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Zimmer MIS Multi-Reference 4-in-1 Femoral Instrumentation Surgical Technique

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Transverse Axis

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90°

Preoperative Planning

Use the template overlay (available 
through your Zimmer Representative) 
to determine the angle between the 
anatomic axis and the mechanical 
axis. This angle will be reproduced 
intraoperatively. This surgical technique 
helps the surgeon ensure that the 
distal femur will be cut perpendicular 
to the mechanical axis and, after soft 
tissue balancing, will be parallel to the 
resected surface of the proximal tibia. 

Surgical Approach

The femur, tibia, and patella are 
prepared independently, and can be 
cut in any sequence using the principle 
of measured resection (removing 
enough bone to allow replacement  
by the prosthesis). Adjustment cuts 
may be needed later.

Summary of Contents for MIS Multi-Reference

Page 1: ...For NexGen Cruciate Retaining NexGen Legacy Posterior Stabilized Knees Zimmer MIS Multi Reference 4 in 1 Femoral Instrumentation Surgical Technique ...

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Page 3: ...Distal Femur 12 Size Femur Establish External Rotation 13 Finish the Femur 15 Anterior Referencing Technique 15 Posterior Referencing Technique 17 MIS Notch Chamfer Trochlear Guide 19 MIS QS Notch Guide 21 Resect Proximal Tibia 22 Check Flexion Extension Gaps 27 Prepare the Patella 28 Resect the Patella 29 Finish the Patella 31 Patella Protectors 32 Perform a Trial Reduction 33 Tibial Position bas...

Page 4: ...nce 4 in 1 Femoral Instrumentation Surgical Technique 2 5a Set External Rotation Anterior Referencing 1 Drill 8mm Pilot Hole 2 Insert and Secure Mini Distal Femoral Cutting Guide 5b Set External Rotation Posterior Referencing ...

Page 5: ...strumentation Surgical Technique 3 1 4 3 2 Size the Femur 3 Cut Distal Femur 4 6 Place Femoral Finishing Guide Adjust M L Pin Anterior Referencing Finish the Femur 1 Anterior condyles 2 Posterior condyles 3 Posterior chamfer 4 Anterior chamfers 7 ...

Page 6: ...llow replacement by the prosthesis Adjustment cuts may be needed later The Multi Reference 4 in 1 instruments provide a choice of either anterior or posterior referencing techniques for making the femoral finishing cuts The anterior referencing technique uses the anterior cortex to set the A P position of the femoral component The posterior condyle cut is variable The posterior referencing techniq...

Page 7: ... will be reproduced intraoperatively This surgical technique helps the surgeon ensure that the distal femur will be cut perpendicular to the mechanical axis and after soft tissue balancing will be parallel to the resected surface of the proximal tibia Surgical Approach The femur tibia and patella are prepared independently and can be cut in any sequence using the principle of measured resection re...

Page 8: ... on the size of the femoral component needed Although the goal of a MIS technique is to complete the surgery with an approximately 10cm 14cm incision it may be necessary to extend the incision if visualization is inadequate or if eversion of the patella is not possible without risk of avulsion at the tibial tubercle If the incision must be extended it is advisable to extend it gradually and only t...

Page 9: ...llofemoral ligament to facilitate full eversion and lateral translation of the patella Then use hand held three pronged or two pronged hooks to begin to gently evert the patella Be careful to avoid disrupting the extensor insertion To help evert the patella slowly flex the joint and externally rotate the tibia while applying gentle pressure Once the patella is everted use a standard size Hohmann r...

Page 10: ...ctors Incise the underlying synovium in a slightly more proximal position than is typical with a standard subvastus approach This will allow a two layer closure of the joint The deep layer will be the synovium while the superficial layer will be the medial retinaculum and the myofascial sleeve of tissue that has been left attached to the inferior border of the vastus medialis Carry the synovial in...

Page 11: ...needed during the procedure In addition with the knee in flexion the incision will stretch 2cm 4cm due to the elasticity of the skin allowing broader exposure The goal of minimally invasive surgery is to limit the surgical dissection without compromising the procedure The medial parapatellar arthrotomy is used to expose the joint but the proximal division of the quadriceps tendon should be limited...

Page 12: ...en altered as in a femur with a long stemmed hip prosthesis or with a femoral fracture malunion use the Adjustable IM Alignment Guide Short and use the optional extramedullary alignment technique NOTE The Mini Adjustable IM Alignment Guide Short Fig 1b is a shortened version of the Mini Adjustable IM Alignment Guide Long When the Mini Standard Cut Plate is attached to the Mini Adjustable IM Alignm...

Page 13: ... achieved impact the IM guide until it seats on the most prominent condyle After impacting check to ensure that the valgus setting has not changed Ensure that the guide is contacting at least one distal condyle This will set the proper distal femoral resection Optional Technique An Extramedullary Alignment Arch and Alignment Rod can be used to confirm the alignment If this is anticipated identify ...

Page 14: ...ing guide indicate in millimeters the amount of bone resection each will yield relative to the standard distal resection set by the Adjustable IM Alignment Guide and Standard Cut Plate If more fixation is needed use two 3 2mm Headed Screws or predrill and insert two Hex head Holding Pins in the small oblique holes on the Mini Distal Femoral Cutting Guide or Silver Spring Pins may be used in the la...

Page 15: ...stal femur MIS Screws are available in 3 lengths 27mm 33mm 48mm The length needed will vary depending on the patient s bone dimensions NOTE Remove the Threaded Handle before using the Screw Inserter Extractor Slightly extend the knee and retract soft tissues to expose the anterior femoral cortex Clear any soft tissue from the anterior cortex Ensure that the leg is in less than 90 of flexion 70 80 ...

Page 16: ...A P Sizing Guide Fig 3d Place two Headless Holding Pins in the plate through the two holes that correspond to the desired external rotation and impact them Fig 3e Leave the pins proud of the guide NOTE Do not impact the Headless Holding Pins flush with the External Rotation Plate Fig 3d Fig 3e Careful attention should be taken when placing the headless pins into the appropriate External Rotation P...

Page 17: ...licates the width of the NexGen CR Femoral Component The width of the flex finishing guide replicates the width of the NexGen LPS LPS Flex and CR Flex Femoral Components When the M L position of the Femoral Finishing Guide is set use the Screw Inserter Extractor to insert a 3 2mm Headed Screw or predrill and insert a Hex head Holding Pin through the superior pinhole on the beveled medial side of t...

Page 18: ...es the depth at which the anterior femoral cut will exit the femur Fig 4e Fig 4f 1 4 3 2 Fig 4g Fig 4h Fig 4i Fig 4j Use the 1 27mm 0 050 in narrow reciprocating saw blade to cut the base of the trochlear recess Fig 4i and score the edges Fig 4j Remove the finishing guide to complete the trochlear recess cuts Use a 1 27mm 0 050 in narrow oscillating saw blade to cut the femoral profile in the foll...

Page 19: ...desired attach the MIS Locking Boom to the face of the finishing guide to check the location of the anterior cut and determine if notching will occur Fig 4n The boom tip indicates where the anterior femoral cut will exit the bone Remove any lateral osteophytes that may interfere with guide placement Position the finishing guide mediolaterally The width of the finishing guide replicates the width o...

Page 20: ...anner For additional stability predrill and insert two Short head Holding Pins through the inferior holes on one or both sides of the guide Fig 4o Use a 1 27mm 0 050 in narrow oscillating saw blade to cut the femoral profile in the following sequence for optimal stability of the finishing guide Fig 4p 1 Anterior condyles 2 Posterior condyles 3 Posterior chamfer 4 Anterior chamfers Use the Patellar...

Page 21: ...Cut the sides and base of the intercondylar box Fig 4u Insert two short headed pins or short screws through the anterior flange Fig 4x Cut the anterior and posterior chamfers Use a reciprocating saw to cut the sides and base of the intercondylar box Fig 4w Protect the tibia with a wide osteotome Use the Patellar Femoral Drill to drill the femoral post holes Note Do not use the LPS Flex Femur Peg D...

Page 22: ...ld be drilled prior to assembling the MIS Trochlear Guide If the MIS Femoral Finishing Guide is used the flexion gap should equal the extension gap If the MIS Flex Femoral Finishing Guide is used then the flexion gap will be approximately 2mm greater For a Flex implant use an MIS Spacer Block with the MIS Spacer Block Flex Adapter to check flexion gap An oscillating saw with a narrow blade may als...

Page 23: ...ide will not contact the anterior chamfer Use the previously prepared trochlear recess and or the femoral post holes to position the MIS QS Notch Guide mediolaterally Secure the MIS QS Notch Guide to the femur with two 3 2mm 1 8 inch Headed Screws or predrill and insert two 3 2mm 1 8 inch Holding Pins Fig 4bb Use a reciprocating saw to cut the sides and the base of the intercondylar notch Fig 4cc ...

Page 24: ...ut Guide Right or Left MIS Tubercle Anchor Right or Left MIS Tibial Adjustable Rod MIS Distal Telescoping Rod Ankle Clamp or Spring Ankle Bar Resection Guide MIS Tibial Depth Resection Stylus Osteotome Various retractors Kocher clamp Hex head Screwdriver Drill Reamer MIS Screw Inserter Extractor MIS Screws Assemble the Guide The MIS Tibial Cut Guide Assembly consists of instruments for right or le...

Page 25: ...de of the MIS Tibial Adjustable Rod For a left knee the left anchor is inserted into the right hole Fig 5c NOTE The Tibial Cut Guide and Tubercle Anchor are available in left and right configurations If the incorrect Tubercle Anchor is used the Cut Guide will not fully retract into the Adjustable Rod and the varus valgus angle of the tibial cut may be affected Insert the correct right or left Tibi...

Page 26: ...tellar tendon Fig 5h When correctly aligned the Distal Telescoping Rod and Adjustable Rod should be parallel to the tibia in the coronal and sagittal planes To help avoid rotational malalignment of the rod check its position from a direct anterior view ie stand at the foot of the operating table Adjust the distal end of the MIS Distal Telescoping Rod by moving the slide at the foot of the rod medi...

Page 27: ...ig 5n Set the Final Resection Level With the Tibial Cut Guide flush against the anteromedial edge of the tibia insert the MIS Tibial Depth Resection Stylus into the hole on the top of the Tibial Cut Guide For a minimal cut swing the 2mm arm of the stylus over the defective tibial condyle Adjust the Tibial Cut Guide up or down by rotating the thumb wheel until the tip of the 2mm stylus rests on the...

Page 28: ... the lateral side NOTE Take care to protect the patellar tendon when cutting the lateral side Use a Kocher clamp to remove the tibial bone fragment Then trim any remaining bone spikes and meniscus on the posterior and lateral aspects of the resected tibial surface Fig 5q Use the Hex head Screwdriver to tighten all of the screws on the tibial assembly to maintain position Insert an MIS Screw throug...

Page 29: ...e MIS Flex Femoral Finishing Guide the flexion gap will be approximately 2mm greater than the extension gap For example if the extension gap is 10mm the flexion gap will be 12mm To account for this difference the appropriate MIS CR Flex Spacer Adapter or MIS LPS Flex Spacer Adapter Fig 6c should be placed on top of the Spacer Alignment Guide that was used in extension to accurately check ligament ...

Page 30: ...a Be careful not to damage tendon insertions on the bone Use the Patellar Caliper to measure the thickness of the patella Fig 7a Subtract the implant thickness from the patella thickness to determine the amount of bone that should remain after resection NOTE At least 11mm of total bone will remain to allow for implant pegs if the Patella Reamer is used Patella Thickness Implant Thickness Bone Rema...

Page 31: ...7e Apply the Patellar Reamer Clamp at a 90 angle to the longitudinal axis with the Patellar Reamer Surfacing Guide encompassing the articular surface of the patella Squeeze the clamp until the anterior surface of the patella is fully seated against the fixation plate Fig 7f Turn the clamp screw to hold the instrument in place The anterior surface must fully seat upon the pins and contact the fixat...

Page 32: ...sure until the step on the reamer shaft bottoms out on the depth gauge wing of the Patellar Reamer Clamp Remove the reamer clamp assembly Proceed to Finish the Patella on page 31 Insert the appropriate size Patellar Reamer Insetting Guide into the Patellar Reamer Clamp Turn the locking screw until tight Apply the Patellar Reamer Clamp at a 90 angle to the longitudinal axis with the Patellar Reamer...

Page 33: ...seat the drill guide on hard sclerotic bone surfaces Fig 7l Fig 7k The depth gauge wing on the Patellar Reamer Clamp can be used instead of the stops to control the amount of bone remaining rather than the amount of bone removed Insert the reamer assembly into the Patellar Reamer Insetting Guide Raise the reamer slightly off the bone and bring it up to full speed Advance it slowly until the promin...

Page 34: ...gh the hole on the Patella Protector Attach a hemostat to the end of the suture material Leave an adequate amount of suture material to position the hemostat away from the incision After the initial patella cut is completed use thumb pressure to press the Patella Protector against the bone If the bone is particularly hard apply the Patellar Clamp against the Patella Protector Squeeze the clamp unt...

Page 35: ...rial reduction observe the relative position of the Femoral Provisional on the tibial Articular Surface Provisional by using the lines on both provisionals The lines can be used to determine if posterior rollback is occurring whether the PCL is functional and if the femoral component will contact the tibial articular surface in the proper location If the PCL is properly balanced the Femoral Provis...

Page 36: ...on and instructions for the MIS Tibial Stemmed component Fig 8c Pegged Tibial Sizing Plate Stemmed Tibial Sizing Plate Attach the Universal Handle to the selected Tibial Sizing Plate Provisional by depressing the button on the handle and engaging the dovetail on the handle with the dovetail on the sizing plate provisional and secure it by tightening the thumbscrew Fig 8d Fig 8d Generally the handl...

Page 37: ... B PS or CR tension setting C Femoral rotation adjustment knob D Tension adjustment knob E Trigger F Instrument hook G Locking handle H Slaphammer slot Determine type of NexGen implant or provisional being used Posterior Stabilized PS or Cruciate Retaining CR Refer to the side of the instrument labeled PS or CR see A B which corresponds with the implant or provisional type Fig 9a Initially adjust ...

Page 38: ...sh on the lateral side The Femoral Provisional should be centered mediolaterally on the distal femur Attach the appropriate Tibial Articular Surface Provisional and perform a trial reduction Check ligament stability in extension and in 30 60 and 90 flexion Attempt to distract the joint in flexion to ensure that it will not distract If a posterior stabilized component is used hyperflex the knee and...

Page 39: ...a mallet to allow the ring on the taper to deform Position the PCL Retractor posteriorly the Collateral Soft Tissue Protector laterally and the Collateral Retractor medially Sublux the tibia anteriorly Place a layer of cement on the underside of the tibial base plate around the keel on the resected tibial surface and in the tibial IM canal Position the tibial base plate onto the tibia and use the ...

Page 40: ...rter fully to either side Place the articular surface onto the tibial base plate engaging the dovetails Fig 10b Steady the surface on the base plate with one hand by applying downward pressure near the posterior cruciate cutout Engage the hook on the inserter with the mating slot in the front of the base plate and close the lever with your index finger This should lock the inserter to the base pla...

Page 41: ...ely from the tibial articular surface container but in the same box Before inserting the tibial articular surface insert the metal locking clip into the anterior slot of the compartment The rail should be aligned with the space in the slot There is an arrow on the superior side of the locking clip that indicates the correct direction for insertion The purpose of the rail is to prevent the clip fro...

Page 42: ... tibial plate is impacted 2 Implant the tibial plate Remove the Replacement Stem Extention Locking Screw and discard If bone cement is being used wait for the cement to completely cure before inserting the articlular surface An articular surface provisional may be inserted to use as space while the cement cures 3 Remove the articular surface provisional and insert the articular surface onto the pl...

Page 43: ...ould be removed and repositioned perpendicular to the resected surface Insert the patella again and reclamp applying an even distribution of pressure on the patellar surface Apply cement to the anterior surface and pegs of the patellar component while in a doughy consistency Locate the drilled peg holes and use the Patellar Clamp to insert and secure the patella in place Fully open the jaws of the...

Page 44: ...elescoping Boom is attached to the yoke of the A P Sizing instrument Fig B The Stylus Tip is extended to the ideal point on the anterior femoral cortex which is located slightly lateral of patellar femoral groove proximal of the lateral condyle where the slope begins to flatten i e valley The Telescoping Boom can easily be adapted for use on either left medial right lateral or right medial left la...

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Page 47: ...Zimmer MIS Multi Reference 4 in 1 Femoral Instrumentation Surgical Technique 45 ...

Page 48: ...ww zimmer com Please refer to package insert for complete product information including contraindications warnings precautions and adverse effects 97 5967 002 00 Rev 7 0901 K17 3 5ML Printed in USA 2003 2008 2009 Zimmer Inc H124975967002001 090415R6L09E ...

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