LCS Complete: Surgical Technique
LCS Complete: Surgical Technique
LCS Complete: Surgical Technique
MILESTONE™ Instruments
with MBT Tray Preparation
SURGICAL TECHNIQUE
CONTENTS
Preface 2
Surgical Concepts 3
Instruments 4
Surgical Technique 8
Preparation 8
Ligament Balancing 9
Tibial Resection 10
Femoral Sizing 14
Femoral Preparation 15
Trial Reduction 26
Patellar Resection 29
Patellar Trial 30
Non-Cemented Implantation 32
Cemented Implantation 35
Ordering Information 39
Any new concept that is introduced usually This surgical technique has been
goes through a series of evolutionary developed to provide the surgeon with a
changes as it is perfected. Each change clear explanation describing the use of the
hopefully improves the original concept. MILESTONE Instruments. The technique
has gone through an evolutionary process
The LCS® Total Knee System was first with input from a number of surgeons and
implanted by the designer in 1977. The engineers. Shortcuts and technique tips
system was subjected to a rigorous FDA have been identified through the 24 years
approved multicenter clinical investigation of usage and many are included in the
to prove its safety and efficacy.1 It became following technique.
nationally available in the United States in
1985. The instruments that were initially I am grateful to Louis Jordan, MD, for his
used reflected a very conservative surgical help in defining the patellar portion of the
approach. The objective was to ensure that technique and to Peter A. Keblish, MD, for
a precise and reproducible surgical his review of the interim manuscript and
procedure could be performed and that for his suggestions.
equal flexion and extension gaps could be
achieved in the process. I am also grateful to Frederick F. Buechel,
MD, and Michael J. Pappas, PhD, who
Since 1985, total knee arthroplasty (TKA) started it all.
instrumentation has evolved significantly. As
technique improvements have been made,
they have been evaluated and R. Barry Sorrells, MD
Total knee arthroplasty represents a If the posterior cruciate is absent or Primary femoral bone cuts preserve
major advance in the management of substituted, the axis of rotation a maximum of bone stock using the
severe, crippling arthritis. Success of remains central and equally shared by anterior femoral cortex and the
the procedure is dependent on the both compartments. The design of isthmus of the femoral canal for
skills of the surgeon and the surgical the implant allows for this and surgical reference. Slight external
team, coupled with the design of the eliminates the need for right and left rotation of the femoral component
implant and instrumentation. A tibial components or bearings. In this results from referencing the resected
scientifically sound design must be technique, the objective is to produce proximal tibia. This allows the
complemented by easily used a knee that has equal soft tissue femoral resections to parallel the
instruments and a technique that tension medially and laterally in both proximal tibia with the collateral
assures accuracy and reproducibility. flexion and extension. This results in ligaments tensioned. This also
a stable total knee throughout the provides a stable tracking position for
The surgical procedure to follow range of active and passive motion. the patella that helps avoid
provides the surgeon with the Such stability maintains contact subluxation.
necessary information to achieve pressure on the mobile bearings and
accurate and reproducible results protects against subluxations and A measured resection of the patellar
using the LCS Total Knee System with dislocations. articular surface, usually at the level
the MILESTONE Instruments. The of the quadriceps and patellar tendon
technique incorporates the basic Femoral component sizing is chosen insertion, allows sufficient bone stock
surgical philosophies of balanced to approximate the original A/P and and blood supply to implant a 3-peg
flexion and extension gaps developed M/L anatomy. A tibial-cut-first fixturing element. This stabilizes a
by Michael Freeman, FRCS, and John approach is used to provide a logical, rotating bearing or all polyethylene
Insall, MD. time-tested method that first fixed patellar replacement.
establishes the flexion gap, and then
In the normal knee, the majority of an extension gap to match. Since the
rotation occurs laterally with less sagittal tibial cut is non-variable,
motion seen medially; both condyles subsequent femoral cuts are
pivot about the intercondylar referenced from the resected tibia.
eminence as the center of rotation.
This surgical technique is based on The proximal tibia is cut with a
the principle that reproducing normal posterior inclination parallel to the
knee rotation is desirable when the patient’s anatomic inclination angle.
anterior and/or posterior cruciate This provides better flexion, creates
ligaments are sacrificed. compressive loading of the tibial
components and avoids shearing
effects associated with perpendicular
plane resections.
Tibial Instruments
Tibial Stylus
Anterior/Posterior Cutting Block
General Instruments
Saw Capture
Slap Hammer
Flatness Gauge
Pin Extractor
Pin Holder
Alignment Rod
1. Resect proximal tibia and balance 2. Size femur, position A/P block and drill intramedullary guide hole.
soft tissues in extension.
4-7
2-3
1-1.5
Anatomic Axis
Mechanical Axis
Valgus Angle
Alternate skin
incision for
varus exposure
Pre-operatively, obtain a standing the I.M. line at the level of the With the knee slightly flexed, make
A/P x-ray of both the femur and anticipated resection. It is a straight midline incision from 3 to
tibia centered on the knee joint. On recommended by the author that 4 in. above the patella, over the
the x-ray, draw a line through the the following valgus angles be used patella, and ending at the tibial
center of each femoral canal to the based on the patient’s height: tubercle (Figure 2). With neutral
center of the knee joint (anatomic alignment or with varus deformity,
axis). Draw a line through the Height < 5’11” 5 degrees make a median parapatellar incision
center of each femoral head to the through the retinaculum, capsule
Height 5’11” – 6’1” 4 degrees
center of the knee joint (mechanical and synovium (Figure 3). The
axis). The angle between these two Height > 6’1” 3 degrees subvastus approach may be used. If
lines is the “valgus angle” significant valgus deformity exists, a
(Figure 1). Measure the valgus angle Pre-operatively assess component lateral parapatellar deep incision as
of both knees. The normal angle sizing and resection depths in both part of a lateral release may be
varies from 3 to 8 degrees and the A/P and M/L planes using the preferred (Figure 4).3, 4
should be individualized for each x-ray templates.
patient in the distal femoral
resection. Draw a transverse tibial
line perpendicular to
LCL and PT
elevated with
periosteal attachment
ITB elevated
subperiosteally MCL and
pes anserinus
elevated
subperiosteally
Following a median parapatellar with an osteo-periosteal flap if on page 29) By reducing patellar
incision, reflect the patella laterally necessary for patellar reflexion. bulk, eversion may not be necessary.
to expose the entire tibiofemoral Reflect the patella The patellar remnant can simply be
joint (Figure 5). Should tension and periosteal attachments displaced to the side, lessening
prevent adequate lateral medially.3, 4 Excise hypertrophic tension on its tubercle insertion.
displacement of the patella, detach synovium and a portion of the
the medial one-fourth to one-third infrapatellar fat pad to allow access Remove femoral and tibial
of the patellar tendon from the to the medial, lateral and osteophytes, especially any deep to
tibial tubercle. To further mobilize intercondylar spaces. Excise the collateral ligaments. Lateral soft
the extensor mechanism, continue redundant synovium to prevent tissue release and, occasionally,
the sharp incision of the medial possible impingement or post- osteotomy and removal of the
portion of the quadriceps tendon operative overgrowth. Some fibular head (severe valgus) will
proximally. surgeons prefer a complete enable correction of valgus
synovectomy. contracture (Figure 6). Medial
Following a lateral parapatellar release will be necessary for a fixed
incision in the valgus knee, incise For better exposure, a preliminary varus deformity (Figure 7). An
the anterior compartment fascia patellar resection may be performed extensive medial tibial subperiosteal
longitudinally 1 cm from the tibial at this stage. (see Patellar Resection sleeve may be necessary in severe
tubercle. Elevate the tibial tubercle varus angulation.
Ankle clamp
After the proximal tibia and distal Make a longitudinal mark from a Flex the knee to 90 degrees,
femur are cleared of soft tissue point 6 - 8 mm medial to the position the tibia in about 10
debris, sharply develop the soft midpoint between the prominence degrees external rotation and clearly
tissue planes between the collateral of the medial and lateral malleoli, mark the center of the tibia with
ligaments and the joint surfaces. extending to the second toe reference to the intercondylar notch
Expose approximately 1 in. of (Figure 8). Select the tibial cutting of the femur (Figure 10).
proximal tibia anteriorly, medially block (7 or 10 degrees) compatible
and laterally. Slide retractors deep with the posterior slope of the
to the collateral ligaments and patient’s tibia and attach it
anterior to the posterior capsule to proximally to the tibial cutting
protect the posterior neurovascular guide. Attach the ankle clamp to
structures during resection of the the rod distally (Figure 9).
tibial articular surface. An “S” or
“Z” shaped retractor works well
(Figure 5).
Introduce the long spike of the the tibia, usually slightly medial to When the rod is parallel to the
alignment guide into the proximal the tibial tubercle. It should be intramedullary axis of the tibia as
tibial spines (Figure 11). Attach the directly over the longitudinal mark viewed laterally, the posterior slope
ankle clamp by wrapping the spring distally, just lateral to the tibialis of the tibia should parallel the
around the ankle. Establish proper anterior tendon (Figure 13). chosen resection block (7 or 10
rotational alignment by positioning degrees). The slope may be further
the appropriate malleoli wings adjusted by loosening the ankle
parallel to the transmalleolar axis clamp knob and sliding the rod
(Figure 12). Place the alignment rod anteriorly or posteriorly. When
proximally over the center mark on proper positioning is achieved,
impale the second spike (Figure 14)
and lock the ankle clamp knob.
Attach the stylus (0 or 2 mm) to the stylus. (A 6 mm stylus is also Check alignment by attaching the
tibial cutting block on the side of provided. The 6 mm measurement alignment tower and rod to the
the lower tibial compartment is used when referencing the tibial cutting block. The distal end
(Figure 15). Lower the cutting block unaffected plateau.) of the rod should lie over the
and stylus by turning the knurled longitudinal ankle mark, in line with
cylinder to the left until the tip Disconnect the spring from the the second toe and just lateral to
of the stylus contacts the tibial ankle clamp and turn the knurled the anterior tibialis tendon insertion
plateau. Ensure that a minimum of cylinder to the left until it drops (Figure 17A). If alignment is found
10 mm (total) of bone and cartilage free. Using a mallet or slap-hammer, to be in variance, the cutting block
is resected from the unaffected side gently remove the tibial cutting can be removed from the pins and
of the tibia. Determine that the level guide, taking care not to misalign
of tibial resection is satisfactory, the cutting block (Figure 16). Slide
then predrill and place two the cutting block flush to the tibia
3 in. long fixation pins in the and further impact the two fixation
marked row of holes. Remove the pins.
(figure 17B)
the 2 degree varus/valgus block been removed, further ligament The electrocautery cord or suction
applied to the pins for correction balancing becomes easier. With pre- tubing can be stretched from the
(Figure 17B). Use corresponding existing flexion contracture, center of the femoral head
holes. Since the fixation pin holes of preliminary removal of the tibial (approximately two finger breadths
all tibial cutting blocks are parallel plateau usually allows full extension medial to the ASIS) to the center
to the cutting surface, this block of the knee to facilitate ligament mark on the ankle. The line should
will only alter the varus/valgus angle balancing. pass through the center of the knee
by 2 degrees and will not affect the joint. This confirms that the
posterior slope. Before proceeding further, assure ligaments are balanced in extension.
that the extremity can be brought
Apply the saw capture and into normal medial-lateral alignment
(Figure 18) resect the proximal tibia in extension. Place traction on the
(Figure 19). With the RP insert, the foot or introduce medial and lateral
PCL is generally sacrificed, but can spreaders to tension the collaterals,
be recessed based on surgeon and perform additional soft tissue
preference. Remove the block. balancing until the normal
Leave the fixation pins in place. mechanical axis is obtained.
Once the proximal tibial bone has
Center Line
Articular
Cartilageˇ
Lateral View
Select a femoral sizing template. With the knee in flexion, place the The best fitting femoral component
The inside of each template femoral template against the lateral in the M/L plane will be as follows:
corresponds to the inside geometry condyle to visually determine the
of the selected size of femoral best fit. Check to ensure the bony Width of femur at widest point:
component. The outside of the resection depths look reasonable Size mm
template corresponds to the outside (Figure 20). This will define the best Small 54
surface of the femoral component. A/P component fit and should be
Small+ 59
When sizing, it is important to keep the primary sizing method.
Medium 62
the anterior flange of the femoral
The M/L width of the femur can be Standard 65
component in the same plane as
the anterior cortex. measured at its maximal width with Standard+ 70
the knee flexed and can be used as Large 75
a secondary reference for sizing Large+ 81
(Figure 21).
It is advisable to mark the center
line for the femur at this point as it
will subsequently help define the
location of the femoral I.M. hole.
(figure 22)
Attach the guide yoke to the Slip the yoke beneath the muscle Center the guide between the
appropriate size A/P femoral anteriorly on the periosteum. epicondyles (Figure 24).
resection guide (Figure 22). Establish the center of the I.M.
canal by positioning the yoke
centrally on the anterior femoral
shaft (Figure 23).
(figure 25)
The centering mark that was Drill the femoral I.M. guide hole Slide the femoral guide positioner
previously drawn will be helpful. using a 9 mm diameter initiator drill into the joint space, engaging the
(Figure 26). Remove the temporary slot of the femoral A/P resection
In this position, the only contact pin and yoke. Insert the 7 in. long, guide (Figure 27). Slightly flex or
between the resection guide and 9 mm diameter rod. extend the knee until the positioner
the distal femoral condyles may be lies flat on the previously resected
on the posterior medial condyle. proximal tibia. If the positioner will
The position of the femoral guide not fit into the joint space, use the
hole is generally 3 to 5 mm medial tibial fixation pins to realign the
to the apex of the intercondylar tibial resection block by selecting a
notch (Figure 25). Place one more proximal row of holes on the
temporary pin in any of the femoral block, lowering the block and
resection guide holes for stability. removing additional proximal tibial
bone.
15.0 mm
17.5 mm
20.0 mm
If the positioner does not fit snugly Evaluate femoral rotation prior to Pin the femoral A/P resection guide
into the joint space, add tibial pinning the resection guide in place. in two places, using the middle
spacer shims and reassess until It is customary to implant the holes in the lower set of holes.
equal medial and lateral collateral femoral component in relative Remove the femoral guide
ligament tension is achieved external rotation. In this system, positioner.
(Figure 28). Evaluate tibial alignment however, specific external rotation is
once more by sliding the external defined by the femoral guide
alignment rod through the femoral positioner, which also establishes
positioner (Figure 29). equal compartmental tension. The
goal is to establish a quadrilateral
space with the resected posterior
femoral condylar surfaces parallel to
the resected tibial surfaces when
the collateral ligaments are
tensioned.
Attach the saw capture and cut the The fixation pin hole pattern on the Note: If one compartment is still
anterior and posterior femoral A/P femoral resection guides is the too tight in flexion, release
condyles. The anterior resection is same distance from the anterior additional soft tissue to achieve
flush with the anterior cortex of the cutting surface regardless of equal compartmental tension.
femur (Figure 30). component size. Thus, the anterior Note that this will affect
femoral resection will remain flush extension alignment. Insert the
Once the resections are completed, with the shaft if downsizing is external alignment rod through
remove the guide and pins. Insert performed. Therefore, resection the spacer block handle to again
the spacer block assembly into the of additional posterior condylar check the frontal and lateral
flexion gap. The assembly mimics bone is simplified. plane alignment on the tibia
the thickness of the femoral, tibial (Figure 31). Make note of the
and 10 mm bearing components. thickness of the spacer block
Assure equal medial and lateral utilized to fill the flexion gap.
compartmental tension. If necessary, This will subsequently determine
add a tibial shim to the spacer block the extension gap.
to fill the gap.
Calibrated stop
(figure 32)
Intercondylar
notch contact
point
(figure 33)
Select a distal femoral cutting block that is approximately 3 mm neutral position, flipping up the
that corresponds to the pre- proximal to the intercondylar notch. calibrated stop and sliding the block
operatively determined valgus The 3 mm matches the thickness of proximally or distally on the arm of
correction angle (3, 4, 5 or 6 the femoral component in that area. the alignment guide (Figure 32).
degrees). Attach the cutting block Incremental markers of 2 mm are
to the distal femoral cutting guide It is recommended by the author provided for this adjustment.
with the correct indication, “Right” that the following valgus angles be
or “Left,” facing up. Move the used based on the patient’s height: With the cutting block locked into
block until it abuts the calibrated place, insert the 8 mm femoral I.M.
Height < 5’11” 5 degrees rod into the distal femoral cutting
stop on the alignment guide. The
arrow at the top of the block will guide assembly (Figure 33).
Height 5’11” – 6’1” 4 degrees
point to the corresponding arrow
on the alignment guide. Lock the Height > 6’1” 3 degrees
cutting block into place by turning
The depth of the distal cut can be
the wing nut 45 degrees clockwise.
fine-tuned by turning the wing nut
The 5 degree cutting block will
45 degrees counterclockwise to the
allow a cut of 5 degrees of valgus
The rod is fluted and 1 mm smaller The modular cutting block should the proximal end of the external
than the pilot hole to minimize rest flush on the anterior femoral alignment rod is centered over the
pressure build-up in the canal and cut. Secure it in place by predrilling head of the femur, or approximately
to allow the isthmus to dictate rod and inserting two pins through the two finger breadths medial to the
placement. Slowly advance the marked center row of holes. anterior superior iliac spine. If
femoral I.M. rod into the distal Disengage the alignment guide alignment is found to be other than
femur. Full seating is not necessary from the cutting block by turning desired, the valgus angle can be
as the rod may reach the isthmus. the wing nut to the neutral altered by two degrees with the use
The blunt tip will easily pass into the position. Remove both the I.M. rod of a two degree varus/valgus cutting
I.M. canal while minimizing the and the alignment guide, leaving block.
chances of perforation (Figure 34). the block in place (Figure 34).
If more correction is necessary, then
Verify varus/valgus alignment by choose another cutting block,
using the external alignment tower mount it on the I.M. guide and
(Figure 35). With the femur in reposition it on the anterior cut.
extension and in neutral rotation,
correct alignment is indicated when
(figure 36)
To ensure the correct depth of the parallel and aligns with the tibial cut extension gaps. The distal
distal-femoral cut, have an assistant while medial and lateral tissues are femoral cut will affect the
place traction on the ankle with the equally tensioned, the distal femoral extension gap; the tibial resection
knee in extension. Place a spacer cutting block is correctly located. will affect both flexion and
block parallel with the tibial cut and extension gaps. The extension gap
the anticipated femoral cut The cutting block can be positioned must equal the flexion gap.
(Figure 36). in a different row of holes (2.5 mm
apart) to resect a greater or lesser Attach the saw capture and cut the
To ensure accuracy, the tibial cutting amount of distal femur to assure distal femur (Figure 37). Extend the
block may be repositioned on the the spacer block will fit in the knee and insert the spacer block
retained tibial pins, flush against the extension gap. (with the shim if it was used for the
resected tibia. Apply a shim to the flexion gap). It should fit snugly in
spacer block if it was used in Note: Before proceeding, if the gap with equal MCL and LCL
determining the flexion gap. The necessary, correct either the tension (figs 38 and 39). Remove
extension gap must equal the distal-femoral or proximal-tibial the spacer block and fixation pins.
flexion gap. If the spacer block is cut to assure equal flexion and
(figure 42)
(figure 40)
(figure 43)
Flex the knee. Center the finishing Using an osteotome or a narrow After all femoral cuts have been
guide between the epicondyles and oscillating saw, make the recessing made, check again for maximal
impact it until fully seated. The cut from the proximal end of the bone prosthesis contact using the
finishing guide is the exact width of finishing guide. Save this bone to femoral template (Figure 44).
the corresponding femoral fashion a cone to plug the femoral
component size. Use fixation pins to I.M. hole. Use a power saw or
secure the guide to the femur osteotome to resect the posterior
(Figure 40). Ensure the anterior and femoral condyle remnants to assure
distal surfaces are flush. Cut the adequate flexion clearance
anterior and posterior chamfers (Figure 43). Remove the finishing
with the oscillating saw (Figure 41). guide.
Using the 1/4 in. diameter stop drill,
create two 3/4 in. deep holes
through the distal guide holes
(Figure 42).
Drill Bushing
(figure 45)
In cases where the proximal tibial Use of MBT Stem Drill: drill through the MBT drill bushing
bone is sclerotic, drill two small Assemble the drill stop onto the and into the cancellous bone until it
holes posteriorly to facilitate the MBT drill and position it at the hits the drill stop (Figure 50).
placement of the spikes on the drill selected tray size. Advance the MBT
bushing onto the tray trial.
Table A: Creating Central Stem Cement Mantle
Use of MBT Stem Punch For Tray Size Drill Stop Setting Cement Mantle
Non Cemented Application:
1 - 1.5 1 - 1.5 None (line-to-line fit)
Advance the MBT stem punch into
the drill bushing and impact it into 2-3 0.5 mm per side / 4 mm distal
the cancellous bone until the 2 - 3 2 - 3 None (line-to-line fit)
appropriate tray size marking is
4-7 0.5 mm per side / 4 mm distal
reached (Figure 49). In the case of
sclerotic proximal tibial bone, 4-7 4-7 None (line-to-line fit)
introduce the drill into the drill Drill “bottoms out” on tray trial 0.5 mm per side / 4 mm distal
guide first to begin the hole to
Note: If over-reaming is desired, remove the tray trial to avoid impingement of the
facilitate the stem punch.
reamer on the tray trial. To compact cancellous bone, advance the drill in reverse.
Keel Punch
Assemble the universal handle to Note: If the bone of the medial or Select the tibial insert trial that
the appropriately sized MBT keel lateral plateau is sclerotic, it is matches the chosen femoral size
punch and insert it into the MBT helpful to initially prepare the and thickness (as determined by
keel punch bushing, being careful keel slot with an oscillating saw spacer blocks) and slide it onto the
to avoid malrotation (Figure 54). or high speed burr. MBT bushing on top of the tray trial
Impact this composite into the (Figure 56).
cancellous bone until the shoulder
of the punch is in even contact with
the MBT keel punch bushing
(Figure 55). Disconnect the universal
handle, leaving the MBT keel punch
in place.
Flex the knee 100 to 120 degrees stability in flexion and extension Check for:
and slide the femoral trial into while still allowing full extension. • Adequate range of motion
position using the two peg holes
and anterior surface for guidance The appropriate thickness bearing • Equal flexion and extension gaps
(Figure 57). Avoid the tendency to has been chosen when it cannot be • Proper ligamentous tension in
place the trial in flexion. Extend the removed with the femoral extension and in flexion
knee to 60 to 80 degrees of flexion component in place and in 90
degrees of flexion. The rotating • Correct mechanical alignment
and seat the femoral trial using the
platform should not allow of the extremity
femoral impactor (Figure 58).
malrotation with the knee in flexion • Correct rotation of the tibial
Note the anterior/posterior stability, and with the femoral component in component
medial/lateral stability and overall place. • Natural motion without
alignment in the A/P and M/L plane.
Flex and extend the knee while restrictions
If there is any indication of
instability, substitute a tibial insert evaluating component function and
trial with the next greater thickness stability.
and repeat reduction. Select the
insert that gives the greatest
Size 1 Size 1.5 Size 2 Size 2.5 Size 3 Size 4 Size 5 Size 6 Size 7
39/59 41/62 43/65 44/67 46/70 49/75 53/81 57/87 60/92
Small+ 39/58
LCS COMPLETE RP Tibial Inserts - Sizing AP/ML (mm)
COMPLETE RP
Bearing size is critical. The bearing size must match the femoral size to maintain congruency.
(figure 59)
Free the synovial tissue and There should be equal amounts of LCS 3-Peg Patellar Thickness Chart
retinaculum from the periphery of bone remaining in the medial/lateral Implant Thickness
the patella down to the plane of the and superior/inferior portions of the Size
(mm)
quadriceps tendonand patellar patellar remnant. A remnant of at
All
tendon reflection. Measure the least 13 mm thickness is suggested. Metal-Backed
Polyethylene
patellar thickness. Small 9.5 9.0
Resection of the patella can also be
Resect the patellar articular surface accomplished by using the patellar Small+ 10.2 9.7
parallel to and at the level of the resection guide (figs 60A/B). Medium 10.6 10.2
quadriceps tendon attachment Standard 10.9 10.4
(Figure 59). Resect articular bone Set the reference arm of the
Standard+ 11.6 11.1
thickness approximately equal to resection guide to the appropriate
Large 12.3 11.8
the implant’s overall thickness. size, which will allow for the proper
resection for the patellar implant. Large+ 13.0 12.5
Place the thin patellar template that Flex the knee and assure that the With the knee extended, evert the
matches the femoral component’s patellar template remains patella while pressing the template
size over the trial femoral perpendicular to the long axis of the to the patellar remnant. The handle
component and perpendicular to extremity and parallel to the of the template will usually lie
the long axis of the extremity with prosthetic joint line. approximately 20-30 degrees
pegs pointing upward (Figure 61). downward from the perpendicular
Reduce and press the resected (Figure 62). Mark the three pegs for
patella onto the template, engaging the trial patellar component with
the pegs in the resected patellar the cautery or a marking pen.
surface.
Remove the template and press the Reduce the patella. While flexing Prepare the three pegs using the
trial patellar component onto the and extending the knee, evaluate femoral lug drill. Ensure that the
resected patellar surface in the patellar tracking. The metal portion peg holes are sufficiently deep to
same location as the patellar of the patella should remain parallel avoid any resistance to the three
template (Figure 63). with the knee joint. Make pegs of the final patellar component
adjustments as necessary. Align the (Figure 64).
appropriate size thick patellar
template over the mark on the
patellar remnant, representing
proper alignment.
Remove the trials and implant the If the keeled MBT tray is selected, Insert Implantation
final components in the following attention is required to ensure the Carefully clear and remove any
order: implant keel aligns with the loose fragments or particulate from
• MBT Tray prepared bone. When the tray is the implanted tibial tray. Anteriorize
fully inserted, impact the top of the the proximal tibial for improved
• LCS Complete RP Tibial Insert universal handle with several mallet visualization and insert the
• LCS Complete Femoral blows to seat the implant fully appropriate size tibial insert into the
Component (Figure 66). MBT tray (Figure 67).
• LCS Patellar Component
(figure 70)
(figure 72)
Patellar Implantation
Insert the fixation pegs of the Assemble the patellar clamp with
patellar component into the drill the appropriate size patellar head
holes in the resected patellar (Figure 71). Press the patellar
surface (Figure 70). anchoring plate flat against the
anterior patella surface using the
patellar clamp (Figure 72).
(figure 75)
MBT Tray Implantation When the tray is fully inserted, Then place the knee in full flexion,
Thoroughly cleanse the entire site impact the top of the universal remove the trials and carefully
with pulsatile lavage. Prepare handle with several mallet blows to excise all extruded cement.
methyl methacrylate cement and seat the implant fully (Figure 74).
apply it in its low viscous state by Tibial Insert Implantation
At this point, the surgeon may elect
syringe or with digital pressure to to assemble the RP trial plateau post Carefully clear and remove any
assure maximum penetration into and the tibial insert trial onto the loose fragments or particulate from
the trabecular bone. seated MBT tray and the trial the permanent tibial tray.
femoral component onto the Anteriorize the proximal tibial for
Assemble the universal handle onto improved visualization and insert
the tray impactor and carefully prepared femur (Figure 75). Place
the knee in 20 – 30 degrees of the appropriate size tibial insert into
insert the MBT tray into the the MBT tray (Figure 76).
proximal tibia avoiding malrotation flexion and apply axial compression
(Figure 73). If the keeled MBT tray is to maintain equal pressure at the
selected, attention is required to bone-to-tibial implant interface until
ensure the implant keel aligns with the cement has set.
the prepared bone.
Femoral Component
Implantation
Plug the femoral medullary with Fully seat the femoral component
cancellous bone. Apply methyl with the femoral impactor and clear
methacrylate cement to all cut any extruded cement (Figure 78).
surfaces and press it into the Bring the knee into full extension to
cancellous bone at the anterior, produce maximum axial pressure on
anterior chamfer and distal chamfer the bone-cement interface until the
surfaces and onto the femoral cement has polymerized. Then place
component at the posterior chamfer the knee in flexion and excise all
and posterior condylar recesses. remaining extruded cement with an
Care is taken to avoid the articular osteotome.
surface of the implant. As the
component is implanted, ensure
that the lead edges are advanced in
alignment with the bone cuts
(Figure 77).
(figure 79)
(figure 81)
Patellar Implantation
Apply methyl methacrylate cement Assemble the patellar clamp with
to the prepared patellar surface. the appropriate size patellar head
Insert the fixation pegs of the (Figure 80). Press the patellar
patellar component into the drill anchoring plate flat against the
holes in the resected patellar anterior patella surface using the
surface (Figure 79). patellar clamp (Figure 81).
DePuy MBT Trays LCS COMPLETE Femoral Components 3-Peg Metal-Backed Patella
Cat No. Description Cat No. Description Cat No. Description
1294-31-110 Cemented, Size 1 1294-01-010 Cemented, Right, Small 1779-81-025 Cemented, Small
1294-31-115 Cemented, Size 1.5 1294-01-020 Cemented, Right, Small+ 1779-82-025 Cemented, Small+
1294-31-120 Cemented, Size 2 1294-01-030 Cemented, Right, Medium 1779-87-025 Cemented, Medium
1294-31-125 Cemented, Size 2.5 1294-01-040 Cemented, Right, Standard 1779-83-025 Cemented, Standard
1294-31-130 Cemented, Size 3 1294-01-050 Cemented, Right, Standard+ 1779-84-025 Cemented, Standard+
1294-31-140 Cemented, Size 4 1294-01-060 Cemented, Right, Large 1779-85-025 Cemented, Large
1294-31-150 Cemented, Size 5 1294-01-070 Cemented, Right, Large+ 1779-86-025 Cemented, Large+
1294-31-160 Cemented, Size 6 1294-02-010 Cemented, Left, Small
1779-71-000 POROCOAT, Small
1294-31-170 Cemented, Size 7 1294-02-020 Cemented, Left, Small+
1779-72-000 POROCOAT, Small+
1294-02-030 Cemented, Left, Medium
1294-32-110 POROCOAT®, Size 1 1779-77-000 POROCOAT, Medium
1294-02-040 Cemented, Left, Standard
1294-32-115 POROCOAT, Size 1.5 1779-73-000 POROCOAT, Standard
1294-02-050 Cemented, Left, Standard+
1294-32-120 POROCOAT, Size 2 1779-74-000 POROCOAT, Standard+
1294-02-060 Cemented, Left, Large
1294-32-125 POROCOAT, Size 2.5 1779-75-000 POROCOAT, Large
1294-02-070 Cemented, Left, Large+
1294-32-130 POROCOAT, Size 3 1779-76-000 POROCOAT, Large+
1294-32-140 POROCOAT, Size 4 1294-03-010 POROCOAT, Right, Small
1294-32-150 POROCOAT, Size 5 1294-03-020 POROCOAT, Right, Small+
3-Peg All-Polyethylene Patella
1294-32-160 POROCOAT, Size 6 1294-03-030 POROCOAT, Right, Medium
Cat No. Description
1294-32-170 POROCOAT, Size 7 1294-03-040 POROCOAT, Right, Standard
1497-71-025 Cemented, Small
1294-03-050 POROCOAT, Right, Standard+
1497-72-025 Cemented, Small+
1294-03-060 POROCOAT, Right, Large
DePuy MBT Trays - With Keel 1497-77-025 Cemented, Medium
1294-03-070 POROCOAT, Right, Large+
Cat No. Description 1497-73-025 Cemented, Standard
1294-04-010 POROCOAT, Left, Small
1294-33-110 Cemented, Size 1 1497-74-025 Cemented, Standard+
1294-04-020 POROCOAT, Left, Small+
1294-33-115 Cemented, Size 1.5 1497-75-025 Cemented, Large
1294-04-030 POROCOAT, Left, Medium
1294-33-120 Cemented, Size 2 1497-76-025 Cemented, Large+
1294-04-040 POROCOAT, Left, Standard
1294-33-125 Cemented, Size 2.5
1294-04-050 POROCOAT, Left, Standard+
1294-33-130 Cemented, Size 3
1294-04-060 POROCOAT, Left, Large
1294-33-140 Cemented, Size 4
1294-04-070 POROCOAT, Left, Large+
1294-33-150 Cemented, Size 5
1294-33-160 Cemented, Size 6
1294-33-170 Cemented, Size 7
1294-34-110 POROCOAT®, Size 1
1294-34-115 POROCOAT, Size 1.5
1294-34-120 POROCOAT, Size 2
1294-34-125 POROCOAT, Size 2.5
1294-34-130 POROCOAT, Size 3
1294-34-140 POROCOAT, Size 4
1294-34-150 POROCOAT, Size 5
1294-34-160 POROCOAT, Size 6
1294-34-170 POROCOAT, Size 7
2294-05-310 Medium, 10 mm
3-Peg Polyethylene Patella Trials
2294-05-312 Medium, 12.5 mm
2294-05-315 Medium, 15.0 mm Cat No. Description
2294-05-317 Medium, 17.5 mm 2289-04-007 With Pegs, Small
2294-05-320 Medium, 20.0 mm 2289-04-008 With Pegs, Small+
2289-04-013 With Pegs, Medium
2294-05-410 Standard, 10 mm
2289-04-009 With Pegs, Standard
2294-05-412 Standard, 12.5 mm
2289-04-010 With Pegs, Standard+
2294-05-415 Standard, 15.0 mm
2289-04-011 With Pegs, Large
2294-05-417 Standard, 17.5 mm
2289-04-012 With Pegs, Large+
2294-05-420 Standard, 20.0 mm
2497-61-000 With Pins, Small
2294-05-510 Standard+, 10 mm
2497-62-000 With Pins, Small+
2294-05-512 Standard+, 12.5 mm
2497-67-000 With Pins, Medium
2294-05-515 Standard+, 15.0 mm
2497-63-000 With Pins, Standard
2294-05-517 Standard+, 17.5 mm
2497-64-000 With Pins, Standard+
2294-05-520 Standard+, 20.0 mm
2497-65-000 With Pins, Large
2497-66-000 With Pins, Large+
References:
1. Davenport, J.M., Friddle, N.S., Hastings, C.K., Peoples, S.J. & Voorhorst, P.E. 3. Buechell, F.F. (1990). A sequential three-step lateral release for correcting
(1992). Multi-center clinical results of cemented and cementless mobile- fixed valgus knee deformities during total knee arthroplasty. Clinical
bearing total knee replacement. DePuy, Inc. Orthopaedics and Related Research, 170-175.
2. Buechel, F.F. & Pappas, M.J. (1989). New Jersey low contact stress knee 4. Keblish, P.A. (1991). The lateral approach to the valgus knee surgical
replacement system - ten year evaluation of meniscal bearings. Orthopaedic technique and analysis of 53 cases with over two-year follow-up evaluation.
Clinics of North America, 147-177. Clinical Orthopaedics and Related Research, 52-62.
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