ZUK Technique

unicompartmental knee

SURGICAL TECHNIQUE

ZUK is marketed by Lima Corporate since July 2015 as Physica ZUK.

In compliance with EU Antitrust Authorities and pursuant the Asset Purchase Agreement executed with Zimmer Holdings Inc., Lima Corporate acquired “intellectual property rights and know-how, transfer of licences, permits and authorisations, transfer of access to CE marks, customer contracts, leases, commitments, orders and records”. The above mentioned rights and permits have been acquired for European Economic Area, Switzerland, UK and Japan.

Therefore, ZUK & Physica ZUK are identical prostheses, implant combination is allowed and the historical clinical data referred to ZUK is also applicable to Physica ZUK.

The following technique presents the implantation of the Physica ZUK with the Physica ZUK instrument set.

PHYSICA ZUK SURGICAL TECHNIQUE Index

Introduction, Indications and Contraindications

Page >> 04 Page >> 05 Page >> 06 Page >> 07

Rationale

Preoperative Planning and Patient Preparation

Approach and Exposure

SURGICAL TECHNIQUE

Step 1 Proximal Tibial Resection Step 2 Distal Femoral Resection

Page >> 08 Page >> 14 Page >> 16 Page >> 17 Page >> 21 Page >> 24 Page >> 27 Page >> 30

Step 3 Check Extension and Flexion Gaps

Step 4 Femoral Sizing

Step 5 Finishing the Femur

Step 6 Sizing and Finishing the Tibia

Step 7 Trial Reduction

Step 8 Implant Final Components

Closure

Page >> 32

PHYSICA ZUK IMPLANTS

Page >> 34

Page >> 40

PHYSICA ZUK INSTRUMENT SET

Limacorporate S.p.A., is a manufacturer of medical (prosthetic) devices, and does not practice medicine. This document – referring to the surgical technique – has been developed in consultation with an experienced surgeon team, and provides the surgeon with general guidance when implanting Physica ZUK System. Proper surgical procedures and techniques are and remain the total responsibility of the surgeon. The surgeon must evaluate the appropriateness of the surgical technique to be specifically used for each individual patient, based on personal medical training, professional experience and clinical evaluation of the individual case. This document is intended exclusively for surgeons and physicians, and is not intended for lay persons. Information on the product and procedures contained in this document is of a general nature and does not represent and does not constitute medical advice or recommendation. The information contained in this document does not purport to constitute any diagnostic or therapeutic statement, with regard to any individual medical case. Each patient must be examined and advised individually, after due and diligent study of his specific case, and this document does not replace the need for such examination and/or advice and/or study, in whole or in part. Please refer to product package insert for important product information, including (but not limited to) contraindications, warnings, precautions and adverse effects.

PHYSICA ZUK Surgical Technique 3

PHYSICA ZUK SURGICAL TECHNIQUE Introduction, Indications and Contraindications

 INTRODUCTION Unicompartmental knee arthroplasty (UKA) has been shown to be an effective treatment for isolated osteoarthritis affecting the medial or lateral compartment. The new Physica ZUK System instruments are designed to provide accurate and reproducible results. The goals of the surgical procedure are to:

 INDICATIONS AND CONTRAINDICATIONS Indications: • Painful and/or disabling knee joints due to osteoarthritis or traumatic arthritis; • Previous tibial condyle or plateau fractures with loss of anatomy or function; • Varus or valgus deformities; • Failed corrective osteotomy procedures or previous unicompartimental arthroplasty; when only one compartment of the knee is involved. The Physica ZUK Unicompartmental Knee System is designed for use when load bearing ROM is expected to be less than or equal to 155°. These devices are indicated for cemented use only.

• • • •

Facilitate the patient’s recovery;

Provide less pain;

Provide earlier mobilization; Provide shorter hospital stay.

This instrument allows the surgeon to operate without everting the patella.

Contraindications include:

This surgical technique is written for a medial compartment UKA. Many of the same principles can be applied to the lateral compartment but it may be necessary to extend the incision a few centimeters given the proximity of the patella to the lateral condyle.

• Previous history of infection in the affected joint and/or local/systemic infection that may affect the prosthetic joint; • Insufficient bone stock on femoral or tibial surfaces; • Skeletal immaturity; • Neuropathic arthropathy; • Rheumatoid arthritis; • Obesity 1 ; • Varus/valgus deformities greater than 15°; • Chondrocalcinosis; • Osteoporosis; • Damage to the articular cartilage of the opposite compartment; • Inflammatory synovitis; • Eburnated bone in the patellofemoral joint.

1 According to the definition of the World Health Organization (WHO), Body Mass Index (MBI) greater than or equal to 30.

4 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Rationale

 RATIONALE The basic goals of unicompartmental knee arthroplasty are to improve limb function and to reduce pain. The development of instruments specifically designed to be used through a smaller exposure has had a significant impact on the effort to minimize disruption of the surrounding soft tissue during the procedure. Limb alignment is described by the mechanical axis of the lower extremity, which is a straight line running from the centre of the femoral head to the center of the ankle. When the center of the knee lies on this mechanical axis, the knee is said to be in neutral alignment. Unicompartmental knee disease typically reduces the joint space in the affected compartment, causing a malalignment of the joint. Full correction of the malalignment would return the knee to neutral alignment. (Fig. 1) The alignment goals for unicompartmental knee arthroplasty differ from those that are customary in an osteotomy where overcorrection is desirable to displace the weight bearing forces away from the diseased compartment. In contrast, when adjusting limb alignment in a unicompartmental procedure, it is particularly important to strive for slight under correction of the mechanical alignment to avoid overload in the contralateral compartment and heighten the potential for opposite compartment cartilaginous breakdown. Studies of unicompartmental procedures have shown that slight under correction of the limb alignment correlates to long-term survivorship. 1

Mechanical Axis

Transverse Axis

Figure 1

PHYSICA ZUK Surgical Technique 5

PHYSICA ZUK SURGICAL TECHNIQUE Preoperative Planning and Patient Preparation

 PREOPERATIVE PLANNING

In UKA, varus/valgus alignment is determined by the total thickness of the prosthetic unicompartmental components. The amount of tibial bone resection is variable while the amount of distal femoral bone resection is constant.

Take standing weight-bearing A/P, lateral, and skyline radiographs of the affected knee.

In this technique, the tibia is resected first and the femoral resection is based of the tibial cut.

A long-standing A/P radiograph showing the center of the femoral head, the knee, and as much of the tibia as possible (preferably including the ankle) may also be beneficial to determine the mechanical axis. TECHNIQUE TIP. It is important to avoid overcorrection. An additional radiograph while stressing the limits of the collateral ligaments may be helpful in assessing the maximum correction.

When evaluating the patient and planning for the procedure, consider TKA if:

• Degenerative changes are present in the contralateral compartment and/or the patellofemoral joint; • The ACL is deficient; • A significant flexion contracture exists; • Slight under correction is not attainable; • A significant overcorrection is likely with a varus stress; • There is an existing valgus or varus deformity › 15°.

 PATIENT PREPARATION

With the patient in the supine position, test the range of hip and knee flexion. If unable to achieve 120° of knee flexion, a larger incision may be necessary to create sufficient exposure.

Wrap the ankle area with an elastic wrap. Do not place bulky drapes on the distal tibia, ankle, or foot.

A bulky drape in this area will make it difficult to locate the center of the ankle, and will displace the Tibial EM Guide, which may cause inaccurate cuts. Before surgery, mark the tibial crest, the tibial tubercle, and the second metatarsal.

6 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Approach and Exposure

 APPROACH AND EXPOSURE

The incision can be made with the leg in flexion or extension. A suggested medial parapatellar incision extending from the superior pole of the patella to about 2 cm - 4 cm below the joint line adjacent to the tibial tubercle is shown in Fig.2. (Fig. 2) Incise the joint capsule in line with the skin incision beginning just distal to the vastus medialis muscle and extending to a point distal to the tibial plateau. (Fig. 3) Excise a minimum amount of the fat pad, as necessary to facilitate visualization, being careful not to cut the anterior horn of the lateral meniscus. Reflect the soft tissue subperiosteally from the tibia along the joint line back towards, but not into, the collateral ligament. Excise the anterior third of the meniscus. The remaining meniscus will be removed after bone resection. A subperiostal dissection should be carried out towards the midline, ending at the patellar tendon insertion. This will facilitate positioning of the tibial cutting guide. TECHNIQUE TIP. It may be necessary to extend the incision intraoperatively to achieve appropriate exposure and visualization. Debride the joint and inspect it carefully. Remove intercondylar osteophytes to avoid impingement with the tibial spine or cruciate ligament. Also, remove peripheral osteophytes that interfere with the collateral ligaments and capsule. With medial compartment disease, osteophytes are commonly found on the lateral aspect of the medial tibial eminence and anterior to the origin of the ACL. Final debridement will be performed before component implantation. TECHNIQUE TIP. Careful osteophyte removal is important in achieving full extension. It is important for osteophytes to be removed before balancing your flexion and extension space.

Figure 2

Figure 3

PHYSICA ZUK Surgical Technique 7

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

 SURGICAL TECHNIQUE

STEP 1 PROXIMAL TIBIAL RESECTION

The Physica ZUK Unicompartmental Knee System is designed for an anatomic position with a 5° posterior slope.

It is important that the proximal tibial cut is made accurately. The EM Tibial Guide assembly consists of the following:

• Appropriated Tibial Cutting Block 5° (RM/LL or LM/RL); • Tibial Resection Stylus; • Tibial EM Guide Ankle Clamp; • Tibial EM Guide Slope Adjuster; • Tibial EM Guide Height Adjuster; • Tibial EM Guide Cutting Block Connection.

Insert the Tibial EM Guide Height Adjuster into the EM Guide Slope Adjuster. (Fig. 4)

Figure 4

TECHNIQUE TIP. Inserting the cutting block connection into the height adjuster facilitates the assembly with the slope adjuster.

Turn the red dial anti-clock wise to the zero position.

8 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

Depress and hold the red button of the Tibial EM Guide Slope Adjuster, insert the Tibial EM Guide Ankle Clamp and press the red button. NOTE. Pay attention to the correct position of the part as shown in the picture. (Fig. 5) . The numbers on the ankle clamp show proximal. The Tibial EM Guide Slope Adjuster and the Tibial EM Guide Height Adjuster are marked proximally. NOTE. The Tibial EM Guide Cutting Block connection can be flipped left or right by pressing the red button according to the involved knee. (Fig. 6).

NOTE. RM=Right Medial (to be used for Left Lateral); LM= Left Medial (to be used for Right Lateral).

Figure 5

Select the appropriate Tibial Cutting Block and connect it to the Tibial EM Guide Cutting Block Connection according to the involved knee. (Fig. 7) .

RM/LL

LM/RL

Figure 6

Figure 7

PHYSICA ZUK Surgical Technique 9

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

Insert the EM Tibial Guide Cutting Block Connection into the Tibial EM Guide Height Adjuster by pressing the red button. (Fig. 8) . Place the knee in 90° of flexion with the tibia translated anteriorly and the whole leg held firmly in place on the surgical table.

Position the EM Tibial Guide assembly around the ankle and place the cutting block against the proximal tibia.

Position the EM Tibial Guide assembly following the bony landmarks:

• • • •

Medial / Lateral malleoli;

Tibial Crest;

Tibial tubercle (2/3 - 1/3);

Second Metatarsal.

The red button at the proximal end of the Tibial EM Guide Height Adjuster is used for macro-adjustment of the height of the proximal tibial cutting block.

Adjust the EM Tibial Guide assembly approximately along the length of the tibia.

Figure 8

The red dial on the EM Tibial Guide Height Adjuster is used for micro-adjustment of the height of the tibial cutting block. (Fig. 8 inset) Fine-tune the proximal tibial cut height exactly to achieve the need of the patient’s knee by using the Tibial Resection Stylus, feeler blade or by checking the X-Rays. When the approximate M/L position is achieved place a 35 or 50 mm headed screw into the proximal tibial cutting block central hole by using the pin driver to fix the position of the EM Tibial Guide. This still allows some degree of fine tuning in height, slope and varus/valgus. (Figs. 9 and 9 inset)

Figure 9

10 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

The Pin Driver has to be used to insert the screws. Pressing the screws into the Pin Driver will automatically capture them. To release the screws press the red lever. (Fig. 10) VARUS/VALGUS ADJUSTMENT (IF NEEDED) Adjust the varus/valgus alignment of the EM Tibial Guide by turning the red knobs on either side of the ankle clamp. This enables the mediolateral position of the EM Guide to be fine-tuned to accurately line up with the long axis of the tibia. (Fig. 11) TECHNIQUE TIP. Use the Feeler Blade to verify that the Tibial Cutting slot is horizontally aligned. SLOPE ADJUSTMENT (IF NEEDED) Tibial Cutting Blocks have a built-in 5° posterior slope. However, if it is necessary to adjust the slope in the sagittal plane, press and hold the red button on the end of the Tibial EM Guide Slope Adjuster. Moving the Tibial EM Guide Slope Adjuster away from the ankle joint will increase the slop. (Fig. 12) TECHNIQUE TIP. In order to identify 5° of posterior slope, the EM proximal rod should be parallel to the tibial axis in the sagittal and frontal planes.

Figure 10

Figure 11

Figure 12

PHYSICA ZUK Surgical Technique 11

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

RESECTION LEVEL The Tibial Resection Stylus should be used to ensure that the selected proximal tibial resection level is achieved. Each tip of the stylus indicates a different depth. The “+2” tip is used to set the resection depth from the most damaged part of the tibial plateau for a minimal cut. In this position, the tibial cutting block removes 2 mm of bone below the tip of the stylus. Alternatively, the “+4” tip is used to set the resection depth from the least damaged part of the tibial plateau. Rest the “+4” tip of the stylus on the cartilage of the least damaged part of the tibial articulation. Insert the Tibial Resection Stylus into the slot of the tibial cutting guide in the desired position. (Fig. 13) PROXIMAL TIBIAL RESECTION When the desired resection level is achieved secure the Tibial Cutting Block with Hexagonal Headless Long Pins using the “0” holes. (Fig. 14) Pay particular attention if the tibial bone is small. If an additional 2 mm tibial cut is required pull out first the central pin and then the Tibial Cutting Block leaving in place the headless pins. Reattach the block ensuring that it passes over the +2 mm holes and secure it with a 35 mm or 50 mm headed screw in the central pin hole. If required the Tibial Cutting Block can be disconnected from the EM Tibial Guide assembly and reinserted after Tibial Cutting block +2 mm repositioning. TECHNIQUE TIP. Alternatively headed screws can be used. In case of a tibial recut replace the headed screws by headless screws so you can move the Tibial Cutting Block to the +2mm holes easily.

Figure 13

Lateral

Medial

Figure 14

12 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 1 | Proximal Tibial Resection

The depth of cut can be verified by using the feeler blade. Use a 1.27 mm (0.050-inch) oscillating sawblade through the slot in the cutting guide to make the transverse cut. The Tibial Cutting Block must remain against the bone during resection. TECHNIQUE TIP. Insert a retractor medially to protect the medial collateral ligament. With the knee flexed, use the reciprocating saw at the base of the tibial eminence and parallel to the eminence in the A/P plane to perform the sagittal L-cut. Cut along the edge of the ACL down to, but not beyond, the intended level of the transverse cut. (Fig. 15) Be careful to avoid the ACL attachment. Perform the horizontal cut. (Fig. 16) After both tibial cuts are performed, remove the EM Tibial Guide assembly. (Fig. 17)

Figure 15

TECHNIQUE TIP. You can use the rasp to refine the edge between the proximal and sagittal cut.

NOTE: Aternatively to the above mentioned + 2mm recut technique, a specific instrument for recutting is available [9061.10.002]. Remove the tibial cutting block and the EM guide leaving in place the two headless pins. Insert the recutter [9061.10.002] over the two pins and proceed with recutting of the tibia. (Fig. 18)

Figure 16

Figure 17

Figure 18

PHYSICA ZUK Surgical Technique 13

PHYSICA ZUK SURGICAL TECHNIQUE Step 2 | Distal Femoral Resection

STEP 2 DISTAL FEMORAL RESECTION

After resecting the proximal tibia, bring the knee into full extension. Insert the 8 mm Spacer Block into the joint space until the anterior stop contacts the anterior tibia in order to assess the gap. (Fig. 19) The Spacer Block must be fully inserted and sit flat on the resected tibial surface to ensure that the proper amount of distal femoral bone will be resected. If the 8 mm Spacer Block is too tight, remove an additional 2 mm from the proximal tibia with the Tibial Cutting Block by using the +2mm holes. If the 8 mm Spacer Block is too loose, use a thicker Spacer Block. The Spacer Blocks are available in 8 mm, 9 mm, 10 mm, 11 mm, 12 mm and 14 mm thicknesses. If necessary, for additional stability, insert a 35 mm headed screw into the anteromedial angled hole in the Spacer Block. The Physica ZUK System has been designed for 5° of posterior tibial slope. The angle on the handle of the Spacer Block is angled at 5° relative to the Spacer Block. This ensures that the distal femoral resection is made perpendicular to the long axis of the femur. Place the Spacer Block Distal Femoral Resector over the handle of the Spacer Block. (Fig. 20) Check the alignment by inserting the Alignment Tower into the sawblade slot. (Fig. 21)

Figure 19

Figure 20

Figure 21

14 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Step 2 | Distal Femoral Resection

Use the alignment rods through the Alignment Tower to verify the alignment. Then secure the guide by inserting a 50 mm headed screw through the Distal Femoral Resector hole. (Fig. 22)

Use a 1.27 mm (0.050-inch) narrow oscillating saw blade to resect the distal femur. (Fig. 23)

TECHNIQUE TIP. To avoid that the distal femoral cut is done in pre-flexion, it can be helpful to check that the alignment rod is parallel to the femoral bone in the lateral view. ATTENTION. To avoid damaging the posterior popliteal area, do not extend the sawblade posteriorly past the distal femur USE OF FEMORAL SHIMS In case of excessive laxity in extension or excessive wear of the distal condyle, less distal bone should be resected. The use of shims should be carefully evaluated. The Spacer Block Femoral Shims can be added to each Spacer Block to cut less distal femoral bone. (Fig. 24)

Figure 22

Shims are available in 1 mm and 2 mm thicknesses.

TECHNIQUE TIP. When using the shims, please re-verify the correct alignment by using the alignment tower with the alignment rods a thinner spacer block may be needed.

Figure 23

Figure 24

PHYSICA ZUK Surgical Technique 15

PHYSICA ZUK SURGICAL TECHNIQUE Step 3 | Check Extension and Flexion Gaps

STEP 3 CHECK EXTENSION/FLEXION GAPS

Check the extension gap by inserting the thick end of the Flexion/Extension Gap Spacer into the joint. Flex the Knee to 90° and check the flexion gap by inserting the thin end of the selected Flexion/Extension Gap Spacer into the joint (Figs. 25 and 26) . If, in both flexion and extension, the joint space is too tight to insert the selected Flexion/Extension Gap Spacer, then use a smaller Gap Spacer, or remove more tibial or femoral bone. Then use the selected Flexion/Extension Gap Spacers to recheck the gaps . If in both flexion and extension the joint space is too loose, insert progressively thicker Flexion/Extension Gap Spacers and repeat the gap checking. If tight in extension and acceptable in flexion, two options may be pursued: 1. recut proximal tibia with less tibial slope; 2. recut 1 mm - 2 mm of distal femur. NOTE: to recut 2mm on the distal femur use the recutter block [9061.10.002]. Align the recutter off the tibial surface and fix it in extension with two pins (preferably headed screws). Proceed with the +2 mm distal femur cut. (Fig. 27)

Figure 25

If tight in flexion and acceptable in extension carefully evaluate the option to increase tibial slope.

Figure 26

NOTE. Accurate verification of the flexion and extension gaps at this stage of the procedure will reduce the likelihood of a gap imbalance during the trial reduction and final implantation.

Figure 27

16 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Step 4 | Femoral Sizing

STEP 4 FEMORAL SIZING There are seven sizes of femoral implants and corresponding sizes of Femoral Cutting Guides (A - G). The outside contour of the Femoral Cutting Guides matches the contour of the trial and the final implant. Insert the Femoral Trial Positioner into the corresponding lugs of the appropriate left or right Femoral Cutting Guide (Fig. 27) and close the lever. Insert the foot of the Femoral Cutting Guide into the joint and rest the flat surface against the distal femoral condyle. (Fig. 28) Move the foot of the guide anteriorly until it contact the cartilage/bone of the posterior condyle. TECHNIQUE TIP. You can use the Tension Gauge or the 8mm Flexion/Extension spacer to position the cutting guide against the femur.

Figure 27

There should be 2 mm - 3 mm of exposed bone above the anterior edge of the Femoral Cutting Guide. (Fig. 29)

Figure 28

Repeat with another Femoral Cutting Guide until the proper size is selected. If the condyle appears to be between two sizes, choose the smaller size. This helps prevent the patella from impinging on the prosthesis.

2 - 3 mm

Figure 29

PHYSICA ZUK Surgical Technique 17

PHYSICA ZUK SURGICAL TECHNIQUE Step 4 | Femoral Sizing

USE OF POSTERIOR FEMORAL SHIMS In case of excessive laxity in flexion, less posterior bone should be resected. The use of the posterior shims should be carefully evaluated. The posterior femoral shims can be added to each Femoral Cutting Block in order to cut less posterior bone of the Femur. (Fig. 30)

Posterior shims are available in 1mm and 2mm. (Fig. 30 inset)

Figure 30

18 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Step 4 | Femoral Sizing

TECHNIQUE TIP. Be sure that there is no soft tissue or remaining osteophytes between the Femoral Cutting Guide and the distal cut. It is important that the Femoral Cutting Guide sits flush against the bone. Any gaps between the guide and the bone will compromise the accuracy of the cuts and, subsequently, component fit may be compromised. Do not allow the patella to cause improper alignment of the guide. The patella may move the Femoral Cutting Guide medially in a medial UKA. (Figs. 31/32/33 - too small / too large / correct size)

Figure 31 too small

Figure 32 too large

Figure 33 correct size

PHYSICA ZUK Surgical Technique 19

PHYSICA ZUK SURGICAL TECHNIQUE Step 4 | Femoral Sizing

OPTIONAL. It is possible to select the most likely femoral size by using the Femoral Sizing Template. Place the Femoral Sizing Template against the resected distal femoral condyle and read the size, that now corresponds to the profile approximately about 2-3 mm below the anterior limit of the distal cut. (Fig. 34) If needed, the Femoral Trial Positioner can be used to easily maneuver the Femoral Sizing Template.

Figure 34

20 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Step 5 | Finishing the Femur

STEP 5 FINISHING THE FEMUR

The following steps are recommended to maximize the stability and fixation of the Femoral Cutting Guide. This will help to ensure that the cuts and holes are precise. 1. With the selected Femoral Cutting Guide in position, insert a of 35 mm or 50 mm Headed Screw into the top screw hole. (Fig. 35) In case of a small femoral bone, approximately up to size C, it is recommended to use the orange coloured 35 mm screw. Rotate the guide on the screw until the slot of the posterior cut is parallel to the cut surface of the tibia. (Fig. 36) Check there is exposed bone on both sides of the guide to ensure that the Femoral component will not overhang. TECHNIQUE TIP . When performing a medial unicompartmental knee, try to position the Femoral cutting guide as lateral as possible on the medial femoral condyle.

Figure 35

Figure 36

PHYSICA ZUK Surgical Technique 21

PHYSICA ZUK SURGICAL TECHNIQUE Step 5 | Finishing the Femur

The colour code on the pin holes indicates the maximum screw length to be used without interference with the cuts.

2. Insert the orange coloured 35 mm Headed Screw into the angled anterior pin hole, which is parallel to the chamfer cut. (Fig. 37) 3. Insert a 35 mm or 50 mm headed screw into the side pin hole. (Fig. 37 inset) 4. Insert the Femoral Drill into the anterior hole and drill the peg hole. Remove the drill. For increased stability place the Femoral Holding Peg into the anterior peg hole before drilling the posterior peg hole. (Fig. 38). NOTE. Do not attempt to insert or align the drill bit while the drill is in motion. When the proper alignment is achieved, drill the anterior peg hole.

Figure 37

Drill the posterior hole in the same manner. (Fig. 39) The hole is at the same angle as the anterior hole.

Figure 38

Figure 39

22 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Step 5 | Finishing the Femur

TECHNIQUE TIP. You can use the Femoral Holding Peg in the anterior peg hole to secure fixation of the Femoral Cutting Block before performing the posterior cut. (Fig. 40) To perform the chamfer cut remove the Holding Peg with the slap hammer. (Fig. 41) Debride the joint and inspect the posterior condyle. If any prominent spurs or osteophytes are present, especially in the area of the posterior femoral condyle, remove them with a curved osteotome, as they may inhibit flexion or extension (Fig. 42) TECHNIQUE TIP. Use the appropriate Femoral Trial, with the knee flexed, to aid in identifying and removing any residual posterior condylar bone which could limit flexion.

Figure 40

Figure 41

Figure 42

PHYSICA ZUK Surgical Technique 23

PHYSICA ZUK SURGICAL TECHNIQUE Step 6 | Sizing and Finishing the Tibia

STEP 6 SIZING AND FINISHING THE TIBIA

Inspect the proximal tibial cut and remove any remaining meniscus and osteophytes, especially those interfering with the medial collateral ligament. Select the Tibial Sizer that best covers the resected proximal tibia in both the A/P and M/L dimensions. TECHNIQUE TIP. Use the resected tibial bone fragment as an aid in sizing. If necessary, a second sagittal cut can be made to allow for optimal coverage with the next larger size tibial base plate. Place the head of the Tibial Sizer on the cut surface of the tibia moving it flush against the sagittal cut. Verify the proper rotation of the sagittal cut in the transverse plane. The rotation is correct when the sizer is 90° to the coronal plane. (Fig. 43) The Tibial Sizer accommodates a Tibial Slider which facilitates measurement in the A/P dimension. (Fig. 44) Ensure the head of the Tibial Sizer rests on cortical bone near the edge of the cortex around its entire perimeter without any overhang. Pull the Tibial Slider anteriorly until the hook on the tip of the slider contacts the posterior edge of the tibia. (Fig. 45) The A/P length is indicated on the sizer handle. (Fig. 46a) An additional measurement on the slider at the tip of the sizer handle indicates the length of exposed bone posteriorly (behind the implant) with the sizer head in this particular position. (Fig. 46b)

Figure 43

Figure 44

Figure 45

TECHNIQUE TIP. Clean the edge of the bone cut with a curette or rasp so the sizer will fit flush against the cut.

Figure 46a

If the slider is used without the sizer the marks 1 to 6 on the slider indicate the A/P length of the corresponding implant. (Fig. 47)

Figure 46b

Remove the Tibial Sizer. Then remove all soft tissue debris from the popliteal region.

Figure 47

24 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 6 | Sizing and Finishing the Tibia

TIBIAL KEEL PREPARATION The Tibial Fin Osteotome can be used to prepare the keel by inserting the osteotome in the slot of the Tibial Sizer. (Fig. 48) The Tibial Fin Osteotome or a small chisel can also be used as a freehand instrument to prepare the keel. (Fig. 49)

NOTE. Fin preparation is not needed if an All-Poly tibia is used.

Figure 48

Figure 49

PHYSICA ZUK Surgical Technique 25

PHYSICA ZUK SURGICAL TECHNIQUE Step 6 | Sizing and Finishing the Tibia

Ensure the Tibial Trial plate is properly seated according to the cuts and the anatomy of the tibia and flush against the bone. (Fig. 50) When the Tibial Trial Plate is positioned you can secure the Tibial Trial Plate with one Tibial Headed pin or with a 20mm screw. (Figs. 51a and 51b) The 20mm Tibial Headed Pin can be inserted and removed with the Tibial Pin Inserter. The 20mm Tibial Headed Screw can be inserted and removed with the Pin Driver.

Figure 50

TECHNIQUE TIP. To facilitate insertion of the Tibial Trial Plate, externally rotate the tibia while the knee is flexed.

TIBIAL PEG PREPARATION Use the Tibial Drill to drill the two tibial peg holes. (Fig. 52) Note that these holes are angled 20° posteriorly. It is recommended to start with the anterior peg hole. The drill is automatically guided to ensure that the holes are at the correct inclination. (Fig. 52 inset) Although the pegs on the implant are at 90°, the drill is designed so that the pegs will fit into these angled holes. Leave the Tibial Trial Plate in place on the bone.

Figure 51a

Figure 51b

Figure 52

26 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 7 | Performing Trial Reduction

STEP 7 PERFORMING TRIAL REDUCTION

With all bone surfaces prepared, perform a trial reduction with the appropriate size Femoral Trial, Tibial Trial Plate and Tibial Trial Liner. Insert the Femoral Trial Positioner into the corresponding lugs on the Femoral Trial. (Fig. 53)

Impact the Femoral Trial onto the femur by using the femoral impactor. (Fig. 54)

Figure 53

TECHNIQUE TIP. To help guide the Femoral Trial Component past the patella, place the leg in deep flexion to begin the insertion. Insert the long peg first. Then adjust the leg into the mid- flexed position, impacting the femoral component until it sits flush against the bone with both pegs in the correct position. Reposition the leg in deep flexion to complete the insertion.

Figure 54

PHYSICA ZUK Surgical Technique 27

PHYSICA ZUK SURGICAL TECHNIQUE Step 7 | Performing Trial Reduction

To insert the Tibial Trial Liner on the already placed Tibial Trial Plate, slide the rails on the bottom of the Tibial Trial Liner into the grooves on the Tibial Trial Plate. (Fig. 55) Check the fit of the components. If the bone cuts are not flush, use the rasp to provide minor changes to the bony surfaces. With all trial components in place, check the range of motion and ligament stability. The Tibial Trial Liner should allow for full flexion and full extension.

NOTE. Overstuffing should be avoided, as this will overload the contralateral compartment.

Figure 55

The correct thickness of the final liner is one that provides the desired alignment and dœs not cause excessive stress on the collateral ligaments. As a rule, the correct thickness of the liner should allow the joint space to be opened approximately 2 mm when a stress is applied, with the knee in full extension and without soft tissue release. The knee must also be tested in 90° of flexion to allow a 2 mm flexion gap. Excessive flexion tightness will prevent postoperative flexion and may cause the tibial prosthesis to lift up anteriorly as the femoral component rolls posteriorly on the tibial component. If the joint is too tight in flexion, or extension, review the options described for the extension/ flexion gap (check step 3, p. 16). TECHNIQUE TIP. Use the 2 mm end of the Tension Gauge to check the balance of the knee in both flexion and extension. With the knee flexed 90°, position the 2 mm end of the Tension Gauge between the Femoral Trial and the Flexion/ Extension Gap Spacer. This should be a snug fit but not overly tight. Then perform the same test with the knee in full extension. (Fig. 56) If the 3 mm end of the Tension Gauge can be inserted easily, then the knee may be too loose and a thicker tibial liner may be considered.

Figure 56

28 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 7 | Performing Trial Reduction

TECHNIQUE TIP. Alternatively the Extension Spacer can be used to perform a trial reduction. Correctly place the Femoral Trial component and use the appropriate extension spacer to perform a trial reduction. (Fig. 57) TECHNIQUE TIP. After the trial reduction remove the trial implants. The Femoral Trial Component can be removed with the Femoral Trial Positioner and the Slap Hammer. (Fig. 58)

Figure 57

Figure 58

PHYSICA ZUK Surgical Technique 29

PHYSICA ZUK SURGICAL TECHNIQUE Step 8 | Implant Final Components

STEP 8 IMPLANT FINAL COMPONENTS

TECHNIQUE TIP . If the resected surfaces of the tibia and/ or femur are sclerotic, drill multiple holes with a small drill to improve cement intrusion. TIBIAL COMPONENT To facilitate insertion, flex the knee and externally rotate the tibia.

Apply cement on both the tibial component and proximal tibial bone surface.

Press the tibial base plate onto the tibia and press down the posterior portion of the component first. (Figs. 59 and 60) Then press the anterior portion of the component expressing excess cement anteriorly. Use a mallet with the Tibial Tray Impactor to impact the tibial component into its final position. After impacting the Tibial Baseplate remove the Tibial Tray Impactor carefully.

Figure 59

NOTE. If an All-Poly tibial component is used, use the Tibial tray Impactor or the Tibial Liner Impactor to impact it.

Use the Cement Remover to remove any excess cement.

TECHNIQUE TIP. Place an opened and slightly moist sterile gauze sponge behind the tibia before implanting the components to help collect excess cement behind the tibia.

Figure 60

30 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Step 8 | Implant Final Components

FEMORAL COMPONENT Apply cement on all cut bone surfaces and start the femoral component and position the knee in deep flexion. Insert the posterior long peg first. Adjust the leg to a mid- flexion position, rotating the implant around and behind the patella. Then reposition the leg in deep flexion and impact the femoral component with the Femoral Component Impactor until proper seating against the bone is achieved. (Fig. 61) TIBIAL ARTICULAR SURFACE After the cement has cured, proceed with the placement of the tibial liner. Confirm the correct size and thickness of the final tibial articular surface by first testing with the Tibial Trial Liner in flexion and extension. Slide the edge of the articular surface under the posterior lip of the baseplate. Then use a mallet and the Tibial Liner Impactor to impact the Tibial Liner into the Tibial Baseplate. (Fig. 62)

Figure 61

Figure 62

PHYSICA ZUK Surgical Technique 31

PHYSICA ZUK SURGICAL TECHNIQUE Closure

 CLOSURE

Irrigate the knee for the final time and close. Cover the incision with a sterile dressing and wrap the leg with an elastic bandage from the tœs to the groin.

32 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE Implants

 FEMORAL COMPONENTS CoCrMo + PMMA

Size

REF

Lt Medial/Rt Lateral

00-5842-011-01 00-5842-011-02 00-5842-012-01 00-5842-012-02

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

00-5842-013-01

Rt Medial/Lt Lateral

00-5842-013-02

Lt Medial/Rt Lateral

00-5842-014-01 00-5842-014-02 00-5842-015-01 00-5842-015-02 00-5842-016-01 00-5842-016-02 00-5842-017-01 00-5842-017-02

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

34 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Implants

 ARTICULAR SURFACE UHMWPE

ARTICULAR SURFACE #1

Size

REF

THICKNESS

00-5842-021-08 00-5842-021-09 00-5842-021-10 00-5842-021-11 00-5842-021-12 00-5842-021-14

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

h. 12 mm

h. 14 mm

ARTICULAR SURFACE #2

Size

REF

THICKNESS

00-5842-022-08 00-5842-022-09 00-5842-022-10 00-5842-022-11 00-5842-022-12 00-5842-022-14

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

h. 12 mm

h. 14 mm

ARTICULAR SURFACE #3

Size

REF

THICKNESS

00-5842-023-08 00-5842-023-09 00-5842-023-10 00-5842-023-11 00-5842-023-12 00-5842-023-14

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

h. 12 mm

h. 14 mm

ARTICULAR SURFACE #4

Size

REF

THICKNESS

00-5842-024-08 00-5842-024-09 00-5842-024-10 00-5842-024-11

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

00-5842-024-12

h. 12 mm

00-5842-024-14

h. 14 mm

PHYSICA ZUK Surgical Technique 35

PHYSICA ZUK SURGICAL TECHNIQUE Implants

 ARTICULAR SURFACE UHMWPE

ARTICULAR SURFACE #5

Size

REF

THICKNESS

00-5842-025-08 00-5842-025-09 00-5842-025-10 00-5842-025-11 00-5842-025-12 00-5842-025-14

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

h. 12 mm h. 14 mm

ARTICULAR SURFACE #6

Size

REF

THICKNESS

00-5842-026-08 00-5842-026-09 00-5842-026-10 00-5842-026-11 00-5842-026-12 00-5842-026-14

h. 8 mm

h. 9 mm

h. 10 mm

h. 11 mm

h. 12 mm h. 14 mm

36 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Implants

 ALL POLY TIBIAL COMPONENT

UHMWPE + AISI 316 L

ALL POLY TIBIAL COMPONENT #1

Size

REF

THICKNESS

00-5842-031-08 00-5842-031-10 00-5842-031-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-031-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-032-08 00-5842-032-10 00-5842-032-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm h. 14 mm

Rt Medial / Lt Lateral

00-5842-032-14

Rt Medial / Lt Lateral

ALL POLY TIBIAL COMPONENT #2

Size

REF

THICKNESS

00-5842-041-08 00-5842-041-10 00-5842-041-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-041-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-042-08 00-5842-042-10 00-5842-042-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm h. 14 mm

Rt Medial / Lt Lateral

00-5842-042-14

Rt Medial / Lt Lateral

ALL POLY TIBIAL COMPONENT #3

Size

REF

THICKNESS

00-5842-051-08 00-5842-051-10 00-5842-051-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-051-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-052-08 00-5842-052-10 00-5842-052-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm h. 14 mm

Rt Medial / Lt Lateral

00-5842-052-14

Rt Medial / Lt Lateral

ALL POLY TIBIAL COMPONENT #4

Size

REF

THICKNESS

00-5842-061-08 00-5842-061-10 00-5842-061-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-061-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-062-08 00-5842-062-10 00-5842-062-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm h. 14 mm

Rt Medial / Lt Lateral

00-5842-062-14

Rt Medial / Lt Lateral

PHYSICA ZUK Surgical Technique 37

PHYSICA ZUK SURGICAL TECHNIQUE Implants

 ALL POLY TIBIAL COMPONENT UHMWPE + AISI 316L

ALL POLY TIBIAL COMPONENT #5

Size

REF

THICKNESS

00-5842-071-08 00-5842-071-10 00-5842-071-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-071-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-072-08 00-5842-072-10 00-5842-072-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm

Rt Medial / Lt Lateral

00-5842-072-14

h. 14 mm

Rt Medial / Lt Lateral

ALL POLY TIBIAL COMPONENT #6

Size

REF

THICKNESS

00-5842-081-08 00-5842-081-10 00-5842-081-12

h. 8 mm

Lt Medial / Rt Lateral

h. 10 mm

Lt Medial / Rt Lateral

h. 12 mm

Lt Medial / Rt Lateral

00-5842-081-14

h. 14 mm

Lt Medial / Rt Lateral

00-5842-082-08 00-5842-082-10 00-5842-082-12

h. 8 mm

Rt Medial / Lt Lateral

h. 10 mm

Rt Medial / Lt Lateral

h. 12 mm

Rt Medial / Lt Lateral

00-5842-082-14

h. 14 mm

Rt Medial / Lt Lateral

38 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Implants

 TIBIAL COMPONENTS Ti6Al4V + PMMA

Size

REF

Lt Medial/Rt Lateral

00-5842-001-01 00-5842-001-02 00-5842-002-01 00-5842-002-02

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

00-5842-003-01

Rt Medial/Lt Lateral

00-5842-003-02

Lt Medial/Rt Lateral

00-5842-004-01 00-5842-004-02 00-5842-005-01 00-5842-005-02 00-5842-006-01 00-5842-006-02

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

Lt Medial/Rt Lateral

Rt Medial/Lt Lateral

PHYSICA ZUK Surgical Technique 39

PHYSICA ZUK SURGICAL TECHNIQUE Instrument set

 9061.15.000 Physica ZUK - Femoral Preparation Set

CODE

DESCRIPTION

Qty.

A15 9061.10.002

2mm Femoral Recutter

B15 9061.10.020

Femoral Trial Positioner

C15 9061.10.025

Slap Hammer

D15 9061.10.026

Femoral Cutting Guide Holding Peg

E15 9061.10.100

Femoral Sizing Template RM / LL

E15 9061.10.500

Femoral Sizing Template LM / RL

F15 9061.10.1A0

Femoral Trial A LL / RM

F15 9061.10.1B0

Femoral Trial B LL / RM

F15 9061.10.1C0

Femoral Trial C LL / RM

F15 9061.10.1D0

Femoral Trial D LL / RM

F15 9061.10.1E0

Femoral Trial E LL / RM

F15 9061.10.1F0

Femoral Trial F LL / RM

F15 9061.10.1G0

Femoral Trial G LL / RM

F15 9061.10.5A0

Femoral Trial A LM / RL

F15 9061.10.5B0

Femoral Trial B LM / RL

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

F15 9061.10.5C0

Femoral Trial C LM / RL

F15 9061.10.5D0

Femoral Trial D LM / RL

F15 9061.10.5E0

Femoral Trial E LM / RL

F15 9061.10.5F0

Femoral Trial F LM / RL

F15 9061.10.5G0

Femoral Trial G LM / RL

G15 9061.10.710

Femoral Component Impactor Head

H15 9095.11.S01

Impactor Handle

I15 9061.10.808

Flexion/Extension Gap Spacer 8mm

I15 9061.10.809

Flexion/Extension Gap Spacer 9mm

I15 9061.10.810

Flexion/Extension Gap Spacer 10mm

I15 9061.10.811

Flexion/Extension Gap Spacer 11mm

I15 9061.10.812

Flexion/Extension Gap Spacer 12mm

I15 9061.10.814

Flexion/Extension Gap Spacer 14mm

J15 9061.10.900

Femoral Peg Drill

K15 9061.11.1A0

Femoral Cutting Guide A LL / RM

K15 9061.11.1B0

Femoral Cutting Guide B LL / RM

K15 9061.11.1C0

Femoral Cutting Guide C LL / RM

K15 9061.11.1D0

Femoral Cutting Guide D LL / RM

40 Surgical Technique PHYSICA ZUK

PHYSICA ZUK SURGICAL TECHNIQUE

Instrument Set

1 1 1 1 1 1 1 1 1 1 1 1 3 3 2 2 2 1 1 1 1 1

K15 9061.11.1E0

Femoral Cutting Guide E LL / RM

K15 9061.11.1F0

Femoral Cutting Guide F LL / RM

K15 9061.11.1G0

Femoral Cutting Guide G LL / RM

K15 9061.11.5A0

Femoral Cutting Guide A LM / RL

K15 9061.11.5B0

Femoral Cutting Guide B LM / RL

K15 9061.11.5C0

Femoral Cutting Guide C LM / RL

K15 9061.11.5D0

Femoral Cutting Guide D LM / RL

K15 9061.11.5E0

Femoral Cutting Guide E LM / RL

K15 9061.11.5F0

Femoral Cutting Guide F LM / RL

K15 9061.11.5G0

Femoral Cutting Guide G LM / RL

L15 9095.11.121

Pin Driver

M15 9095.11.122

Tibial Pin Inserter

D15 9095.11.D35

Headed Screw 35mm

D15 9095.11.D50

Headed Screw 50mm

D15 9095.11.E90

Long Pin Hexagonal Headless

D15 9095.11.F20

Tibial Headed Pin 20mm

D15 9095.11.G20

Tibial Headed Screw 20mm

N15 9095.11.600

Curved Osteotome

O15 9095.11.801

Rapid Connector

D15 9061.11.001

Femoral Cutting Guide Augment 1mm

D15 9061.11.002

Femoral Cutting Guide Augment 2mm

9061.15.9PY

Instrument Tray

PHYSICA ZUK Surgical Technique 41

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