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ODYSSEY TM

Tissue Preserving InitiativeMIS Anterior Rough Cut

Surgical Technique

The ADVANCE Knee System wasdeveloped in conjunction with:

J. DAVID BLAHA, MDClinical Professor Department of Orthopedic Surgery,University of Michigan Ann Arbor Michigan

DAN DALUGA, MDOrthopaedic Surgeon Arnett Clinic,Lafayette Home Hospital,St. Elizabeth Medical Center Lafayette, Indiana

M.A.R. FREEMAN, MD, FRCSHonorary Consultant Orthopaedic SurgeonRoyal London Hospital London, U.K.WILLIAM MALONEY, MD,Elsbach-Richards Professor and ChairmanDepartment of Orthopaedic Surgery Stanford University School of MedicineStanford, California

KENT SAMUELSON, MD Attending Orthopaedic Surgeon,LDS Hospital Salt Lake City, Utah

ROBERT SCHMIDT, MDThe Texas Hip and Knee Center ,Fort Worth, Texas

STEVEN STUCHIN, MD Associate Professor, Clinical Orthopaedics,Director of Orthopaedic Surgery Hospital for Joint Diseases Orthopaedic Institute ,New York University Medical Center New York, New York

The Hospital for Special Surgery New York, New York.

MICHAEL J ANDERSON, MD Attending Orthopaedic SurgeonBlount Orthopaedic Clinic Milwaukee, Wisconsin

BRAD PENENBERG, MD Attending Orthopaedic Surgeon,Cedars Sinai Medical Center ,Midway Hospital Medical Center Los Angeles, California

JOHN BALL, MD Attending Orthopaedic SurgeonSt. Bernard's Regional Hospital Jonesboro, Arkansas

Special thanks to the following surgeonsfor development of ODYSSEY Anterior Rough Cut Instrumentation:

Instrumentation for theADVANCE Knee Systems

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ODYSSEY TM M I S A N TERI O R ROU G H CU T I N S TRUM EN TATIO N

o n e

Proper surgical techniques are necessarily the responsibility of the medical professional. The following guidelines are furnished only as recommendedtechniques. Each surgeon must evaluate the appropriateness of the techniquesbased on his or her own medical training and experience.

ODYSSEY TM instrumentation is designed to be applicable to both minimally invasive and standard total knee procedures . Therefore, surgeons shouldemploy the technique they are most comfortable with; be it standard midline,mid-vastus, or subvastus.

NOTE |Recessed patellar instrumentation is available but may not be applicable to aminimally invasive procedure. To use this instrumentation, see Appendix A

With the leg extended, the patella is tilted to almost a 90 angle. The onlay patellarresection guide can be used with or without the 8mm resection depth gauge. When used without the gauge, the resection guide is positioned at the desiredlevel of resection. For a calibrated resection, the 8mm resection depth gaugeshould be attached to the top of the resection guide with the lock screw.| FIGURE 1APosition the resection guide jaws parallel to the articular marginand securely clamp the guide to the bone; ensuring the gauge is contacting the apex of the articular surface . Remove the gauge and locking screw andmake the patellar resection along the top face of the jaws. | FIGURE 1B Attachthe appropriate drill guide to the patellar clamp and clamp the patella.| FIGURE 2The drill guides have grooves on their surfaces indicating the patellar diameter options. The appropriate tri-peg or central peg reamer

is used to prepare the peg hole(s).NOTE | The patellar peg holes may beprepared after the tibial and femoralresections.

NOTE |Instead of utilizing a clampfor patellar resection some surgeonsprefer a non-instrumented technique.

NOTE | The tri-peg patellae have thesame peg patterns between sizes andcan be easily changed during trialreduction.

general PRECAUTIONS

surgical APPROACH

patella PREPARATION

ODYSSEY TISSUE PRESERVING INITIATIVE

MIS ANTERIOR ROUGH CUT Instrumentationfor the ADVANCE Knee Systems

FIGURE 1A |

FIGURE 1B | FIGURE 2 |

TM

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ODYSSEY TM M I S A N TERI O R RO UG H CU T I N S TRU MEN TATI O N

t w o

PREPARATION OF THE DISTAL FEMURNOTE |Prior to femoral preparation, draw a line down the deepest part of the trochlear

groove to represent the A/P axis (see below). This line will be utilized later in thetechnique as a reference for femoral guide rotation.

Tibial and femoral resections are made independently; therefore, the order in which they are made is left to the discretion of the orthopaedic surgeon.

STARTER HOLE PREPARATION

Initiate an opening in the femoral canal with the 3/8" (9.5 mm) diameter drill bit.The hole is placed medial and anterior to the anteromedial corner of theintercondylar notch (PCL origin), or in the center of the trochlear groove.| FIGURE 3

NOTE |Osteophytes may need to be removed from the intercondylar notch to identifylandmarks.

ALIGNMENT ROD INSERTION

Insert the f luted intramedullary (IM) reamer/rod into the femoral canal, being sure to irrigate and aspirate several times to reduce the chance of a fat embolus.Turn the reamer during insertion with the t-handle. | FIGURE 4 Remove the t-handle and IM reamer rod.

DISTAL FEMORAL ALIGNMENT/ EXTERNAL ROTATION

Utilizing the driver cap and pin, insert the appropriate 10 mm diameter valgusangled IM rod (3, 5, 7) into the femoral canal without sinking the anti-rotationfins. Each valgus rod can be used for a left or right knee and is markedaccordingly. For a left knee, the LT marking on the shaft of the rod should

be facing up. For a right knee, the RT marking should be facing up | FIGURE 5To set external rotation of the rod, utilize the alignment crosshair, the externalrotation clamp, or the driver pin.

NOTE |When impacting the fins of the valgus rod make sure not to completely immersethem in cancellous bone.

NOTE |It is recommended that the cap and pin always be utilized to impact the valgusrod. Impaction directly on the end of the valgus rod may deform it and make removal

of the alignment instruments difficult.

FIGURE 3 |

FIGURE 4 |

FIGURE 5 |

LT 7 5

3

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ALIGNMENT CROSSHAIRSlide the crosshair down the shaft of the valgus rod and tighten it to the flats of the

rod. Align the vertical arm of the crosshair with the trochlear groove (A/P axis).| FIGURE 6 Once the vertical arm is aligned with the trochlear groove, impact therod until the fins are no longer visible. The horizontal arm of the crosshair may be utilized to reference the medial epicondyle as a secondary landmark.

EXTERNAL ROTATION CLAMP

Slide the external rotation clamp over the rod. | FIGURE 7 The central rod captureshould be steadied with a thumb to prevent it from swiveling as it is loaded ontothe shaft of the rod. | FIGURE 7A Ensure the anterior clamp stylus rests on the

most proximal region of the articular cartilage between the raised anteriorcondyles, and the posterior stylus straddles the intercondylar ridge .| FIGURE 8 When clamped, the valgus rod will be rotated in line with thetrochlear groove. The adjustable clamp crosshair may be aligned with themedial epicondyle by loosening the tightening outrigger and raising or lowering the crosshair. | FIGURE 7B Once rotation is determined, impact the rod until thefins are no longer visible. Care should be taken to ensure the alignment is notaltered during impaction.

DRIVER PIN

After preliminarily impacting the valgus rod, remove the driver cap, but return the

pin to the hole in the shaft of the rod. Align the pin vertically with the deepest part of the trochlear groove. | FIGURE 9 Once aligned with the trochlear groove,impact the rod until the fins are no longer visible.

FIGURE 6 |

FIGURE 7 |

FIGURE 8 | FIGURE 9 |

B

A

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ANTERIOR ROUGH CUTNOTE |All ODYSSEY femoral resection slots are designed for use with a .050" (1.3mm)

thick saw blade.

Slide the IM alignment body down the shaft of the valgus rod until it contactsthe distal femur. Lock the IM alignment body to the f lats of the valgus rod by tightening the locking screw | FIGURE 10A with a 3.5mm hex head screwdriver.Slide the support bars of the anterior rough cut guide into the IM alignmentbody. | FIGURE 10BIntroduce the tip of the anterior stylus through the hole inthe stylus body. | FIGURE 11AThe stylus should be pushed cephalad until it"clicks". Each click represents one femoral size . The stylus should be pusheduntil the number of clicks equals the estimated femoral size. ( femoral size is

estimated based on pre-operative templating) The femoral size markings areindicated posteriorly on the stylus where it meets the stylus body. | FIGURE 11B

NOTE |For additional stability, headed pins may be placed in the holes on the distal faceof the IM alignment body. | FIGURE 11CHowever, these pins should be removed prior

to a distal resection and before removal of the alignment body is attempted.

Once the anterior stylus has determined the depth of anterior resection, fix theanterior rough cut guide position by tightening the two screws on the distal faceof the IM alignment body. | FIGURE 11D This is performed with a 3.5mm hex head screwdriver. Resect the anterior condyles and remove the anteriorrough cut guide, leaving the IM alignment body in place.

DISTAL FEMORAL RESECTION

Insert the distal resection guide with attached crosshead into the IM alignmentbody. | FIGURE 12A Lower the crosshead as close as possible to the anteriorrough cut. In some cases, the crosshead will not touch the anterior rough cut. With the crosshead in the standard position, 9mm of the distal femur will be

FIGURE 10 |

FIGURE 11 | The dual reference gauge maybe placed through the resection slot toconfirm resection depth

FIGURE 12 |

A

A

B

C

D

A

B

FIGURE 13 |

A

B

resected from the prominentdistal condyle. If 13mm of resection is necessary, thecrosshead may be repositionedby pushing the locking buttondown and sliding the crosshead

proximally until the "+4mm"mark is seen. | FIGURE 13AThecrosshead is then locked into position by pushing the locking button up. | FIGURE 13B

+4 +4

STD+2mm

LEFT

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After the resection amount is set, the crosshead is pinned to the anterior cortex with two headless pins. Push down the locking button to separate the alignmentbody from the crosshead. With the IM alignment body affixed to the valgus rod,utilize the slap hammer and hook to carefully remove the valgus rod andassembled IM alignment body. | FIGURE 14

At this point, if headless pins are used, the crosshead can be readjusted 2 mm proximally by sliding it down the pins through the "+2mm" holes. A divergent pin hole is available and recommended for additional stability.

FEMORAL SIZING

Place the A-P femoral sizer flush against the resected distal femur and adjust the

sizer so the feet contact the posterior condyles and the stylus rests on theanterior rough cut. | FIGURE 15

The femoral size is indicated on the distal face of the A-P femoral sizer.

If the femur measures between sizes, the femoral resection block

correlating to the smaller of the two sizes should be utilized .

NOTE | Resecting the proximal tibia before femoral sizing may facilitate placing theposterior feet of the sizer under the posterior femoral condyles.

ANTERIOR AND POSTERIOR RESECTIONS

Place the femoral resection block flush against the distal and anterior femoralsurfaces. | FIGURE 16 The distance between the pin outriggers on the sides of

the block is the same M/L width as the corresponding femoral component . Affix the block to the bone with headed pins on the medial and lateral sides of the block. Secondary fixation pins may be placed through the distal face of theblock, but must be removed prior to the chamfer resections. The recommendedorder of the resections is: posterior, posterior chamfer, anterior, anteriorchamfer. A narrow sawblade (12.5mm) is recommended for the chamferresections .

NOTE |Use of threaded pins in the side outriggers of the femoral resection blocks maylead to a higher incidence of pin cross-threading and shearing. Use of standard, non-

threaded pins is recommended.

FIGURE 14 |

FIGURE 15 |

FIGURE 16 |

1

2

34

5

6

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SULCUS RESECTIONPlace the sulcus resection guide on the femur that corresponds to the previous

femoral resection block. Ensure the top of the guide rests on the resectedanterior cortex. Generally, the guide is lateralized on the femur to reacquire theQ-angle. Pin the guide through the holes overlying the anterior chamfers. Theedges of the guide represent the M/L dimensions of the femoral implant .| FIGURE 17 Drill for the femoral implant fixation pegs through the distal holes inthe sulcus resection guide using the 3/16 4.8mm drill bit. The trochlear grooveshould be resected by using a 12.5mm saw blade on the either the anterior or posterior angled surface and along the sides of the central portion of the guide.

EXTRAMEDULLARY TIBIAL RESECTION

NOTE | The ODYSSEY tibial resection guides are designed for use with a .050" (1.3 mm)thick saw blade.

Position the ankle clamp of the extramedullary (EM) tibial resection guide againstthe lower leg just proximal to the malleoli and collapse the arms around theankle. | FIGURE 18 Attach the appropriate left or right tibial crosshead onto theguide and adjust the guide until the resection slot is located a few millimetersbelow the lowest articular surface. Use the adjustment knobs at the ankle toalign the resection guide in the coronal and sagittal planes. When the vertical

axis of the guide is parallel to the tibial axis, it is positioned for a 3 posterior sloped resection . Attach the external alignment guide and slide thealignment rod through the appropriate TR or TL (Tibia Left or Tibia Right) hole.If the rod is parallel to the tibia, 3 slope is confirmed . | FIGURE 19

FIGURE 17 |

FIGURE 18 |

FIGURE 19 |

tibial PREPARATION

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Slide the 2mm/10mm stylus into the slot of the crosshead to set the desired level of tibial resection. | FIGURE 24A Pin the crosshead to the proximal tibia throughthe 0mm holes. When the crosshead is detached from the guide, the block canbe moved proximally or distally 2 mm if headless pins are used. Varus/valgusangulation can be checked to the ankle using the external alignment guide androd. | FIGURE 25

TIBIAL SIZING, KEEL PREPARATION, AND TRIAL REDUCTIONNOTE |In all ADVANCE Total Knees,with the exception of the ADVANCE Double-High

Knee, the trial insert size must match the femoral trial size (see chart 1 and 2 onnext page ). There are two tibial base trial sizes that can be used with any one size

femoral trial. For example, a size 3 femoral trial can be used with either a size 3 or 3+tibial trial base. When using the ADVANCE Double-High insert trial, a femoral trial one

size greater than the tibial insert trial may be utilized. For example, a size 3 ADVANCE

Double-High insert trial may be used with a size 3 or 4 femoral trial and a size 3 or 3+

tibial base trial. (Implant dimensions are listed at end of technique.)

Assemble the trial tibial base equal in size to the femoral implant with the trial

base handle and place against the proximal tibial surface. | FIGURE 26If using the

ADVANCE Double-High insert, a trial base one size smaller than the femur may

be utilized. The alignment rod can be inserted through the handle to check

alignment to the ankle. | FIGURE 26A Align the base and pin it to the tibia using

short headed tibial fixation pins. | FIGURE 26B

FIGURE 24 |

A

FIGURE 25 |

FIGURE 26 |

AB

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If the tibial size is too small, a "plus size" will provide additional tibial coverage. Attach the keel punch guide to the keel punch handle and secure it to the trialbase by turning the knurled handle. | FIGURE 27 Prepare the entry hole for thetibial stem using the 15mm drill guide and reamer (press-fit or oversize).| FIGURE 28Ream to the first line on the reamer for a size 1, 1+, or 2 base; to thesecond line for a 2+, 3, 3+, or 4 base; and to the third line for a 4+, 5, 5+, or 6base. Using the threaded punch handle and appropriate keel punch, plungethrough the guide until the punch is fully seated and the punch collar islevel with the edge of the guide. | FIGURE 29A Remove the punch and punchguide, leaving the trial base in place for a trial reduction.

TRIAL REDUCTION/IMPLANT INSERTIONNOTE |In all ADVANCE total knees, with the exception of the ADVANCE Double-HighKnee, the tibial insert size must match the femoral implant size (see Chart 1).

There are two tibial base sizes that can be used with any one size femoral component.

For example a size 3 femoral implant can be used with either a size 3 or 3+ tibial base.

| FIGURE 30 When using the ADVANCE Double-High insert, a femoral component

one size greater than the tibial insert may be utilized. For example, a size 3

ADVANCE Double-High insert may be used with a size 3 or 4 femur and a size

3 or 3+ tibial base trial (see Chart 2)

FIGURE 27 |

FIGURE 28 |

FIGURE 30 |

FIGURE 29 | CHART 1 CHART 2

A

MEDIAL-PIVOTFEMUR INSERT TIBIA

1 1 1 or 1+

2 2 2 or 2+

3 3 3 or 3+

4 4 4 or 4+

5 5 5 or 5+

6 6 6

DOUBLE-HIGHFEMUR INSERT TIBIA

1 or 2 1 1 or 1+

2 or 3 2 2 or 2+

3 or 4 3 3 or 3+

4 or 5 4 4 or 4+

5 or 6 5 5 or 5+

* Implant dimensionsare listed at the endof this technique.

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The patellar implant can be held in place while the cement cures using the parallel patellar recessing clamp and plastic seater. | FIGURE 35

TIBIAL INSERT SEATING

Once the cement surrounding the tibial base has cured, the appropriate tibialinsert may be locked into place. Initial seating is accomplished by pushing theinsert as far posterior as possible with hand pressure, paying special attention toengage the central dovetail and posterior captures of the tibial base. For finalseating of the insert, two options are available. In the first option, the 45 insertimpactor may be utilized by placing the impactor tip in the anterior slot of thetibial insert. | FIGURE 36 The impactor handle should be at an angle slightly

greater than 45. Keeping the impactor tip in the slot, decrease the angle of theimpactor handle until the tip is felt to impinge within the slot. This should beapproximately 45. While maintaining this 45 angle relative to the tibial base,apply several strong mallet blows directing the insert posteriorly. After theanterior edge of the insert has been pushed past the anterior capture of thetibial base, it will automatically drop behind the anterior capture and the insertface will be f lush against the surface of the tibial base. | FIGURE 37

In the second option, an insert assembly gun may be utilized by placing the lower jaw in the anterior slot of the tibial base. | FIGURE 38 With the bottom jaw inserted, slide the locking shim completely forward to ensure proper gun position. | FIGURE 39A To seat the insert, squeeze the handle until the top jaw

pushes the insert fully posterior and flush against the surface of the tibial base.| FIGURE 37 Withdraw the locking shim to loosen the assembly gun.

FIGURE 35 |

FIGURE 36 |

FIGURE 37 | FIGURE 38 | FIGURE 39 |

A

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APPENDIX A |RECESSED PATELLAR PREPARATION Attach the patellar reamer guide to the parallel patellar clamp. Center the guide

over the apex of the patellar articular surface, and clamp the patella. | FIGURE 1Slightly loosen the two thumbscrews on the depth regulator until it sits at thebottom of the patellar reamer guide. Insert the appropriate patellar reamer intothe guide until it rests on the apex of the patellar articular surface. Note thereamer depth by referencing the bottom of the reamer collar | FIGURE 2Ato thescale on the side of the reamer guide. Set the top edge of the depth regulator to14mm below the patellar reamer collar for a high dome patellar implant, and12mm below the reamer collar for a low dome. Ream until the depth regulatorstops the patellar reamer.

NOTE | The reamer is a "one step" instrument that resects bone for the patellar body andpeg simultaneously.FIGURE 1 |

FIGURE 2 |

A

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APPENDIX B |FLEXION/EXTENSION GAP MEASUREMENTThe flexion/extension gaps are measured following the tibial resection and

femoral resections. With the knee flexed at 90, insert the 10mm spacer block assembly into the space between the posterior femoral condyle and tibial bonesurfaces. | FIGURE 1 If the 10mm spacer block does not fit in f lexion, additionaltibial resection or a smaller femoral size may be needed. Use progressively thicker spacer blocks until the appropriate tension is obtained in flexion. Slidethe external alignment rod through the holes in the tibial trial base handle tocheck accuracy of the tibial cut to the center of the ankle. After the flexion gaphas been determined, place the leg in extension | FIGURE 2 If the 10mm spacerblock does not fit, use the minus 2mm spacer block to determine the amount of

additional distal femoral bone resection required to achieve full extension.NOTE | The spacer blocks indicate the thickness of the appropriate tibial insert. The

thicknesses of the femoral condyles, tibial base, and tibial insert are built into thespacer block thickness.

APPENDIX C |2MM RESECTION GUIDE

The 2mm resection guide is generally employed for use on the anterior femoralrough cut, distal femoral resection, and resected proximal tibia.To position the guide, place the anterior wings on the resected surface with theresection slot abutting the edge of the surface. Two divergent pin holes areavailable for fixation.

FIGURE 1 |

FIGURE 2 |

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SIZE A B C

1 60 52 8

2 65 57 8

3 70 62 8

4 75 66 8

5 80 71 8

6* 85 76 9

FEMORAL

Porous and Non-Porous CoCr femoral components accommodate patient anatomy, restore naturalpatellofemoral function, maximize fixation and enhance stress distribution.

SIZEDIAMETER

SINGLEPEG TRIPEG

THICKNESS(MM)

PATELLAR

All-Poly Patellar Components are offered in both single and tri-peg configurations. Patellar components arecompletely interchangeable with any size femoral component, improving the flexibility required to match patient

anatomy and available bone with implant size. Both designs incorporate cement interlock features. The tri-pegdesign maintains a constant peg pattern easing intraoperative size changes.

A B C

1 60 41 35 11+ 65 44 35 12 65 44 35 22+ 70 48 43 23 70 48 43 33+ 75 51 43 3

4 75 51 43 44+ 80 54 50 45 80 54 50 55+ 85 58 50 56 85 58 50 6

TIBIAL

The CoCr Tibial Trays a re avai lable in 11 sizes (6 regular sizes, 5 plus sizes). The 3 posterio rly inclined keel i sproportional by size and offers improved rotational control and fixation with less compromise of proximal tibialbone stock. Instrumentation allows control of cement mantle thickness around the stem.

TRAYSIZE

DIAMETER

25 M N/A 7 OR 926 N/A M 828 M N/A 7 OR 929 N/A M 832 M M 835 M M 838 M M 1041 M M 11

C

C

BA

A B

C

* Not available for ADVANCE Stemmed Medial-Pivot

RECESSED

RECESSED

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DOUBLE HIGH INSERT | PCL RETAINING

ANTERIOR MEDIALBALL-IN-SOCKET

10MM RAISEDANTERIOR MEDIAL LIP

MEDIAL POSTERIORLIP REDUCED TOALLOW PCLDICTATED FLEXION

MEDIAL PIVOT INSERT| PCL SACRIFICING

PCL SACRIFICINGFULL MEDIALBALL IN-SOCKET

11MM RAISEDANTERIOR MEDIALLIP

MEDIAL POSTERIORLIP PROVIDES

STABILITY

1012

1417

2025

MEDIAL PIVOT INSERT THICKNESS(MM)

DOUBLE-HIGH INSERT THICKNESS(MM)

1012

1417

ROTATION AROUND ANYPOINT ON MEDIAL SIDE

ROTATION AROUNDMEDIAL CONDYLE

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Trademarks and Registered marks o f Wright Medical Technology, Inc.2007 Wright Medical Technology, Inc. All Rights Reserved. MK006-105 R311

Wright Medical Technology, Inc.5677 Airline RoadArlington, TN USA 38002901.867.9971 phone800.238.7188 toll-freewww.wmt.com

Wright Medical EMEAKrijgsman1186 DM Amstelveen The Nether lands011.31.20.545.0100www.wmt-emea.com

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