the USA The Ci™ logo and Ci™ are trademarks of DePuy International Ltd. Preservation™ and Sigma™ are trademarks and LCS®, P.F.C.® and Specialist® are registered trademarks of DePuy Orthopaedics, Inc. © 2004 DePuy International Limited. All rights reserved. Cat No: 52527 BrainLAB AG Ammerthalstraße 8 85551 Heimstetten Germany Tel: +49.89.991568-0 Fax: +49.89.991568-33 DePuy International Ltd St Anthony’s Road Leeds LS11 8DT England Tel: +44 (113) 270 0461 Fax: +44 (113) 272 4191
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