• Incisize and expose using surgeon’s preference 

• Excise any hypertrophic synovium and a portion of the infrapatellar fat pad to allow access to the medial, lateral, and intercondylar spaces. 

• Before proceeding, consider removing prominent osteophytes, particularly medial and lateral osteophytes, as they can affect soft tissue balancing.

Note: Accurate patella alignment is important for proper placement and tracking. It is recommended not to drill the patella lug holes prior to the trialing step so that correct rotation and position of the patella trial may be assessed. 

SUMMARY: The Pinning Technique and uses for Headed and Non-Headed pins

TIP: Do not overtighten 

• Headed Pins best for flat surface 

• Non-Headed Pins best for curved surface

TIP: Threaded Headed Pins in divergent holes provide stability against distal femoral cut

• With Balanced Sizer, IM hole should be 3 - 5 mm medial to the apex of intercondylar notch and 7 - 10 mm anterior to origin of Posterior Cruciate Ligament (PCL)

TIP: Drawing Whiteside’s Line and pre-operative X-ray helpful for location of IM hole  

• Step feature of Step Drill increases diameter of IM hole

CAUTION: For Balancing Block technique, don’t use stepped portion of Step Drill

• Assemble Distal Demoral Jig

Order of Assembly:

1. Rotate the Resection Knob of the Outrigger counterclockwise until the padlock symbol is aligned with the arrow. 
2. Insert the Outrigger Slide into the Outrigger 
3. Rotate the Resection Knob clockwise to set the desired resection level. 
4. Engage the Distal Femoral Cutting Block with the Outrigger Slide and the Cutting Block Clip.

• A 9 mm resection will match thickness of implant. 

• Arrow on Outrigger, near Resection Knob, indicates resection level when using Cutting Slot. 

• Each click moves Distal Femoral Cutting Block 1 mm proximal or distal.

• Set desired Valgus angle Distal Femoral Jig

TIP: Be sure Varus/Valgus Dial is FULLY disengaged by sliding it back from Distal Plate before rotating it.

• Insert IM Rod into femoral canal to level of isthmus

• Disengage Distal Femoral Jig from Handle 

• Slide Jig toward femur until distal plate contacts distal femur 

TIP: Jig may be pinned temporarily using pin holes in distal resection plate 

• Position Distal Femoral Cutting Block on anterior femur 

• Secure Cutting Block to femur with two Universal or Non-Headed Pins through holes marked with a center line

TIP: For additional stability, insert Universal or NonHeaded Pin through one of the divergent pin holes on Cutting Block

• Remove Distal Femoral Jig

• Resect distal femur

• Assemble Tibial Jig 

With the Height Adjustment Knob fully unscrewed on the Tibial Proximal Uprod, attach the Tibial Distal Uprod to the Proximal Uprod. Then attach the Tibial Ankle Clamp to the Distal Uprod.

Assemble the appropriate Cutting Block to the Tibial Proximal Uprod.

Set tibial posterior slope

place knee in 90 degrees of flexion

Check and set sagittal alignment

• Ankle clamp 

• Set Varus/Valgus rotation

Attach Adjustable Tibial Stylus to Cutting Block through slot or on top of slot

If planning to resect through the slot, position the foot of the Stylus marked “slot” into the Slot Feature of the Cutting Block.

If planning to resect on top of the Cutting Block, place the foot marked “non-slot” into the Slot Feature. Rotate the Resection Knob to set the resection level on the Stylus (0 to 10). Each number corresponds to a resection amount in millimeters. Rest the pointer of the Adjustable Tibial Stylus on the lowest point of the tibial plateau. Then lock the Height Adjustment Knob on the Proximal Uprod.

Note: The minimum composite thickness of the tibial implant (4 mm base + 5 mm insert) is 9 mm.

Once height set, pin block through holes marked by center line using two Universal Pins

Resect tibia

Note: Place retractors to protect the PCL and collateral ligaments during tibial resection if a CR implant is chosen.

Fully extend leg, fit Spacer Block snugly in extension space

Tip: If extension gap is not balanced, adjust angle of tibial or the femoral cut, or perform soft-tissue releases to achieve balance

SUMMARY: Setting the femoral rotation with the Measured Sizer.

Mark A/P Axis (Whiteside’s line) on resected distal femur
 

Place Measured Sizing/Rotation Guide against resected surface of distal femur with feet contacting posterior condyles.

Use stylus to determine rotation and femoral component size, insert pins

• Remove Sizing/Rotation Guide leaving pins. 

CAUTION: Be very careful not to apply a large force when contacting the anterior femur with the Stylus, avoiding excessive deflection of the Stylus which may bias the sizing.

SUMMARY: Preparing the femur with bone cuts using the Chamfer Block.

Place A/P Chamfer Block over pins

Check flexion space with space block

Confirm location of cut & degree of rotation with Angel Wing

Insert Threaded Headed Pins into divergent pin holes on medial and lateral aspects of A/P Chamfer Block

• Use Retractors to protect collateral ligaments and popliteal tendon 

• Recommended: Re-attach the appropriate size Modular Posterior Saw Capture to the A/P Chamfer Block to provide for capture guidance on all cuts.

Resect anterior and posterior femur, as well as anterior chamfer if posterior referencing or posterior chamfer if anterior referencing

• Remove Universal or Non-Headed Pins and cut remaining anterior or posterior chamfer

• Remove Threaded Headed Pins and A/P Chamfer Block 

CAUTION: Revisit anterior and posterior femoral cuts after initial resection to avoid Saw Blade skiving

TIP: Reduce risk of inadvertent Saw Blade kickout by pointing Blade slightly toward midline before starting the Saw.

SUMMARY: Preparing the posterior condyles by removing excess bone

Removal of Excess Bone

• Remove excess bone between posterior tibial implant and posterior femoral condyles in flexion 
• Select Femoral Finishing Guide that corresponds to femoral trial component size 
• Push instrument onto resected distal femur and position mediolaterally 
• Fix instrument flush to distal cut using 4.7 mm diameter Base Pins

• Verify osteophytes have been removed. If not, use Curved Osteotome or Gouge to remove remaining bone

TIP: Always work carefully under direct vision to avoid damage to neurovascular structures in popliteal fossa

CR Sulcus Femoral Preparation

• When implanting ATTUNE™ Knee System CR component, use Femoral Finishing Guide to perform sulcus cut.
• Using Sulcus Cut Ramp as a guide, remove bone from sulcus with Rasp, a 0.5 in. Saw or Osteotome 
• Remove Femoral Finishing Guide 

SUMMARY: Preparing the posterior condyles by making cuts using the Notch Guide.

• When implanting ATTUNE™ Knee System PS component, use Notch Guide to perform notch cut 

• Position Notch Guide on resected anterior and distal surfaces of femur as far laterally as possible while assuring that lateral border of implant does not overhang lateral femoral cortex 

• Pin Guide in place using Threaded Headed Pins 

• Perform the notch cut

CAUTION: When completing notch cut, avoid excessive angulation of Saw Blade or penetration past posterior femoral cortex to avoid injury to neurovascular structures. Avoid undercutting condyles. 

SUMMARY: Positioning, impacting, and removing the Femoral trial

• Position Femoral Trial onto femur by hand

• Use ATTUNE™ Knee System Impactor to impact trial 

• Femoral Trial Gripper (Optional Instrument): 

  • Insertion: Position appropriate Femoral Trial onto femur by hand or using Femoral Trial Gripper 

    1. Squeeze Femoral Trial Gripper slightly until prongs align with lug holes of Femoral Trial 

    2. Remove the Gripper and use Femoral Impactor to fully seat trial

• Extraction: Place Femoral Trial Gripper in lug holes and remove by hand

CAUTION: Femoral Trial Gripper should not be used to fully seat Trials. Used for Sizes 3 - 10 only. When extracting, rocking medio-laterally may cause condylar fracture. Avoid rocking.

• If preserving PCL, PCL balance is extremely important for proper kinematics of the knee.¹

• A knee that is tighter in flexion than extension may require one or a combination of the following: 

  • PCL release, increasing amount of tibial slope, or downsizing the femoral component.¹ 

  • During trialing, surgeon selects trials that provide greatest stability in flexion while still allowing full extension. Indications of excessively tight flexion space may include one or more of the following: 

    1. Femoral trial lifting off 

    2. Tibial trial lift-off or booking 

    3. Excessive rollback of the femoral component on the tibia 

3. If there is any indication of imbalance, it is not uncommon to perform a gradual release of the PCL.   

References

1. Scott, R.D. & Chmell, M.J. (2008). Balancing the posterior cruciate ligament during cruciate retaining fixed and mobile-bearing total knee arthroplasty. Description of the pull-out lift off and slide-back tests. The Journal of Arthroplasty, 23(4), 605-608.

• Tibial Trial 
  • Attach Alignment Handle to Tibial Base Trial and place onto resected tibial surface 
  • LowProfile Tibial Pin Puller can be used to posteriorly pin Base Trial to proximal tibia using Posterior LowProfile Tibial Pins. 

• Rotating Platform 

  • Secure Impaction Handle to Spiked Evaluation Bullet and insert Bullet into cutout of Base Trial. Tap down lightly on Impaction Handle to secure Base Trial to proximal tibia.  

• Fixed Bearing 

  • Snap Fixed Bearing (FB) Float Evaluation Bullet into cutout of Base Trial by hand 

• Select Tibial Articulation Surface Trial that matches femoral size and style 

• Alternative Technique: ATTUNE™ Knee System Tibial Insert Trials and Trial Handle 

TIP: Surgeon’s choice to use modular or one-piece insert trials 

TIP: ATTUNE™ Knee System MS FB Tibial Insert Trials are left and right side specific, indicated by “L” or “R” 

TIP: When trialing, match left or right markings on component 

• Select ATTUNE™ Knee System Tibial Insert Trial that matches femoral size and style (CR or PS for either Rotating Platform or Fixed Bearing), and the appropriate thickness (5 mm, 6 mm, 7 mm, 8 mm, 10 mm, 12 mm, 14 mm and 16 mm for CR and PS, and in addition 18 mm for PS, for core sizes 3 - 8). 

• Attach corresponding size Shim of appropriate thickness. 

• Securely engaged Trial and Shim 

• Attach assembly into Tibial Base Trial

• Check for Bal Seal^® Spring damage. If damaged, replace damaged component

• Remove Alignment Handle from the Tibial Base Trial 

• With trial prosthesis in place, extend knee carefully 

• Note anteroposterior and mediolateral stability, and overall alignment in A/P and M/L planes. 

• If indication of instability, use next thicker Shim and repeat check. 

• Select trial assembly that provides greatest stability in flexion while still allowing full extension

• Re-attach Alignment Handle to Tibial Base Trial and attach two-part Alignment Rod to Alignment Handle and confirm overall alignment. 

• Low-Profile Tibial Pin Puller can be used to anteriorly pin Base Trial to proximal tibia using Anterior Low-Profile Tibial Pins

Fully flex knee, and remove Insert Trial

• Tibial Trial Extractor can be used to aid in removal of Insert Trials 

• Insert Tibial Trial Extractor between Tibial Base Trial and Shim 

• lever handle upwards toward femur to remove Insert Trial 

CAUTION: Do not insert Tibial Trial Extractor between Shim and articulation surface to prevent damage to connection feature. When removing Tibial Trials with Tibial Trial Extractor, avoid engaging Keel Punch to prevent damage to Tibial Trial Extractor.  

• Place Base Pins through two outside holes on anterior aspect of Base Trial if needed   

• Use Tibial Drill to ream tibia

• Flush out cavity of bone debris after drilling 

CAUTION: Do not protrude through medial tibial cortex if using medial Base Pin. Do not overdrill. Optional Drill Stop available. 

• Attach Keel Punch to Impaction Handle

• Insert assembly into Tibial Drill Tower 

• Impact into cancellous bone until Keel Punch is seated flush on Tibial Base Trial

TIP: Use anterior window in tower to monitor progress of Keel Punch while impacting

Fully seat, remove Impaction Handle and Tibial Drill Tower

Patella Resection

1. Use Caliper to estimate thickness of patella 
2. Place leg in extension and evert patella 
3. Clamp Patella Resection Guide and perform resection using Oscillating Saw through Saw Capture

CAUTION: When resecting patella, avoid Saw Blade excursion into Femoral Trials or Implants.

• Product Info: Patella Implant Options - Two patella options are available, Medialized Dome Patella or Medialized Anatomic Patella.

• Patella Drill Trialing: Select correct size of Patella Drill Trial for maximum patella bone coverage

• Press the trial onto the bone manually or with the Patella Modular Clamp and Clamp Ring to engage spikes.

• The Drill Trials have one larger central spike to allow engagement of only the central spike so that the Drill Trial may be rotated about the central axis to aid in assessment of its optimal position prior to being fully seated on bone.

1. Optional Patella Drilling Technique

1. Mark apex of native patella 
2. Prior to resecting patella, a small hole can be drilled through apex of native patella bone (1 - 2 mm deeper than intended amount of resection) 
3. Once the patella has been resected, remainder of hole will be present on resected bone surface 
4. Drill Trial has a small hole through center of apex, representing peak of patella implant 
5. This hole can be visually aligned with pre-drilled hole on resected patella surface to aid in anatomic placement of trial 

6. Lug Hole Preparation: Use Patella Modular Clamp to secure Drill Trial if needed. Drill holes using Patella/Femoral Lug Drill.

Femoral Lug Hole Preparation: Drill femoral lug holes through Femoral Trial using Patella Femoral Lug Drill.

TIP: Perform this step after patella trialing to ensure adequate medial/lateral placement

CAUTION: If not satisfied with alignment or tracking of Medialized Anatomic Patella Trial after drilling peg holes, use Medialized Dome Patella. Patella peg hole preparation is identical for Medialized Dome Patella and Medialized Anatomic Patella.

Cementing Technique

1. TIP: During cementing, minimize movement of implants while curing 

2. Prepare sclerotic bone to ensure a continuous cement mantle with good cement interdigitation of 2 mm - 4 mm. 
3. Drill holes and cleanse bone with pulsatile lavage

4. Dry bone 

5. Pack residual small cavity bone defects with cancellous autograft, allograft, or synthetic bone substitutes 

6. TIP: If sclerotic bone on proximal tibia, ensure tibial base will be able to fully seat 

7. Sclerotic bone around edge of prepared bone cavity may need to be removed with rongeur prior to cementation to ensure fully seated 

8. Apply thick layer of cement to bone, implant surface or to both. 

9. Clean and dry tibial plateau prior to cementing 

10. Ensure cement fully surrounds cone of tibial base implant. 

11. Additional Information: Refer to the “Guidance for Cementing Total Knee Replacements” document. 

12. CAUTION: It is vital to choose cement that reaches its working phase quickly. If applying cement to both implant and bone, implantation should be completed early in its dough state to ensure good cement-cement adhesion and reduce risk of dry laminations. 

13. CAUTION: Application of cement to roughened implant surface early in dough state has been demonstrated to increase fixation strength of cement to implant.² 

2. Shepard, M.F., Kabo, J.M., Liebermann, J.R. (2000). Influence of cement technique on the interface strength of femoral components. Clinical Orthopaedics and Related Research, Number 381, 26-35. 

• Insert Tibial Base carefully 

• Avoid malrotation using ATTUNE™ Knee System Impactor 

• Impact Tibial base implant directly to bone prior to mating with polyethylene tibial insert 

• Before insertion, place cement onto femoral component and femur 

• Place femoral component onto bone by hand or Femoral Introducer 

• Engage Femoral Lugs in lug holes of distal femur, deliver several Mallet blows to Introducer

• Release Femoral Introducer 

CAUTION: Application of cement to roughened implant surface early in dough state has been demonstrated to increase fixation strength of cement to implant.² 

• Use ATTUNE™ Knee System Impactor for final femoral component impaction

References

2. Shepard, M.F., Kabo, J.M., Liebermann, J.R. (2000). Influence of cement technique on the interface strength of femoral components. Clinical Orthopaedics and Related Research, Number 381, 26-35.

• Use condylar and notch impaction to seat femoral component

• Use a Curette to remove all extruded cement 

• Tibial Trial Extraction:  

  1. TIP: Tibial Trial Extractor is designed to aid in removal of insert trials 

  2. With knee in flexion, insert Tibial Trial Extractor first on medial side, underneath Shim and Articulation Surface construct

3. Lever up Insert Trial. 

4. Pivot Tibial Trial Extractor until both ends are underneath Shim and Articulation Surface construct

5. Push Tibial Trial Extractor into joint and underneath Tibial Insert Trials as far as possible 

6. Lift handle of Tibial Trial Extractor UPWARDS

TIP: A trial reduction may be performed using Insert Trials.   

Rotating Platform

1. Place RP Trial Post into implanted base component 

2. Place Insert Trial over post and perform trial reduction 

3. Verify rotational stability with PCL tension 

4. Remove loose fragments or particulates from Final Tibial Base 

5. Insert final Tibial Insert 

6. CAUTION: Once cement is cured, trials can be used to verify stability throughout range of motion. 

Fixed Bearing

1. Place Insert Trial on Tibial Base 
2. Verify that Insert Trial does not tilt up off front of base during range of motion test 
3. Remove loose fragments or particulates from Final Tibial Base 
4. Angle Tibial Insert posteriorly and slide posterior tabs into posterior undercuts of Tibial Base 

5. CAUTION: Once cement is cured, trials can be used to verify stability throughout range of motion. 

6. NOTE: Fixed Bearing Tibial Insert is impacted into place on Tibial Base using Fixed Bearing Insert Impactor

7. Position Impactor at approximately 60 degrees on insert so that the notch rests on anterior edge of the center of insert 

8. Use a Mallet to strike Fixed Bearing Insert Impactor 

9. Confirm seating by circumferential inspection 

10. Once all components are implanted, extending the leg will further pressurize the cement. The leg should then remain in extension until the cement hardens for the appropriate time depending on the cement type used.

CAUTION: Care should be taken when flexing knee past 45 degrees to avoid putting force on posterior aspect of tibial base while cement is curing  

• Connect Patella Clamp Button Holder to Patella Drill Clamp

• Apply cement to patella implant 

• Thoroughly clean cut surface of patella with pulsatile lavage 

• Apply cement to surface of patella and insert component

• Product Info: The Medialized Dome or Medialized Anatomic Patella Buttons are designed to fully seat and stabilize the implant as cement polymerizes. 

• Center Medialized Dome or Medialized Anatomic Patella Button and Button Holder Assembly over articular surface of implant and metal backing plate against anterior cortex of patella, avoiding skin entrapment.

• Engage Patella Drill Clamp to firmly hold Patella Implant until polymerization is complete 

• Remove all extruded cement with a Curette 

• Release Patella Drill Clamp by unlocking LockingSwitch on handle and slightly squeezing Patella Drill Clamp Handles to disengage locking mechanism 

• Reduce patella

• Close the knee in layers using surgeon’s preferred technique