Surgical Technique

LEGION TKS
Distal Cut First Preparation with Universal Instruments
LEGION™ Total Knee System
Distal Cut First Preparation
Primary Total Knee Arthroplasty

Contents
Introduction ...............................................................2
Technique highlights .................................................3
Preoperative planning ...............................................7
Instrument assembly .................................................8
DCF femoral resection
Intramedullary alignment ....................................10
Distal resection ...................................................11
Sizing guide procedure ......................................12
A/P resection ......................................................16
Extramedullary (EM) tibial resection
EM tibial preparation...........................................18
Tibial resection....................................................20
Tibial sizing .........................................................22
Component trialing .............................................24
Posterior stabilized resection....................................25
Component implantation...........................................30
Options/Alternatives
Patella preparation..............................................34
Intramedullary (IM) tibial preparation..................39
Appendix A
Implant size interchangeability ...........................44

Nota Bene
The technique description herein is made available to the
healthcare professional to illustrate the authors’ suggested
treatment for the uncomplicated procedure. In the final
analysis, the preferred treatment is that which addresses
the needs of the patient.
Additional LEGION Total Knee System surgical technique
brochures are available for the other LEGION components
and sets. LEGION instruments listed within reflect examples
in the LEGION Universal Instrument Set.
1
 Introduction
The LEGION™ Total Knee System has been designed to offer the
orthopaedic surgeon solutions to address intraoperative situations.
Implant function is directly related to accurate surgical technique.
LEGION instrumentation has been developed to be an easy-to-use
system that will assist the surgeon in obtaining accurate and
reproducible knee alignment. The instrumentation can be used in
minimally invasive or standard exposures.

While it has been the designers’ objective to develop accurate,

easy-to-use instrumentation, each surgeon must evaluate the
appropriateness of the following technique based on his or her
medical training, experience and patient evaluation.

Indications
The general principles of good patient selection and sound surgical
judgment apply to the total knee procedure. Preoperative planning and
meticulous surgical technique are essential to achieve optimum results.
Considerations of anatomic loading, soft-tissue condition, and component
placement are critical to minimize a variety of postoperative complications.
Indications for Total Knee Replacement:
1. Rheumatoid arthritis
2. Post-traumatic arthritis, osteoarthritis or degenerative arthritis.
3. Failed osteotomies or unicompartmental replacement or total
knee replacement.

Contra-indications
1. Cases where there is poor bone stock which would make the procedure
unjustifiable.
2. Active, local infection or previous intra-articular infections.
3. Mental or neurologic conditions that tend to pre-empt the patient’s ability
or willingness to restrict activities.
4. Neuropathic (Charcot) joint.
5. Conditions that tend to place increased loads on implants such as age,
weight, and activity level, which are incompatible with a satisfactory
long-term result.
6. Collateral ligament insufficiency (except in cases where a constrained
knee system is indicated and used).
7. Skeletal immaturity.
8. Use of a supracondylar nail through intercondylar notch of PROFIX™
primary femoral components.
9. Use of slotted femoral and tibial stems without adequate bone support.

2
Technique highlights
Distal femoral resection

Use the 9.5mm drill to open up the femoral canal

and slide the valgus alignment assembly until at
least one side contacts the distal femur.

After the assembly is placed in neutral rotation,

impact the floating spikes into the distal femur
and secure the distal block with pins.

Remove the IM rod, unlock the lever on

the valgus alignment guide and remove
the valgus alignment assembly using the
universal extractor.

Resect the distal femur.

Position the sizing guide flush against the

distal femur, while ensuring that the posterior
paddles are contacting the underside of both
posterior condyles.

To set rotation
Pin through lateral pivot pinhole, located on the
lower lateral corner of the sizing guide. Adjust
external rotation of the sizing guide by turning
the rotational adjustment knob clockwise (0-6°).

Fixed posterior referencing

Ensure the sizing guide is set in the ‘0’ position.
Drill and insert two pins through the locator
holes of the sizing guide. Determine the size of
the component by the graduations on the stylus.
If the femur is in-between two sizes, choose the
larger size.

Adjustable anterior referencing

Position the sizing guide stylus so that it
contacts the lateral ridge of the anterior cortex
and determine the size from the graduations on
the shaft of the stylus.
3
If the indicated size is in-between two sizes,
turn the upper hex screw clockwise to the next
lower size for anterior referencing or turn the
upper hex screw counterclockwise to the next
larger size. To lock in position, tighten the locking
hex screw. Drill to mark the locator holes for the
A/P cutting block.

Place the correctly sized A/P cutting block on

the distal femur and make anterior, posterior
and chamfer cuts.

4
Tibial resection

Place the extramedullary tibial guide with the

non-spiked (shown) or spiked rod and place on
tibia. Align guide over medial third of the tibial
tubercle and parallel to the tibia.

Attach the tibial stylus to the tibial cutting block

and lower the cutting block until the stylus
touches the low point on the least affected
side of the tibia. Once the resection level is
determined, insert pins to secure and remove
alignment assembly.

Resect the proximal tibia.

Size the tibia.

Posterior stabilized housing resection

Pin trial through anterior flange. Select the
Housing Resection Collet matching the femoral
trial size (either 1-2 or 3-8).

Ream through the collet in the anterior position

until the depth stop makes contact. Remove
the reamer and move the collet to the posterior
position. Ream through the collet once more until
contact is made.

Impact the Housing Box Chisel anteriorly

and then posteriorly through the Housing
Resection Collet to square the corners of the
PS box resection.

Select the appropriate size femoral trial cam

module, insert the arms of the cam module into
the anterior aspect of the femoral trial box and
rotate posteriorly.
5
Final preparation

After trial range of motion and alignment checks,

select the appropriate trial fin punch and punch
through the trial.

Place the femoral implant on the femur and use

the femoral impactor to fully seat the implant.

Apply tibial baseplate cover to protect

tibial baseplate.

Seat the tibial implant with the tibial impactor.

Insert the articular insert by placing the insert

assembly tool into the center notch of the
anterior lock detail (handle up) and engage the
two tabs of the tool into the two recesses on the
anterior periphery of the insert. Squeeze the
tool handle until the insert is fully seated within
the tibial component.

6
Preoperative planning

Determine the angle between the anatomical M V M A

and the mechanical axes. This measurement 6º
will be used intraoperatively to select the
appropriate valgus angle so that correct limb
3º 3º
alignment is restored. (Beware of misleading
angles in knees with a flexion contracture or
rotated lower extremities.)

Tip Many surgeons prefer to simply select a

standard angle for the distal femoral cut
(ie, 5º, 6º or 7º) based on the patient and
surgical experience.

Recommended sawblades
T
1.27 Sawblade (for standard blocks)
Cutting thickness and blade thickness
should be 0.050" or 1.27mm.

3º 3º

1.35 Sawblade (for MIS blocks)

Cutting thickness and blade thickness
should be 1.35mm.

M = Mechanical Axis

A = Anatomical Axis

T = Transverse Axis

V = Vertical Axis

7
 Instrument assembly
IM femoral assembly

1 Attach the selected valgus angle bushing (5°, 6°

or 7°) to the valgus alignment guide. Check the
bushing position to make sure that ‘left’ is facing
anteriorly when operating on a left knee and
‘right’ is facing anteriorly when operating
on a right knee.

2 Attach a modular T-handle to the IM rod and

insert through the alignment assembly (Figure 1).

3 Assemble the distal femoral cutting block onto

the valgus alignment guide. Positioning the block
at the ‘primary’ resection level will ensure the
cut will equal the distal thickness of the femoral
prosthesis. Lock by pressing the lever in a
horizontal position toward the medial side.
Figure 1

Extramedullary tibial alignment guide

Insert the ankle clamp into the distal end of the

alignment tube and thread the locking pin into
the ankle clamp (Figure 2).
Gold Knob
After the ankle clamp is moved into the proper
position, lock into place with the gold knob.

Choose the correct left or right tibial cutting block.

Select the spiked or non-spiked fixation rod.
Figure 2

Valgus Bushing Alignment Guide T-handle IM Rod Distal Cutting Ankle Clamp
5° 7144-0014 7144-1144 7111-0080 Long 7151-2040 Block 7144-0444
6° 7144-0016 Short 7151-2035 7144-1147
7° 7144-0018 Alignment Tube
7144-0448

8
Instrument assembly
Central Knob
Non-spiked fixation rod

Place the appropriate left or right tibial cutting

block on top of the disc on the non-spiked
fixation rod (Figure 3). Tighten the central knob to
lock the block into position.

Introduce the rod into the extramedullary

assembly and adjust and lock the cam in
the assembly.

Spiked fixation rod

Place the spiked fixation rod through the hole

in the tibial cutting guide; adjust the block
and tighten the central knob to lock the block
into position.
Locking Cam
Introduce the spiked fixation rod into the proximal
end of the alignment assembly and adjust and
Figure 4
lock the cam on the assembly (Figure 4).
Figure 3

Tibial Cutting Block Non-spiked Spiked Fixation Rod

Left 7144-1136 Fixation Rod 7144-0198
Right 7144-1137 7144-0446

9
 DCF Femoral resection
Intramedullary alignment

1 Open the femoral canal with a 9.5mm

intramedullary drill (Figure 5).

Tip If desired, the distal femoral cutting block

may be set to resect an additional +2, +5 or
+7mm of bone.
Figure 5
2 Slide the intramedullary rod of the assembly
into the femoral canal until the alignment guide
Locked
contacts the distal femur (Figure 6).

Tip There may be times when only one side of

the guide will touch bone.

3 Orient rotation of the assembly neutral to the

posterior condyles (Figure 7) and impact one or
both of the floating spikes into the distal femur.

Figure 6

Figure 7

Valgus Bushing Alignment Guide T-handle IM Rod Distal Cutting IM Drill

5° 7144-0014 7144-1144 7111-0080 Long 7151-2040 Block 7401-2111
6° 7144-0016 Short 7151-2035 7144-1147
7° 7144-0018

10
Instrument assembly
Distal resection

1 Using non-headed pins, pin the distal femoral

cutting block to the anterior femur using the
holes marked ‘0’. Once adequate distal femoral
resection is noted, an additional headed or
non-headed pin should be placed obliquely
to provide additional stability (Figure 8).

2 Unlock the lever on the valgus alignment

guide, remove the intramedullary rod and the
valgus alignment assembly using the universal
extractor (Figure 9). Only the distal femoral
cutting block should remain on the femur. Figure 8

3 Resect the distal femur (Figure 10) then remove

the distal femoral cutting block. Unlocked

Tip If the distal femoral resection is not

adequate, remove the oblique pin, and
reposition the block through the pin holes
marked +2 or +4mm for the desired level of
resection and re-insert the oblique pin.

Figure 9

Figure 10

Valgus Bushing Alignment Guide Universal Extractor IM Rod Distal Cutting

5° 7144-0014 7144-1144 7144-0366 Long 7151-2040 Block
6° 7144-0016 Short 7151-2035 7144-1147
7° 7144-0018

11
Instrument assembly
Sizing guide procedure A/P Axis

The sizing guide allows for external rotation to

be set from 0-6º based on surgeon preference
and patient anatomy. Rotational alignment
may be checked by aligning the A/P axis with
the pointer on the sizing guide or by ensuring
that the laser marked lines on the face of the Epicondylar Axis
guide are parallel with the epicondylar axis. The
rotational adjustment knob on the lower portion Rotational Adjustment
Knob
of the guide is turned to dial in rotation (Figure 11).

The guide can be used for fixed posterior

Figure 11
referencing or can be adjusted anteriorly or
posteriorly for fine tuning. When in-between
sizes, the surgeon can choose to adjust sizing
up to 4mm anteriorly, thereby taking up to an
additional 4mm off the posterior condyles, or up
to 2mm posteriorly, taking up to an additional
2mm off of the anterior cortex.

If the anterior surface of the guide is in-between

two sizes when it is at the zero position, the
upper hex screw can be rotated to shift the
anterior face of the sizing guide up to the next
Upper Hex Screw
smaller size or down to the next larger size on
the stylus. As a result, the locator holes for the Locking Hex Screw

A/P cutting block are shifted either anteriorly

or posteriorly to align with the next implant size
(Figure 12).

Tip The gap between the top of the sizing

guide and the stylus graduation line indicates Figure 12 Locator Holes

how much bone will be removed from either the

anterior cortex or posterior condyles by choosing
the next larger size (Figure 13).

Figure 13

Sizing Guide Sizing Stylus Hex Screwdriver

Left 7144-0007 7144-1140 11-5035
Right 7144-0008

12
 Sizing guide procedure: rotation

1 Flex the knee, approximately 90º so the

posterior condyles are accessible.

2 Choose appropriate sizing guide, ‘Left’ for a left

knee and ‘Right’ for a right knee.

3 Position the femoral sizing guide flush against

the distal femur, while ensuring the posterior Lateral Pivot Pin
paddles are contacting the underside of both
posterior condyles. Once correct position of Figure 14
sizing guide is established, place a pin through
lateral pivot pinhole located in the posterior/
lateral corner on the face of the sizing guide
(Figure 14). A/P Axis

4 Adjust the external rotation of the sizing guide

to be aligned anatomically with the epicondylar
and/or A/P axis. This can be achieved by
turning the rotational adjustment knob (0-6º)
using a hex screwdriver (Figure 15).
Epicondylar Axis
5 Once rotation is set, sizing can be established
either by fixed posterior referencing or
adjustable referencing.

Rotational Adjustment Knob

Figure 15

Sizing Guide Sizing Stylus Hex Screwdriver

Left 7144-0007 7144-1140 11-5035
Right 7144-0008

13
 Sizing guide procedure: fixed
posterior referencing

1 Ensure that the anterior surface of the sizing

guide is set in the ‘0’ position.

2 Drill and insert two pins through the locator

holes of the sizing guide to secure the guide.

3 Position the sizing guide stylus so that it contacts

Figure 16
the lateral ridge of the anterior femoral cortex
(highest point on the anterior cortex of the femur)
(Figure 16).

4 Determine the size of the component from the

graduations on the shaft of the stylus.

5 If the femur is between sizes, chose the

larger size.

6 Remove the pins and the sizing guide.

Sizing Guide Sizing Stylus Hex Screwdriver

Left 7144-0007 7144-1140 115035
Right 7144-0008

14
 Sizing guide procedure: adjustable
anterior referencing

1 Ensure that the anterior surface of the sizing

guide is set in the ‘0’ position.
Upper Hex Screw
2 Drill and insert two pins through the oblique
holes of the sizing guide to secure the guide. Locking Hex Screw

3 Position the sizing guide stylus so that it

contacts the lateral ridge of the anterior femoral Locator Holes

cortex (highest point on the anterior cortex of

the femur) (Figure 17).
Figure 17
4 Determine the size of the component from the
graduations on the shaft of the stylus.

5 If the indicated size is in-between sizes, you

can turn the upper hex screw to shift the
anterior surface up to an additional 4mm to the
next smaller size or down an additional 2mm to
the next larger size (Figures 18a and b). Once
the appropriate size is selected, turn the locking
hex screw to lock the anterior surface and
locator holes into position (Figure 17).

6 Drill the locator holes to set the position for the

cutting block. Anterior Reference Shift of 4mm

Figure 18a
7 Remove the pins and sizing guide.

Posterior Reference Shift of 2mm

Figure 18b

Sizing Guide Sizing Stylus Hex Screwdriver

Left 7144-0007 7144-1140 11-5035
Right 7144-0008

15
Instrument assembly
A/P resection

1 Position the fixed spikes on the A/P cutting

block into the predrilled holes.

Tip It is not necessary that the block be

centered M/L on the distal femur.

2 Ensure that the cutting block is flush with the Figure 19

resected distal femur. Several holes in the A/P
block allow fixation of the block. Place one
pin centrally through one of the middle holes
just medial or lateral to the quick-connect
attachment. For additional stability, a headed
pin may be placed through the holes on the
medial or lateral side of the block (Figure 19).

3 Complete the anterior, posterior and chamfer Figure 20

cuts (Figures 20-23). The block is designed
to allow for angling of the sawblade during
the cuts.

Tip To maintain block stability, the anterior

chamfer cut should be completed last.

Figure 21

Figure 22

Figure 23

A/P Cutting Block

sz 5 7144-1153

16
 Downsizing the femoral component

1 Attach the downsizing drill guide to the cut

femur, placing the spikes on the back of the
plate into the same location holes used for the
A/P cutting block (Figure 24).

2 Drill new location holes through the downsizing

drill guide (shifted 2mm anterior).

3 Place the smaller A/P cutting block into the new

location holes. Redo the posterior, anterior and
chamfer cuts.

Tip It is useful to mark the original pin track Figure 24

holes with a marking pen in order to properly
identify the new holes.

Downsizing Drill
Guide
7144-0860

17
 Extramedullary (EM) tibial resection
EM tibial preparation

When using the extramedullary tibial alignment,

the surgeon may use a non-spiked or spiked
fixation rod.

Non-spiked fixation

1 Place the arms of the extramedullary alignment

clamp around the ankle, and adjust the distal
M/L slide directly over the middle of the tibiotalar
joint, which is also approximated by the second
ray of the foot proximal to the malleoli (Figure 25).

The cutting block on the proximal end of the

assembly should be proximal to the tibial
tubercle (Figure 26).

2 Assess rotation of the alignment guide and slope

Figure 25 Figure 26
of the cutting plane. The goal is to align the
extramedullary alignment assembly rotationally
so that it aligns over the medial third of the tibial
tubercle and over the second toe (Figure 27).

3 Rotational alignment is critical due to the 3°

posterior sloped cut. The slope can be adjusted
according to the patient’s anatomy (Figure 28).

Note 3-5° of slope is built into the articular

insert (depending on which insert is chosen) and
3° of slope is built into the tibial cutting block.
A neutral or slightly sloped alignment should
usually be chosen.

Tip Neutral or minimally sloped alignment may

be achieved by palpating the fibula followed by
aligning the alignment guide parallel to the fibula.
Tibial bowing and soft tissue bulk may make
external tibial referencing unreliable.

Figure 27 Figure 28

Ankle Clamp Alignment Tube Tibial Cutting Block Non-spiked

7144-0444 7144-0448 Left 7144-1136 Fixation Rod
Right 7144-1137 7144-0446

18
 Spiked fixation

1 Place the arms of the extramedullary alignment

clamp around the ankle, and adjust the distal
M/L slide directly over the middle of the
tibiotalar joint, which is also approximated
by the second ray of the foot proximal to the
malleoli (Figure 29).

The cutting block on the proximal end of the

assembly should be proximal to the tibial
Figure 30
tubercle (Figure 30).

2 Impact the longer spike of the spiked fixation

rod into the proximal tibia (Figure 31).
Figure 29

3 Assess rotation of the alignment guide and

slope of the cutting plane. The goal is to
align the extramedullary alignment assembly
rotationally so that it aligns over the medial
third of the tibial tubercle and over the second
toe (Figure 32).

4 Rotational alignment is critical due to the

3° posterior sloped cut. The slope can be
adjusted according to the patient’s anatomy Figure 31
(Figure 33). Impact the second spike to secure
the assembly (Figure 34).

Note 3-5° of slope is built into the articular

insert (depending on which insert is chosen)
and 3° of slope is built into the tibial cutting
block. A neutral or slightly sloped alignment
should usually be chosen.
Figure 32
Tip Neutral or minimally sloped alignment may
be achieved by palpating the fibula followed
by aligning the alignment guide parallel to the
fibula. Tibial bowing and soft tissue bulk may
make external tibial referencing unreliable. Figure 33

Figure 34

Ankle Clamp Alignment Tube Tibial Cutting Block Spiked Fixation Rod
7144-0444 7144-0448 Left 7144-1136 7144-0198
Right 7144-1137

19
 Tibial resection

1 Attach the tibial stylus to the tibial cutting block

by inserting the stylus foot into the cutting slot.

2 Lower the cutting block until the stylus touches

the low point on the least affected side of the
tibia (Figure 35). The stylus can be adjusted for
a 1-13mm tibial resection by twisting the knob
on top of the stylus. If the affected side of the
tibia is to be used as a reference, the stylus
may be adjusted for a 1-9mm resection level. Figure 35

3 Pin the tibial cutting block to the tibia by

inserting pins first through the central holes;
then the oblique hole.

Tip Pinning through the central holes marked

0mm with smooth pins will allow the block to
be moved +2mm should additional resection
be required (Figure 36).

Tip A 9mm resection is recommended since

9mm of metal and plastic is the thinnest
available component.

Tip To do an extramedullary alignment check,

Figure 36
place the extramedullary alignment rod through
the tibial cutting block.

4 To remove the assembly:

a For the assembly with spiked rod, release the
cam at the top of the alignment tube and use
the universal extractor to remove the spiked
fixation rod (Figure 37) after loosening the
thumbscrew.

b The assembly with the non-spiked rod may

be left in place or removed by loosening the
thumbscrew and lowering the non-spiked rod
to disengage from the tibial cutting block.

Knob (unlocked)
Figure 37

Tibial Stylus Alignment Rod Tibial Cutting Block

7144-1143 7144-1148 Left 7144-1136
Right 7144-1137

20
5 Cut the tibia by first directing the blade in the
posterior direction and then laterally (Figure 38).

Check Alignment and Balance

1 Assemble the Quick Connect Handle to the

Flexion/Extension block. Attach desired
thickness of Flexion/Extension Spacer onto the
Figure 38
Flexion/Extension block.

2 Insert the Flexion/Extension block into the

extension gap. Evaluate alignment, balance, and
extension space (Figure 39)

3 Adjust the thickness of the spacer as needed to

determine the extension space. Spacer Block

4 Remove the block and reassemble desired

thickness of spacer for flexion gap evaluation.

5 With the knee flexed to 90 degrees, place the

Flexion/Extension Block into the joint space. Figure 39

6 Apply a varus/valgus force and assess the

medial and lateral compartment laxity levels of
the flexion space. Then adjust the thickness of
the spacer as needed to determine the flexion
space.

7 When the flexion space is determined, compare

the thickness selected relative to the extension
space previously determined.

Note: Remember any difference between the

Extension and Flexion Gap Assessments as this
will affect how the femoral implant is positioned
in the steps ahead (e.g. 10mm Ext - 11mm Flex =
-1mm Flex Imbalance).

Universal Extractor Tibial Cutting Block Flexion/Extension Flexion/Extension Quick Connect

7144-0366 Left 7144-1136 Block Standard Spacers Handle
Right 7144-1137 7401-8603 9mm 7401-8608 7144-0044
11mm 7401-8611
13mm 7401-8613
15mm 7401-8615
18mm 7401-8618
21mm 7401-8621

21
 Tibial sizing

Option A – stemless tibial trials

1 Attach a quick-connect handle to a stemless

trial one size below the femoral component size
and place on the cut tibia to assess coverage
(Figure 40). As needed, additional sizes should
be templated using the stemless trials.

2 Once the appropriate size is determined, pin the

medial side of the selected stemless trial with a
short headed pin.

3 Place a trial insert into the stemless tibial trial

tray and perform a trial range of motion to allow
the baseplate to center on the femoral trial. Quick-connect Handle
(As a secondary check, the surgeon may pass
the alignment rod through the quick-connect
handle to assess alignment) (Figure 41). Pin the Figure 40
lateral side of the trial.

Tip After putting the knee through a trial

range of motion, the surgeon should note the
proper rotation of the trial tibial component on
the proximal tibia and mark the tibia for
future reference.

Tip The center-line marks on the femoral and

tibial trial components should line up. Drop Rod

4 Using the tibial fin/stem punch, rotational

alignment may be set now or at the time of
trial placement.

Tip If the tibial bone is sclerotic, first drill for the

stem using the 11mm tibial drill. Begin the fin slot
Figure 41
with a burr or thin sawblade before using the fin
punch to prevent tibial fracture.

Quick-connect Stemless Trials Fin/Stem Punch 11mm Tibial Drill

Handle Left sz 3-4 7144-9993 7144-0040
7144-0044 sz 4 7143-0167
Right
sz 4 7143-0183

22
 Option B – stemmed tibial trials
(NOT AVAILABLE IN UNIVERSAL INSTRUMENT
SETS)

1 Place a tibial drill guide one size below the

femoral component size on the cut tibia to
assess coverage. As needed, additional sizes
should be templated (Figure 42).

2 Once the tibial drill guide has been centralized

Figure 42
on the proximal tibia, pin the drill guide in place.
Retract the gold collar on the drill guide handle
and insert the 11mm tibial collet.

3 With the 11mm tibial collet in place, drill with the

11mm tibial drill (Figure 43) and punch with the
11mm tibial punch (Figure 44).

4 Remove the tibial drill guide.

5 Place the stemmed tibial trial into the

prepared hole. Figure 43

6 Using the tibial fin punch, rotational alignment

may be set now or at the time of trial placement.

Tip After putting the knee through a trial

range of motion, the surgeon should note the
proper rotation of the trial tibial component on
the proximal tibia and mark the tibia for
future reference.

Tip The center-line marks on the femoral and

tibial trial components should line up.

Figure 44

11mm Tibial Punch 11mm Tibial Drill Stem Trials Fin/Stem Punch
7144-0262 7144-0040 Left sz 3-4 7144-0266
sz 4 7143-0166
Right
sz 4 7143-0182

23
 Component trialing
Femoral component trialing

1 Flex the knee to 90° and insert the femoral trial

using the femoral trial impactor (Figure 45).

2 Perform a trial range of motion to assess patellar

tracking. With cruciate-retaining knees, medial/ Figure 45
lateral placement of the femoral trial can be
adjusted to optimize patellar tracking
(Figure 46).

3 For cruciate-retaining femorals, prepare the

femoral lug holes through the femoral trial with
the femoral lug punch (Figure 47).

Note: It is recommended to leave the femoral

trial on at this point to perform full component
trialing. However, if desired, you may attach the Figure 46

end of the universal extractor to the femoral trial

and remove the femoral trial (Figure 48).

Lug Punch

Figure 47

Extractor

Figure 48

Femoral Trial Femoral Trial Lug Punch Universal Extractor

Left Impactor 7144-0183 7144-0366
sz 5 7143-3345 7144-0009
Right
sz 5 7143-3355

24
 Posterior stabilized resection
Femoral housing box resection
1 Pin the femoral trial through the anterior flange
(Figure 49).

2 Choose the housing resection Collet matching

the femoral trial size (either 1-2 or 3-8). Attach the
Collet to the femoral trial by sliding the Housing
Collet (anterior to posterior) into the slots on the
distal face of the femoral trial and threading the
two posts into the femoral trial. The Housing
Collet should be secured in the anterior position
Figure 49
first and then shifted to the posterior position
and screwed (Figure 50).

Housing Collet

Figure 50

Femoral Trial Housing Collet

Left Resection
sz 5 7143-3345 sz 3-8 7143-4424
Right
sz 5 7143-3355

25
3 Attach the Housing Reamer Dome and the PS
Reamer Sleeve to the Patellar Reamer Shaft
(Figure 51).

Ream through the housing resection Collet in

both the anterior and posterior positions until
the depth stop contacts the Collet (Figure 52).

4 Impact the Housing Box Chisel through the

Housing Resection Collet to square the corners
of the housing. The Housing Box Chisel
should be used anteriorly and then posteriorly
to ensure that the full length of the box is
Housing Reamer Dome
prepared (Figure 53).

Figure 51

Figure 52

Figure 53

Housing Reamer Housing Box Chisel Patellar Reamer Reamer Sleeve

Dome 7144-0373 Shaft 7144-0464
7144-0145 7144-0324

26
 Femoral trial cam module assembly

1 Select the appropriate sized femoral trial

cam module (matching the femoral trial
size selected).

2 Insert the arms of the femoral cam module

into the anterior aspect of the femoral trial box
and rotate posteriorly until seated (Figures 54
and 55).
Figure 54

Figure 55

Cam Modules Femoral Trial

sz 5 7143-3365 Left
sz 5 7143-3345
Right
sz 5 7143-3355

27
 Tibial component trialing

1 Use the appropriate insert trial (begin with a

9mm trial) to determine stability and alignment.

2 Perform a trial range of motion. The alignment

marks on the front of the femoral and tibial
trials should line up (Figure 56). The quick-
connect handle may be attached to the tibial
trial and used to set the appropriate rotational
alignment.

Optional Extend the knee fully with the

Figure 56
handle attached to the tibial trial. Pass the
extramedullary rod through the handle to
assess full leg alignment (Figure 57).

Figure 57

PS High Flex Insert PS Insert Trials Constrained Insert Insert Trial Spacers
Trials 9mm Trials 13mm
9mm sz 3-4 7143-0815 9mm sz 3-4 7403-3634
sz 3-4 7143-0408 11mm sz 3-4 7144-0473 15mm
10mm sz 3-4 7143-0817 11mm sz 3-4 7403-3635
sz 3-4 7143-3453 sz 3-4 7143-0524 18mm
11mm CR Insert Trials Deep Dished sz 3-4 7403-3636
sz 3-4 7143-0409 9mm Insert Trials 21mm
12mm sz 3-4 7143-0490 9mm sz 3-4 7403-3637
sz 3-4 7143-3454 11mm sz 3-4 7143-0766
sz 3-4 7143-0492 11mm
sz 3-4 7143-0768
CR Deep Flex
Insert Trials
9mm
sz 3-4 7143-0444
10mm
sz 3-4 7143-3443
11mm
sz 3-4 7143-0445
12mm Note: 10 and 12mm
sz 3-4 7143-3444 Insert Trials are an
Add-On Set

28
3 Mark correct tibial rotational alignment on the
anterior tibia using a cautery knife (Figure 58).

4 If not previously performed, select the

appropriate tibial fin punch to prepare the fins
and punch through the tibial trial (Figure 59).

Tip If the tibial bone is sclerotic, begin the fin

slot with a burr or thin sawblade before using
the fin punch to prevent tibial fracture.
Figure 58
6 Remove the femoral and tibial trials.

Figure 59

29
 Component implantation
Femoral implantation

Cemented

1 Mix and prepare bone cement for femoral

component and distal femur. Apply to the
femoral component or prepared bone, based
on the surgeon’s preference.

Tip Many surgeons put cement on the bone

rather than, or supplemental to, cement on the
underside of the implant.

2 Place the femoral implant onto the femur and

use the femoral impactor to fully seat the
implant (Figure 60).

3 Remove excess cement. Extend the knee to

remove cement anteriorly without retracting the Figure 60
proximal soft tissue.

Tip After tibial implant is implanted, place the

tibial insert trial onto the tibial implant and
extend the leg to pressurize the cement.

Tip Place the CR tibial trial in the tibial

implant tray to assist with aligning the femoral
component during implantation.

Porous

1 Ensure that flat, clean cuts are made to all of the

femoral resection cuts. This will help to achieve
an optimal press-fit.

Tip Lavaging during resection helps ensure flat,

clean cuts.

2 Place the femoral implant onto the femur

and use the femoral impactor to fully seat
the implant.

Tip If extraction of the femoral component is

needed, attach the locking impactor and move
in side-to-side motions to leverage off, then
adjust and reimpact.

OXINIUM™ CR Femoral Impactor PS Femoral Impactor

Impactor (Universal 7144-0190 7144-0005
Impactor)
7144-0890

30
 Tibial implantation

Apply cement on the proximal tibia and/or the

implant, tibial insert covers on the articular surface
of the baseplate, and seat the tibial implant with the
tibial impactor (Figure 61). Remove excess cement.

Recommended Insert Placement Method

1 Clear any debris from the locking mechanism and

manually slide the insert into the tibial baseplate
engaging the locking mechanism until the insert
periphery is within 1-2mm of the Tibial Figure 61
Component periphery.

2 Insert the tip of the JOURNEY™ Articular Insert Tool

into the center notch of the anterior lock detail
(handle up) and engage the two tabs of the Tool
into the two recesses on the anterior periphery of
the insert (Figure 62).
Note: Make sure the tool is level with the plane of
the baseplate.

3 Squeeze the tool handle until the insert is fully

seated within the Tibial Component. The insert Figure 62
should not move under any pressure in flexion
or extension.

Cruciate-retaining, dished and posterior

stabilized insert placement

1 Determine the correct articular insert thickness.

2 Clear any debris from the locking mechanism

and manually slide the insert into the tibial
baseplate engaging the locking mechanism.
For the PS insert, begin insertion in flexion
and extend the leg to engage the locking
mechanism.

3 Attach the articular inserter/extractor to the

tibial tray. Lift the inserter superiorly until the
anterior lip of the articular insert is fully seated
(Figure 63). Figure 63

Tibial Base Articular Inserter/ JOURNEY Articular

Impactor Extractor Inserter Tool
7401-8901 7144-0194 7401-8911

31
 PS and CR high flex insert placement

1 Attach the appropriately sized impactor head

(either 1-2 or 3-8) to the impactor handle.

2 Position the knee in approximately 90° flexion.

3 Align the articular insert with the locking

Figure 64
mechanism of the tibial baseplate.

4 Push the insert posteriorly until the top of the

anterior rail of the baseplate is visible.

5 Place the impactor head on the anterior chamfer

of the insert. The mating surfaces should be very
conforming (Figures 64 and 65).

6 Impact the handle until the insert is fully seated.

Figure 65

High-flex Impactor High-flex Impactor

Head Handle
sz 1-2 7144-1553 7144-1552
sz 3-8 7144-1554

32
 MIS PS high flex insert placement

When using the PS high flex insert in a minimally

invasive procedure, the femoral cam mechanism
is likely to prevent the insert from fully seating
into the locking mechanism while the knee is
in flexion. To use the PS high flex insert in a
MIS case:

1 Flex the knee to 90° and push the insert as far

Figure 66
back as it will go posteriorly with the knee in
flexion (Figure 66).

Tip Lift the distal femur to prevent scratching of

the posterior condyle of the component.

2 Placing your thumb on the anterior of the insert

to hold it on the baseplate (Figure 67), move the
knee into extension.

3 Use the impactor handle with the appropriately Figure 67

sized impactor head to fully seat the insert
and engage the anterior portion of the dovetail
locking mechanism (Figure 68).

Figure 68

33
 Options/Alternatives
Patella preparation
Locking Screw
Instrument assembly

Patellar Reamer Guide

Determine the appropriate diameter patellar

implant, and select the correctly-sized Patellar
Reamer Collet and slide it into place on the
Reamer Collet
Patellar Reamer Guide (Figure 69).

Depth gauge and reamer assembly

1 Attach the appropriate patellar depth gauge Figure 80

Figure 69 Reamer Guide
(red = resurfacing, black = large resurfacing/
round) to the Reamer Guide (Figure 70).

2 Attach the matching sized patellar reamer dome

and patellar depth stop to the patellar reamer
shaft (Figures 71 and 72). Lower the assembly
through the patellar Reamer Guide until the
reamer dome contacts the patella.

Figure 70

Reamer Dome

Figure 71 Figure 72

Reamer Collet Resurfacing Depth Patellar Depth Reamer Shaft

26mm 7144-0512 Gauge Stop 7144-0324
29mm 7144-0514 7144-0330 7144-0326 Reamer Dome
32mm 7144-0516 26mm 7144-0348
35mm 7144-0518 Large Resurfacing/ Large Resurfacing/ 29mm 7144-0342
Oval Depth Gauge Oval Depth Stop 32mm 7144-0344
Reamer Guide 7144-0431 7144-0427 35mm 7144-0346
7144-0311

34
 Resurfacing patellar preparation

The surgeon can choose from a freehand

cutting technique with towel clips, or if desired,
he or she can choose one of the following
instrumented techniques.

Reaming technique

The objective of this technique is to resurface the

articular surface of the patella with the precision
of a reaming technique. The reamed patellar
surface can accommodate an oval or round
resurfacing patellar component.

1 Trim tissue surrounding the patella using

electrocautery (bovie) (Figure 73).
Figure 73
2 Use a rongeur to remove osteophytes and
reduce the patella to its true size (Figure 74). It is
recommended to leave the superior rim of bone
intact. The bovie should also be used to release
soft tissue attachments to the estimated level of
resection.

3 Place the collet over the patella so that it fits

snugly around the patellar diameter (Figure 75).
The goal is to reduce the patella to its smallest Figure 74

diameter so that the smallest possible collet

will fit around the entire patella. Use the patellar
reamer collet as a sizing template to select the
appropriately sized collet and reamer.

Tip The collet should be resting on the soft

tissue surrounding the patella. If the patella does
not enter the collet evenly but instead enters
at an angle, the collet may not be completely
surrounding the patella, but instead resting on
part of the bone. If the collet is only slightly smaller
than the patella, you may trim 1-2mm of the
medial and lateral edges of the patella to ensure a Figure 75
snug fit. If the collet is far smaller than the patella,
choose the next size up and assess fit.

Resurfacing Drill Drill Patellar Calipers Reamer Collet

Guide 7144-0360 11-4943 26mm 7144-0512
26mm 7144-0402 29mm 7144-0514
29mm 7144-0403 32mm 7144-0516
32mm 7144-0404 35mm 7144-0518
35mm 7144-0405

35
4 Measure patella thickness with the patellar
calipers (Figure 76).

Tip The patella should measure a minimum of

19mm before reaming to use this resurfacing
Collet
technique.

Determine the design and diameter of the

patellar implant to be used. The round
resurfacing patella is 9mm thick, and the Figure 76
depth stop for this technique prepares for
9mm of resection.

Tip Minor adjustments may be necessary at the

time of resection to accommodate the largest Depth Stop
diameter oval patellar implants. (Please see chart
on page 44).

5 Rotate the appropriate resurfacing

patellar depth gauge (red = round) Depth Gauge
around so that the hooked end or ‘claw’
surrounds the patellar reamer shaft (Figure 77).
Lower the depth stop by compressing the
button until it meets the depth gauge (Figure 78).
Remove the depth gauge from the assembly. Clamp
Ream the patella until the depth stop engages
Figure 77
the patellar Reamer Guide (Figure 79).

Tip Excessive force on the reamer shaft may alter

the depth of resection, causing overreaming.

Figure 78 Figure 79

Resurfacing Depth Reamer Dome Reamer Guide

Stop 26mm 7144-0348 7144-0311
7144-0326 29mm 7144-0342
32mm 7144-0344 Resurfacing Depth
Reamer Shaft 35mm 7144-0346 Gauge
7144-0324 7144-0330

36
6 After reaming, the patella should have a
completely flat articular surface (Figure 80).
Measure the resected patella to ensure adequate
resection (the resected patella should measure
its original depth minus 9mm).

7 Drill the appropriate fixation holes for the

Target Depth
resurfacing patellar implant using the correctly
Original Depth - 9mm
sized drill guide and resurfacing drill (Figure 81).

8 Place the patellar trial into the prepared patella.

Collet
If desired, use the calipers to remeasure the
composite thickness of bone and trial (Figure 82). Figure 80

Drill Guide

Drill

Figure 81

Figure 82

Resurfacing Drill Drill Patellar Calipers

Guide 7144-0360 11-4943
26mm 7144-0402
29mm 7144-0403
32mm 7144-0404
35mm 7144-0405

37
 Component trialing

1 Place the patellar trial into the prepared

patella (Figure 83).

2 Perform a trial range of motion to assess

patellar tracking. Medial/lateral placement of
the femoral trial can be adjusted to optimize
patellar tracking (Figure 84).

Figure 83

Figure 84

Patellar implantation

1 Assemble the patellar cement clamp to the Clamp

patellar Reamer Guide.

2 Apply bone cement to the patella.

3 Place the patellar implant onto the patella

and clamp into the bone (Figure 85). Remove
excess cement.

Figure 85

Resurfacing Reamer Guide Cement Clamp

Patellar Trial 7144-0311 7144-0322
26mm 7143-0580
29mm 7143-0574
32mm 7143-0576
35mm 7143-0578

38
Intramedullary (IM) tibial preparation

Technique highlights

Place the intramedullary alignment assembly

on the tibia. The alignment rod should align
with the medial third of the tibial tubercle.
Impact assembly.

Attach the tibial stylus to the tibial cutting block

and lower the cutting block until the stylus
touches the low point on the least affected
side of the tibia. Once the resection level is
determined, insert pins to secure and remove
alignment assembly.

Resect the proximal tibia.

Size the tibia.

Final preparation

After trial range of motion and alignment checks,

select the appropriate trial fin punch and punch
through the trial.

Seat the tibial implant with the tibial impactor.

Insert the articular insert by placing the insert

assembly tool into the center notch of the
anterior lock detail (handle up) and engage the
two tabs of the tool into the two recesses on the
anterior periphery of the insert. Squeeze the tool
handle until the insert is fully seated within the
tibial component.
39
 Instrument assembly

Intramedullary Tibial Alignment Guide

1 Insert the external rod of the Intramedullary

Tibial Alignment Guide through the hole on the
correct left or right Tibial Cutting Block and lock
the cam (Figure 86).
Alignment Sleeve
2 Attach the T-handle to the IM Rod and pass it
through the cannulated alignment sleeve on
the alignment assembly (Figure 87).

Alignment Rod

Figure 86

Figure 87

T-handle Tibial Cutting Block IM Alignment IM Rod

7111-0080 Left 7144-1136 Guide Short 7151-2035
Right 7144-1137 7144-0200 Long 7151-2040

40
 IM tibial preparation

1 Make a 9.5mm pilot hole into the tibial canal

(Figure 88). A preliminary resection of the tibial
spine may facilitate seating of the tibial drill guide
onto the proximal tibia.

2 Slowly insert the IM rod into the tibial canal.

3 Assess rotation of the intramedullary tibial Figure 88

alignment guide. Rotational alignment is critical
due to the 3º posterior sloped cut. The
alignment rod of the intramedullary tibial
alignment assembly should align with the
medial third of the tibial tubercle (Figure 89).

4 Impact the proximal end of the cannulated

alignment sleeve to drive the distal spikes into
the proximal tibia to lock rotational alignment
(Figure 90).

Figure 89

Figure 90

Tibial Cutting Block IM Alignment IM Rod

IM Drill
Left 7144-1136 Guide Short 7151-2035
7401-2111
Right 7144-1137 7144-0200 Long 7151-2040

41
 Tibial resection

1 Attach the Tibial Stylus to the Tibial Cutting

Block by inserting the stylus foot into the
cutting slot.

2 Lower the cutting block until the stylus touches

the low point on the least affected side of the
tibia (Figure 91). The stylus can be adjusted for
a 1-13mm tibial resection by twisting the knob
on top of the stylus. If the affected side of the
tibia is to be used as a reference, the stylus
may be adjusted for a 1-9mm resection level.
Figure 91
3 Pin the Tibial Cutting Block to the tibia by
inserting pins first through the central holes;
then the oblique hole.

Tip Pinning through the central holes marked

0mm with smooth pins will allow the block to
be moved +2mm should additional resection
be required (Figure 92).

Tip A 9mm resection is recommended since

9mm of metal and plastic is the thinnest
available component.
Figure 92
Tip To do an extramedullary alignment check,
place the extramedullary Alignment Rod
through the tibial cutting block.

Tibial Stylus Tibial Cutting Block Alignment Rod

7144-1143 Left 7144-1136 7144-1148
Right 7144-1137

42
4 To remove the assembly:
Use the universal extractor leaving the cutting
block on the anterior tibia (Figure 93) after
loosening the thumbscrew.

5 Cut the tibia by first directing the blade in

the posterior direction and then laterally
(Figure 94).

6 Check alignment and balance with spacer

block and rod. Balance ligaments in
standard fashion.

Figure 93

Figure 94

Universal Extractor Flexion / Extension Quick Connect Alignment Rod

(Slap Hammer) Spacers Handle 7144-1148
7144-0366 9mm 7401-8608 7144-0044
11mm 7401-8611
Flexion / Extension 13mm 7401-8613 Tibial Cutting Block
Block Standard 15mm 7401-8615 Left 7144-1136
7401-8603 18mm 7401-8618 Right 7144-1137
21mm 7401-8621

43
Appendix A
Implant size interchangeability

Femoral Size

Insert Size 1 2 3 4 5 6 7 8

1-2 PS, DD, Con

1-2 PSHF, CRHF

3-4 PS, DD, Con

3-4 PSHF, CRHF

5-6 PS, DD, Con

5-6 PSHF, CRHF

7-8 PS, DD, Con

7-8 PSHF, CRHF

PS – Standard posterior stabilized

DD – Deep dish
Con – Constrained
PSHF – Posterior stabilized high flex
CRHF – Cruciate retaining high flex

Note: CR – Standard cruciate retaining inserts are interchangeable with all size femoral components

44
45
Smith & Nephew, Inc. [Link]
7135 Goodlett Farms Parkway [Link]
Cordova, TN 38016
USA

Telephone: 1-901-396-2121
Information: 1-800-821-5700
Orders and Inquiries: 1-800-238-7538
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©2014 Smith & Nephew, Inc. All rights reserved.

™Trademark of Smith & Nephew. Registered US Patent and Trademark Office. 02860 7128-1978 V1 12/14