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Figure 49

29

Tibial Sizing without

Intact/Functional ACL

If the ACL or tibial bone island is compromised, follow
these listed steps:

• Remove the bone island creating a flat surface. There are
two options:

- Use a free-hand approach, or

- Find the pin locations and place the universal tibial

cutting block in place and perform clean-up resection.

•  Place the knee in maximum flexion and sublux the tibia
  anteriorly using a PCL retractor and place a Z-retractor
  medially and laterally.

•  Select the primary tibial tray trial that provides the
  appropriate coverage in both the A/P and M/L planes
  using the tibial template (Figure 49).

• Base tibial template rotation relative to the tibial tubercle
and the malleolar axis.

• Perform an extramedullary alignment check by placing
the 1/4" alignment rod through the tibial template handle.

Note: To optimize patello-femoral tracking, slight external
rotation is preferable.

•  When the final position has been determined, fix the
  tibial template to the tibia by placing drill pins or bone
  nails through the angled holes.

Tibial Preparation

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Summary of Contents for VANGUARD XP

Page 1: ...Surgical Technique ...

Page 2: ...trive to view our work through the eyes of one surgeon and one patient We treat every solution we provide as if it s meant for a family member Our approach to innovation creates real solutions that assist each surgeon in the delivery of durable personalized care to each patient whether that solution requires a minimally invasive surgical technique advanced biomaterials or a patient matched implant...

Page 3: ...l Knee System Table of Contents Biomet does not practice medicine The treating surgeon is responsible for determining the appropriate treatment technique s and product s for each individual patient This technique was prepared in conjunction with the Vanguard XP Total Knee developing surgeons and the eXPert Advice sections provided in this surgical technique represent the Vanguard XP developing sur...

Page 4: ... System Surgical Technique Summary Femoral Preparation 4 in 1 cuts Initial Island Alignment Tibial Resection Depth Tibial Island Alignment Tibial Resection Tibial Posterior Slope Tibial Vertical Resection Patella Preparation Femoral Preparation ...

Page 5: ... 15 18 3 Anterior Rongeur Tibial Slope Gauge Flexion Extension Gap Check Tibial Sizing and Floating Tibial Trial Tibial Preparation Final Trialing Component Implantation Tibial Horizontal Resection Tibial Medial Gap Check ...

Page 6: ...ety of knee joint replacement prostheses intended for application with or without bone cement Knee joint replacement components include femoral tibial and patellar components Components are available in a variety of designs and size ranges intended for both primary and revision applications Specialty components are available including femoral stems femoral screws femoral augments tibial stems tibi...

Page 7: ...ents and all polyethylene patellar components are indicated for cemented application only Regenerex components where available are intended only for uncemented biologic fixation application CONTRAINDICATIONS Absolute contraindications include infection sepsis and osteomyelitis Relative contraindications include 1 an uncooperative patient or a patient with neurologic disorders who is incapable of f...

Page 8: ...oral component size using lateral view X ray Note Confirmation of the appropriate size component intraoperatively is critical for normal kinematics Incision The Vanguard XP Total Knee Instrumentation is designed for a standard surgical technique Figure 2 Release the patella tendon to create space on the lateral side of the tibia Ensure that the patella tendon tibia interface is released so the pat...

Page 9: ...issues down to the level of the quadriceps and patellar tendon insertion Determine the patella thickness and resection amount by using the patella caliper 32 486502 Figure 3 The patella saw guide stylus 32 486501 can be utilizedtodeterminetheappropriateresectionlevel Figure 4 Use the patella clamp surface cut guide to perform the initial flat patellar resection Note Care should be taken to restore...

Page 10: ...tion height 3 peg patellar component Place the appropriately sized 3 peg drill guide 32 486530 32 486535 onto the resected patella andusethe1 4 patellardrill 32 468470 toprepare for the component pegs Figure 5 Option 2 Patella Milling Tilt the patella for patella preparation Remove the osteophytes and peripatellar tissues down to the level of the quadriceps and patellar tendon insertion Determine ...

Page 11: ... marked Bit to the adjustable depth stop Set the adjustable stop by depressing the button on its side and slide the stop down until the bottom of the spacer touches the mill bushing Note The magnetic spacer bit includes the depth of the peg Do not sink the drill bit prior to setting the adjustable stop Remove the magnetic spacer and ream until the adjustable stop touches the mill bushing Remove th...

Page 12: ... cm Figure 8 Place the canal entry location 1 cm above the insertion of the posterior cruciate ligament and slightly medial in the intercondylar notch Note Irrigation and suction of the femoral canal can be performed to decrease canal contents Option 1 Adjustable Distal Femoral Resection Guide Set the adjustable distal cut guide 32 487000 to the desired valgus angle by pressing and turning the val...

Page 13: ...k into the adjustable distal adaptor 32 487010 Attach the adjustable distal adaptor and distal cut block to the adjustable distal cut guide by sliding the two legs on the adjustable distal adaptor through the anterior holes of the adjustable distal cut guide Figure 10 Continue sliding the adjustable distal adaptor until the block is sitting against the anterior cortex Pin the distal cut block into...

Page 14: ...int line when the ACL is intact Check the resected distal femur using a flat instrument surface to confirm a flat resection Recut or file as necessary to achieve proper resection Femoral Preparation Distal Femoral Resection cont Option 2 Fixed Distal Femoral Resection Guide Choose the appropriate left or right valgus wing from 32 485004 to 32 485007 and assemble it onto the IM rod by sliding it th...

Page 15: ...ylar axis flexion gap and the tibial shaft axis can further optimize femoral rotation Due to the tight space hyperflex the knee to place the A P sizer flush with the resected femoral distal surface Drill the two 4 in 1 cutting block location holes utilizing the 1 8 quick release drill pins 32 467619 Figure 16A Leave the pins in place The femoral component size can now be read from the central scal...

Page 16: ...visualization of the femoral notch to ensure the ACL has adequate clearance 4 in 1 Femoral Cuts Choose the Vanguard XP femoral 4 in 1 block that matches the selected size from 32 700000 to 32 700010 Figure 17A Assemble the ACL protector 32 700370 into the back of the femoral 4 in 1 block Figure 17B Place the block into the 1 8 distal femur holes Note A 1 37 mm feeler blade 32 486000 can be used to...

Page 17: ...rees posterior slope built in to the EM tibial guide 32 700365 Position the EM tibial guide on the tibia and place the spring loaded arms of the ankle clamp around the distal tibia just above the malleoli Figure 20 eXPert Advice The three critical measurements in the tibial resection are resection depth slope and varus valgus Caremustbetakentoresectadequatetibialboneandtomatch the patient s native...

Page 18: ...timated resection level Attach the tibial stylus 32 700072 to the tibial universal cutting block by placing the appropriate stylus tongue into the slot on the universal tibial cutting block Figure 22 Select 4 mm off the medial low or 12 mm off the lateral high Use the island outline marked previously to place the tibial universal cutting block in the correct M L location The center of the tibial u...

Page 19: ...rd the body of the handle Adequate extension space will allow the lever to rest easily on the body of the handle If moderate to excessive force is needed to fully depress the lever adjust the depth of the tibial cutting block to resect more tibial bone and confirm the extension space by easily depressing the lever to the paddle body Repeat previous step at 90 degrees of flexion to ensure that flex...

Page 20: ...ercle landmarks to assist in determining rotation If desired place an alignment rod in the end of the tibial alignment guide to verify tibial rotation eXPert Advice To allow for larger tibial tray sizing the vertical cuts should be as far lateral as possible without cutting the ACL Note If the tibial component is downsized intraoperatively from an 87 mm to an 83 mm size the tibial bone island will...

Page 21: ...cutting but should be used as a guide only It is advised not to have the blade hit the pins To create a captured cut slot secure the tibial cutting block insert 32 700074 onto the tibial universal cutting block Figure 29 The cut block may be used as a surface block by not attachingthetibialcuttingblockinsert Resectthemedial plateau only Figure 30 Note Use a 1 4 mm thick narrow 12 13 mm saw blade f...

Page 22: ... plateau being extremely careful not to undercut the tibial island Tibial Preparation Tibial Resection with Intact Functional ACL cont Horizontal Resection cont Check the flexion gap at 90 degrees and full extension gap with a 10 mm medial gap checker 32 700039 to ensure there is adequate space to prevent a bone island fracture while trialing Figure 31 eXPert Advice Always clear away any posterior...

Page 23: ...presenttherangeoftibialimplantsizes Confirmthecut position by aligning the rongeur to both pen markings near the ACL base as well as implant markings on the rongeur Keeping the rongeur flat against the cutting surface remove the central anterior tibial bone to the resection level of the tibial plateau Figure 33 Note While cutting the bone section place a hand over the area to keep it from projecti...

Page 24: ...o shave off more bone º Usetheoscillatingsawbladetoremoveexcessbone until cut surfaces are coplanar within 1 degree Figure 38 Tibial Preparation Tibial Resection with Intact Functional ACL cont Slope Check Usethetibialslopegauge 32 700041 toensurethetibial slope on both the medial and lateral plateaus is coplanar for adequate fixation and function of the system Figure 36 Apply pressure on the post...

Page 25: ... to assure proper varus valgus alignment and slope Tibial Preparation Tibial Sizing Place the knee in maximum flexion with a Z retractor medially and laterally to provide maximum exposure Select the tibial template from 32 700042 to 32 700052 size that provides the appropriate A P and M L coverage Figure 40 Perform an extramedullary alignment check by placing the 1 4 alignment rod through the tibi...

Page 26: ... electrocautery 24 VANGUARD XP Total Knee System Tibial Preparation eXPert Advice When trialing range of motion if the medial and lateral bearings rise up in flexion a confirm the tibial tray is not undersized b confirm that the posterior slope is adequate If the medial trial bearing raises up during flexion a confirm there is not excessive external rotation of the tibial tray Slight modifications...

Page 27: ...he bone island Slight external rotation is preferable to optimize patello femoral tracking eXPert Advice Verify the tibial bone island width is uniform by sliding the tibial template from top to bottom This is critical to ensure bearing clearance and proper assembly of the bearing implant to the tibial tray implant It is recommended to always select a larger size tibial tray if appropriate since t...

Page 28: ...e posterior keel slots Figure 44 Remove the tibial template and tibial template keel mask Clean up the keel cut using the tibial groove cutter 32 422936 Assemble the trial peg and keel insert to the primary tibial tray trial Figure 45A B Insert the trial tray assembly into the tibia Tibial Preparation Note A tibial bearing trial handle 32 700076 is available to ease the insertion of the primary ti...

Page 29: ...ACL touches the femoral component during range of motion it is strongly recommended the ACL be sacrificed and the knee be converted to a posterior cruciate retaining device Failure to convert to a posterior cruciate retaining device may lead to joint pain and dysfunction If ACL femoral component contact occurs it will most likely occur in full extension or hyperextension Fully extend the limb and ...

Page 30: ...al articulations The trial bearing handle can be used to place the trials onto the trial tray Make sure the trials are in proper alignment to fully seat onto the peg Note If the ACL and bone island are removed and the PCL is retained the Vanguard XP tibial bearing trials can be used as the CR option Patella Selectasinglepegor3 pegtrialpatellarcomponentthat corresponds to the appropriate diameter a...

Page 31: ...tor and place a Z retractor medially and laterally Select the primary tibial tray trial that provides the appropriate coverage in both the A P and M L planes using the tibial template Figure 49 Basetibialtemplaterotationrelativetothetibialtubercle and the malleolar axis Perform an extramedullary alignment check by placing the 1 4 alignment rod through the tibial template handle Note To optimize pa...

Page 32: ...ne nails Carefullyimpactthecruciatepunch 32 485521 through the tibial punch mask until fully seated Figure 50 Assemble the appropriate tibial tray trial cruciate stem insert 32 700069 or 32 700070 to the primary tibial tray trial Figure 51A and B Remove the tibial template and cruciate punch mask and insert and impact the assembled primary tibial tray trial into the tibia Tibial Preparation ...

Page 33: ...wider flat osteotome Note Be careful not to apply cement to the sides of the bone island Tibial Tray Implantation with Intact Functioning ACL If a tourniquet above the knee is not already in use place and or inflate throughout preparation of bone for cementation aswellasmixing applicationandhardening of bone cement Perforate cancellous bone on the tibial side of the knee by drilling or punching an...

Page 34: ...slot to protect it from cement and debris Be sure to remove this cover Tibial Tray Implantation with Intact Functioning ACL cont After pressurization all cement that remains proud of the bone should be removed A 1 2 inch 12 7 mm curved osteotome positioned concave down is useful to scrape away excess cement If there is significant blood or saline on the cement surface it can be carefully dried usi...

Page 35: ...ure 54 Insert the tibial component and impact with the tibial impactor 32 700364 Figure 55 Tibial Tray Implantation without Intact Functioning ACL If the ACL and bone island are removed and the PCL is retained prepare the tibia to receive the Vanguard XP CR tibial tray with cruciate stem Prepare the bone for cement application ...

Page 36: ...ure of the tibial bone island Note Ensure there is no bone cement or overhanging bone alongside the bone island which will inhibit the bearing from appropriately engaging Femoral Component Implantation While mixing another 40g unit of cement pulse lavage and dry the femoral side again As soon as the cement properties permit apply a layer overtheentirebone opposingsurfaceoftheappropriate femoral co...

Page 37: ... Implantation Pulse lavage and dry patella With the knee in full extension apply a 2 to 3 mm thick layer of cement onto the appropriate patellar component Place component into the patella Push into position with finger pressure so the peg s engage s the prepared hole s Position the patellar clamp onto the component and tighten the handle until the clamp head contacts the component Clamp tightly to...

Page 38: ...ial tray bearing slot as far as possible using finger pressure Note The Vanguard XP locking bar is packaged with the Vanguard XP tibial tray Place the large curved end of the locking bar inserter etched bar in the notch on the Vanguard XP locking bar The end etched tray should be placed in the notch on the lateral side of the Vanguard XP tibial tray anterior post Figure 60 Make sure the smaller sq...

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Page 40: ...verse effects see the package insert and wwww biomet com Check for country product clearances and reference product specific instructions for use All content herein is protected by copyright trademarks and other intellectual property rights owned by or licensed to Biomet Inc or its affiliates unless otherwise indicated and must not be redistributed duplicated or disclosed in whole or in part witho...

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