Operative Technique
Contents
1. Operative Technique Acknowledgement Knute Buehler M D Chief of Arthritis and Joint Reconstruction The Center Orthopedic and Neurosurgery Care and Research Bend Oregon USA Important Notice Only trained medical personnel may use the Stryker Navigation System As with any technical guide the surgeon should consider the particular condition of the patient and perform the necessary adjustments if required Stryker precisioN Knee module is not a replacement for the surgeon s qualification expertise or judgement Safety and caution notes should be carefully reviewed prior to proceeding For the required safety information and contraindications please refer to the Safety Information supplied with the precisioN Knee software package and to the 3 ER m m Special appreciation is expressed to Dr Knute Buehler for his direct assistance with the development of this Operative Technique and many thanks to the other esteemed surgeons who assisted in the development and validation of the precisioN Knee product Instructions For Use supplied with the system components For a detailed description of the software features and procedures and for a comprehensive definition of the computed mechanical axes and resection levels refer to the online User Manual for the precisioN Knee software For information related to the use of conventional instrumentation please refer to the opera2. EE ab EE FE ab faye co C j Registar Femur Lateral Epicondyle Place the pointer s tip onto the most prominent point of the Medial Epicondyte lateral epicondyle and press the eit E a pointer s SELECT button to record 10 3 Patient Registration Femur Center Place the pointer s tip at the center of the trochlear sulcus anterior toward the distal end of the femoral shaft and press the pointer s SELECT button to record This is essentially where one would place the IM rod when using conventional instrumentation Femoral AP Axis Align the pointer s axis with the most posterior point of the trochlea and the most anterior point of the intercondylar fossa also referred to as Whiteside s line Press the pointer s SELECT button to record Hie HE den fmc rm Register Femur 3 2 Millar Jahn Lan Lag Hsp in Fleer Hip Carni Medial E pecandyle Lateral Eperconaiyla Femur Genter amp Hack Again Bee Register Femur Miter John Len Leg v Hip in Flexion J Hip Center 4 Madial Epicondyle v Lateral Epicondyle r m Leiber Fiemoral AP Axis Misa Neid 11 3 Patient Registration Operative Technique 3 Patient Registration le HH ee ri iT Register Femur L Millar Jenn Let Lag Hig in zi dal Hip Conkor Masdial Enicarnd le afore Epiconadyle Femur Canio Femoral AP Axs Medial Disial Condyle e prem Ec
3. collision with the tibial cutting guide and the keel of the implant For fixation pre drill a pilot hole with a 3 2mm drill The pin can be inserted bi cortically using the Insertion Tool Record Initial Table Record Trial Table Record Final Table The Record Table screen automatically documents the kinematic data flexion extension varus valgus rotation at specific flexion angles throughout the whole range of motion If selected in the User Preferences the Record Table feature is part of the Analyze Initial and Trial and Final Alignment sequences Anterior Referencing Stryker precisioN Knee software supports the posterior as well as the anterior referencing bone cut sequence If anterior referencing is selected in the user settings the Align Femoral Rotation dialog is expanded and displays the rotational and the flexion extension alignment of the anterior cutting plane HTO Workflow With Stryker precisioN Knee software a HTO workflow supporting the assessment of the overall leg alignment can be enabled For HTO navigation the following landmarks have to be digitized Hip in flexion Hip center Femur center Femoral AP axis Tibia center Tibial AP axis Medial lateral malleolus Hotspot Landmark Redigitization During navigation and alignment analysis the following landmarks can be redefined by hotspot redigitization Medial lateral epicondyle Femoral AP
4. posterior condyle Repeat this procedure for the lateral posterior condyle Note Ensure that the most posterior aspect of the condyle has been included and that the pointer s tip does not digitize false points in the air at the back of the knee 8 Automatic Sizing and Implant Positioning Anterior Cortex For automatic sizing and implant positioning adequate digitization of the anterior cortex has to be ensured To provide guidance a digitization grid and the proximal implant contours of every second implant size are superimposed on the bone model The proximal implant contours are derived from the implant database Their positions are determined by the digitized landmarks The proximal implant contours define the area of the anterior cortex most important for an optimized and enhanced anterior implant match In addition the contours determine size specific digitization regions When digitizing the software will check off and change the color of the size specific digitization regions once the minimum amount of points have been obtained for that region and implant size Place the pointer s tip onto the anterior cortex and begin digitizing by pressing the pointer s SELECT button and moving the tip over the surface of the anterior cortex Note For the software to be able to properly calculate the optimal size and best anterior match the following must be ensured The relevant
5. TES i Register Femur Milter John Let Lag the following axes and references are defined Mechanical femur axis Hip Center Femoral rotation axis nm Medial Epicandyle Lateral Epicondyle Reference for resection level Reference for notching rami Lefer c fee D ab iam FED ab A co Hip in Flexion Flex hip at any angle and press the SELECT button on either patient tracker to record i a Hip Center TN bane astia a E Register Femur Miter John Slowly and smoothly circumduct ie s HER the hip with changing radii P Hip Center Medial Epicondyle During rotation avoid pelvic Exp teet movement As soon as a sufficient number of points are recorded the software automatically stops recording Famu Center Note Avoid moving the camera or the OR table during motion analysis zs 1 Camera or OR table movement could B x ae Mus Menu Newt compromise the calculation of the wi vi hip center or cause the software to reject the calculation Note In case of pelvic movement have the assistant stabilize the pelvis and repeat range of motion Operative Technique 3 Patient Registration a 7 g Medial Epicondyle Register Femur ALME Lui YA Place the pointer s tip into the EL UA t sulcus of the medial epicondyle Medial Epicondyle and press the pointer s SELECT 2 V o button to record es prem ihar
6. applied and are supported by the Stryker Knee Navigation System Patient Anchoring The patient trackers must be rigidly fixated to femur and tibia of the leg undergoing treatment For tracker fixation two kinds of anchoring devices are available OrthoLock anchoring device Bi cortical Anchoring Pins OrthoLock anchoring device OrthoLock can be used for standard and minimally invasive TKA Bi cortical Anchoring Pins Bi cortical Anchoring Pins can be used for standard TKA with conventional or dedicated cutting guides For Anchoring Pin fixation refer to the chapter Additional Options 2 Patient Preparation OrthoLock Fixation 2 sa S D gt A D mi ex The OrthoLock can be used in conjunction with OrthoLock Ex and Navigation Pins For fixation a minimum of 2 pins are needed OrthoLock may be fixated prior to inflating tourniquet cuff To provide sufficient stability the pins can be fixated bi cortically On the femur the pins are positioned close to the knee joint To minimize muscle load pins are placed with the knee in flexion On the tibia the pins can be positioned distal of the tibial tubercle to avoid the patella tendon and collisions with the tibial implant Note For bi cortical fixation only engage the second cortex To help prevent drilling through the bone stop pin insertion as soon as the pin penetrates the
7. block s saw capture position Additionally the varus valgus alignment slope and medial lateral resection depth are displayed as a numerical value Align and fix the cutting guide to desired parameters on the bone with headless pins After proper cutting block fixation the adjustment component and eo fixation plate can be removed and Resect Proximal Tibia Malar John X the proximal tibia can be resected N ab oe ca ra c sb co fab az Ke 0 0 0 0 Verify Proximal Tibia Cut For proximal tibia cut verification and documentation Attach the femoral tracker or tool tracker to the Resection Plane Probe and hold the plane probe flush against the cut Make sure the Record Cut button is highlighted and press the Aa Main mony one Hl SELECT button on the tracker to pee record the cut Note For detailed instructions on how to use dedicated cutting guides refer to the IFU supplied with the product and the Operative Technique for Navigated Resection Guides Lit no 9100 091 000 6 Resect Bones Soft Tissue Balancing Within the Reactive Workflow feature an Analyze Alignment screen is integrated to help control soft tissue balancing Attach femoral and tibial tracker to the anchoring devices With the Reactive Workflow feature the software automatically selects the Analyze Alignment screen Distract the knee joint and perform sequential
8. soft tissue releases until the desired varus valgus balance is achieved Align Tibial Rotation For Stryker implants Attach the femoral tracker or tool tracker to dedicated Tibial Alignment Handle and use the alignment handle to position the tibial template onto the resected tibial plateau With the Reactive Workflow feature the software automatically selects the Align Tibial Rotation screen On the software screen the yellow cross represents the actual template rotation Additionally the rotational alignment is displayed as a numerical value Align the tibial template properly and pin the template into position To record the template position Make sure the Record Rotation button is highlighted and press the SELECT button on the tracker To proceed with analyzing the intra operative leg alignment highlight Next and press the SELECT button on any tool Bi h i ee ie Analyze Alignment Align Tibial Rotation Note When using a non Stryker Alignment Handle the femoral tracker or tool tracker can be attached to the square Resection Plane Probe and held E I n ect Screen amp y e E Asch Moe Men Met Y a MONS E Miter John N amp Do eo en o co 22 ab Xs co a See w Recanrd Rotalion E Bai Mas Meni against the handle Make sure the tracker is in line with the handle s axis and the Resection Plane Probe par
9. D D as Ss D ane cD Lateral Distal Cordyla 7 aa Meni Pe Register Femur Milor Jenn 4 nn r onion Pat Ti pl J 4 12 Medial Distal Condyle Place the pointer s tip onto the medial condyle and begin digitizing by pressing the pointer s SELECT button and moving the tip over the surface of the medial condyle in a zig zag painting fashion Note Ensure that the most distal aspect of the condyle has been included and that the pointer has not left the surface of the bone during digitizaton Lateral Distal Condyle For lateral distal condyle digitization follow the instructions provided above for the medial side Anterior Cortex Place the pointer s tip onto the anterior cortex and begin digitizing by pressing the pointer s SELECT button and moving the tip on the anterior cortex in a painting fashion During point acquisition Include the most prominent anterior region and the expected saw blade exit points Select Next to proceed to the Register Tibia dialog 3 Patient Registration Tibia Registration By digitizing tibial landmarks the following axes and references are defined Mechanical tibia axis Tibial rotation axis Reference for resection level 2 BANDO Jahn Lan Leg Tibia Genter LE TSIE UBL T TE SS ERIS Labora Mallealus Tibia Center Place the pointer s tip onto the middle of the interspinous sulcus anteriorly near the anter
10. P shift are ASA applied and assess fit 2a Apply flexion 1 to 5 3a Assess fit Within these iterations the Implant Sizing and Positioning Criteria for Best Fit software selects the femoral implant size and position which fits the following prioritized criteria best Kinin aem d il the gendum ie implast contour law em or Maximusesrun oud 42mm Bh ingat a amp nberr Cortes admis wn i ni 1 Maximum run out of uncovered M bona anterior cortex resection is A smaller than 12 mm 8 Advanced Features 2 Minimum 1 of the proximal implant contour is lying on or above uncut anterior cortex 3 Minimum 60 of the proximal i 3 irmiur E of tha En ml The peli Weis Eo Bae Le implant contour has contact mpland contour llos an cut bons i E bakarren tha l mpiamT ban phe Amg pri r with cut anterior cortex E Aan amallar than 1 5 mm 4 Maximum gap between the proximal implant contour and uncut anterior cortex bone is smaller than 1 5 mm 31 Advanced Features 8 Automatic Sizing and Implant Positioning Notching The software indicates notching if one of the following criteria applies 1 Maximum run out of uncovered anterior cortex resection is larger than 12 mm 2 Entire proximal implant contour has contact with cut anterior cortex Maximum Gap between Proximal Implant Contour and Anterior Cortex Bone A gap between the proximal implant contour and anterior cortex is calc
11. Resection level External internal rotation Anterior posterior shift Flexion extension Size When modifying the implant size and position orange marked areas indicate uncovered anterior bone resection If applicable an orange dot displays the position of the maximum gap between implant and anterior cortex In case of notching a warning message is displayed Fle Lon 41 5 To modify the implant position or size AA Select the arrow control buttons SUUM s To close the Modify Implant Position screen Select OR 30 8 Automatic Sizing and Implant Positioning Automatic Sizing and Implant Positioning Calculations Optimal femoral implant size Implant Sizing and Positioning Iterations and position is calculated in the following manner First the software virtually positions the smallest implant size on the digitized femur For positioning varus valgus and rotational alignment are set to 0 a i f 1 Position smallest implant and 2 Apply flexion 1 to 5 3 Assess fit for each flexion The distal and posterior condyles assess fit are reconstructed in accordance to the principles of conventional surgical technique After positioning the smallest implant size the software iterates this process for all available implant sizes In addition different flexion A 4 Apply AP shift for each 5 Assess fit 1a Select next bigger size angles as well as A
12. Template for AP Alignment Navigated Drill Templates for AP alignment are available for Stryker Triathlon Scorpio and Scorpio NRG implant systems Navigated drill templates can be selected in the user settings if automatic sizing is enabled They can be used to prepare the rotational alignment and AP position of the 4 in 1 cutting block The navigated drill templates can replace the conventional AP sizer With the navigated drill template an additional frontal view of the anterior cortex is displayed The anterior cortex view gives a preview of the position and size of the uncovered bone resection against the given flexion extension of the distal femur cut and the AP implant position Align Femoral Rotation Hataliar 0 0 a DTE RE Defyutl Modify implant Position E Bak ee IA a 7 EZ Miller Jenn Lat Log Record Rotation Main Menu Newt gt H F 8 Advanced Features 33 34 Peyorls Bone Rasecton im Lise Linersal Tracks for too ranpaban Dapy AP distance mi She gaps bane Mane Sur Gap Pre ate req emoral Rotation Use posent referencing amp Lise anterior rterencng Bu aoa DAI Tam pia tor AP Cancel LI E TS Analyze Alignment 20 nn 2 mm Gap Monitoring Gap monitoring enables the surgeon to analyze the size of the flexion extension gap based upon the recorded bone resections Gap monitoring can be enabled in the User Preferences
13. allel to the tibial template 23 Operative Technique 7 Analyze Trial and Final Alignment Analyze Trial Alignment The Analyze Trial Alignment screen is similar to Verify Registration It enables the surgeon to assess the intra operative leg alignment and ROM with the trial implants in place The result of soft tissue balancing v Record Alignment and comparisons between tibial inlays range of motion and leg alignment can be controlled and Back Mir Mew Next gt adjusted a 7 For documentation intra operative alignment can be recorded 7 Analyze Trial and Final Alignment 24 7 Analyze Trial and Final Alignment Analyze Trial Varus Valgus ee The Analyze Trial Varus Valgus eee screen is similar to Analyze Initial Analyze initial Align Varus Valgus It enables the surgeon to assess the varus valgus alignment and the stability of the knee joint with the trial implants in place L Cured Analyze Final Alignment M Record After final prosthesis implantation an outcome assessment can be Back Main Menu Met Y performed I adaa For the outcome assessment the same screen types are used as in Analyze Initial and Trial Alignment c D gt lt L Wasi LL ej gt d D N say lt L r 25 26 Peyerls Implant Positioning Auiomatic implant sizing and positioning F ith rum Cn e Show lfiecanlederab
14. are available for slots from 0 9 mm to 1 5 mm 6541 1 688 Navigated Drill Template Triathlon 2 Note Screwdriver required for OrthoLock Navigated MIS Jig and Dedicated Mini Jig Accessories 6000 006 000 Instrument Battery 10 Part List Software precisioN Knee Navigation 6003 640 000 Navigation Platform ee Navigation System II Cart 7700 100 000 mE Ortho Grip Knee Pointer 6003 012 000 Tibia Pelvis Tracker 6003 005 000 Universal Tracker optional 6000 005 000 Dedicated Mini Jig p Mini Fixation Plate 6003 300 020 Mini Cutting Guide 6003 300 010 Tracker Adapter 6003 100 090 6003 200 010 Navigated MIS Jig B 6003 200 020 Tracker Adapter 6003 200 030 Eo zu c 39 Stryker Joint Replacements Trauma Extremities amp Deformities Craniomaxillofacial Spine Biologics Surgical Products Neuro amp ENT Interventional Pain Navigation Endoscopy Communications Imaging Patient Handling Equipment EMS Equipment Stryker SA Cit Centre Grand Rue 90 1820 Montreux Switzerland t 41 21 966 12 01 f 41 21 966 12 00 www europe stryker com Solely for use by Healthcare Professional The productslisted above are CE marked according to the MedicalDevice Directive 93 42 EEC The information presented in this brochure is intended to demonstrate a Stryker product Always refer to the package insert product label and or user inst
15. avigation screens automatically Reactive screen selection is based upon trackers position and alignment Note Dedicated Mini Jig The posterior referencing workflow is described in the following chapters 6 Resect Bones Hardware Options For distal femur and proximal tibia cuts two different kinds of cutting blocks can be navigated Conventional cutting blocks Conventional cutting blocks with intramedullary fixation are navigated by inserting a Resection Plane Probe with a tracker into the cutting slot Navigated resection guides The Dedicated Mini Jig and the Navigated MIS Jig shown here do not require intramedullary fixation and are equipped with a dedicated tracker interface Navigated MIS Jig 19 Operative Technique 6 Resect Bones Record Cut Resect Distal Femur Milar John Left Lag N rab Q ca a e o N fab s Ke k Tlo Serei 7 Reoord Gul 20 Resect Distal Femur When using the Dedicated Mini Jig Bring the cutting guide into position fixate it to the distal femur and attach the blue tibial tracker or tool tracker to the tracker interface With the Reactive Workflow feature the software automatically selects the Resect Distal Femur dialog On the screen the yellow disc represents the actual cutting block s saw capture position Additionally the varus valgus and flexion extension alignment as well as the medial and lateral resect
16. axis Tibial AP axis To open the hotspot redigitization dialog Move the pointer tip close to the landmark The deviation of the newly defined landmark or axis to the previous registration will be displayed Select Redigitize to redigitize the landmark or axis Align Femoral Rotation E Mister John k r mi Racord Rio alsan E Bai NE Mads Meri Verify lamaral AP axis Deviation to piron AP Aus IS aexigrnal ratali n De yeu wand to re digitize te kamari AP as Radiye Cancel kd vu rum SSO ee 37 38 Appendix 10 Part List Part Number Anchoring Devices 6007 4xx 000 Anchoring Pins 4 mm x 20 25 60 mm 6007 5xx 000 Anchoring Pins 5 mm x 30 40 50 mm 6007 015 000 Insertion Tool for Anchoring Pins 6007 003 000 OrthoLock 6007 10x xxx OrthoLock EX Pins 3x110 4x150 mm 6007 00x xxx Navigation Pins 3x100 3x150 4x100 mm Navigation Hardware 6003 175 000 Pivotal Alignment Handle 6003 027 000 Resection Plane Probe Slots 1 3 mm m 6003 028 000 Resection Plane Probe Round ae 6003 070 000 Posterior Plane Probe Universal Joint Screwdriver Screwdriver 6003 250 000 Pivotal Tracker AP Sizer Interface 6541 002 808 Navigated Tibial Alignment Handle 6541 005 610 MIS Femoral Navigated Stylus 6541 004 401 Navigated Tracker Adapter Triathlon 8001 0315 Navigated Drill Template Scorpio 1 Note Resection Plane Probes
17. cord the patient s first and last name Indicate the leg side undergoing treatment Entering the patient s name and indicating the leg side is mandatory Click Next to proceed Prepare and Initialize Tools The required tools are listed in the Setup System dialog Load sterile batteries into the navigated tools Setup System One sterile battery will be needed for each tool used To initialize the navigated tools Face the LEDs towards the camera and press and hold the SELECT button on the tool for 2 3 seconds Tool initialization is confirmed by an audible alert and a checkmark in front of the software button Upon pointer initialization the Validate Pointer pop up window appears N Validate Pointer A With the pointer validation the accuracy of the pointer tip is calibrated Touch the center of any one of the tracker s validation discs with the pointer tip and press the SELECT button on the pointer for 2 3 seconds to validate Mg Meis Z Mallar Jen Caf Lag Activate Femur Tracker Activaie Tibia Tracker 7 a D Activate Pointi Maii AeA Valoiate Pointer Align the pointer amd any lracker towneds tha Enea im 1 ponies iip inte ihe di amp k canini ered pons bub validate Operative Technique 2 Patient Preparation 2 Patient Preparation Incision Standard and minimally invasive techniques for exposing the knee joint can be
18. d press the pointer s SELECT button to record iibig AP Axis Madial Compartment Lateral Camgpartmant Medial Mallealia Lateral Mallealis 3 Patient Registration bach Mia Meni Lateral Malleolus Register Tibia Miner John Left Leg Place the pointer s tip onto the NIS most prominent aspect of the Tibial AP Axis lateral malleolus and press the uu Madial Compartment gt i Lateral Campartmant pointer s SELECT button to record ateral Campartmen LS TSIE UB TIE ed ERG Lateral Mallealia Select Next to proceed to the Verify Registration dialog n y a i P FE Bara Mis Marji 15 Operative Technique 4 Reference System Reference System Upon completion of femur and tibia registration the reference system is defined The digitized reference landmarks and axes are now used to assess the kinematics and for calculating the alignment of instruments and bone cuts Reference for Varus Valgus Flexion Extension or Slope 4 Reference System With Stryker Navigation the femur reference for varus valgus and flexion extension is the mechanical femur axis defined by the digitized Hip center Hip center and Knee center The tibia reference for varus valgus and slope is the mechanical tibia axis defined by the digitized F Ubia Center Ei i Tibia center and Calculated ankle center The ankle center is calculated by dividing the digitiz
19. e AP Sizer rotation The rotation is displayed as a numerical value with respect to the averaged rotation axis digitized AP axis and transepicondylar line Align Femoral Rotation E Miler John Lot Lag 6 Resect Bones Align the rotation of the AP Sizer OOF J 0 If the Resection Plane probe sits in the slot of the predicted size Check for potential notching Upon proper alignment Fixate the AP Sizer and re check the alignment igi zT 4 Record Rotation Verity With the AP Sizer fixed the peg holes can be drilled The 4 in 1 cutting t A block can be impacted into these holes P mak Man Menu Ne 7 and the remaining four femoral bone ox CAP s resections can be completed For anterior cut verification and documentation Hold the Resection Plane Probe with tibial tracker or tool tracker flush against the anterior cut make sure the Record Rotation button is highlighted and press the SELECT button on the tracker to record 21 Operative Technique 6 Resect Bones Resect Proximal Tibia Tee When using the Dedicated Mini Jig Resect Proximal Tibia Mater Jenn Left Lag gt Bring the cutting block into position fixate it to the tibia and attach the green femoral tracker or tool tracker to the tracker interface With the Reactive Workflow feature the software automatically selects the Resect Proximal Tibia dialog On the screen the yellow disc represents the actual cutting
20. ed transmalleolar axis according to the ratio of 56 lateral to 44 medial Note With precisioN Knee software the anatomical axis of femur and tibia is not taken into consideration 16 4 Reference System Reference for Rotation Reference for femoral rotation is the averaged rotation axis defined and calculated by the digitized Transepicondylar axis medial and lateral epicondyle and Femoral AP axis Reference for tibial rotation is the digitized Tibial AP axis Note With the precisioN knee software the posterior condylar line is not taken into consideration as reference for femoral rotation Reference for Resection Level Reference for the distal femur resection level is the most prominent distal point of the digitized condyle Reference for the proximal tibia resection level is the most recessed point of the digitized compartment The system calculates the length of the perpendicular line from the reference point to the resection plane 4 Reference System 17 Operative Technique 5 Verify Registration Analyze Initial Alignment Verify Registration Analyze Verify Registration amp Maier John Lem Lag Initial Alignment ana Faria The Verify Registration screen 2 0 30 0 enables the surgeon to check the digitized mechanical axes for plausibility and to analyze initial leg alignment with respect to ROM Varus valgus misalignment and laxity Flexion contracture or hypere
21. ion depth is numerically displayed Align and fix the cutting block to desired parameters on the bone with headless pins After proper cutting block fixation the adjustment component and fixation plate can be removed and the distal femur can be resected Verify Distal Femur Cut For cut verification and documentation Attach tibial tracker or tool tracker to the Resection Plane Probe Hold the plane probe flush against the cut Make sure the Record Cut button is highlighted and press the SELECT button on the tracker to record Note For detailed instructions on how to use dedicated cutting guides refer to the IFU supplied with the product and the Operative Technique for Navigated Resection Guides Lit no 9100 091 000 6 Resect Bones 4 Align Femoral Rotation amp Miter Jahn Align Femoral Rotation Position the AP Sizer flat against the distal femur cut When using AP Sizer with size specific slots Slide the Resection Plane Probe with the attached tibial tracker or tool tracker into the slot of the predicted size f ee Record Rotation For AP Sizer without size specific slots Put the Resection Plane Probe onto any flat surface parallel to the DOCE Back Min Men Met gt anterior cutting plane j With the Reactive Workflow feature the software automatically selects the Align Femoral Rotation screen The yellow lines represent th
22. ior mid EX footprint of the ACL attachment s sck Main Menu and press the pointer s SELECT button to record Tibial AP Axis Align the pointer s axis with the v Tibia Cent midpoint of the posterior cruciate Tibial AP Axis ligament and the medial third of UN Mac Compartme i the tibial tuberosity HE Y AWA Press the pointer s SELECT button Nl Lateral Maliealus to define and record a neutral 1 a tibial AP axis 3 Patient Registration 13 Operative Technique 3 Patient Registration Register Tibia Nino da Medial Compartment 4 Place the pointer s tip onto the Tibial AP Axia medial compartment and begin uu digitizing by pressing the pointer s 2 ia o i SELECT button and moving the gt DEM tip over the surface of the medial E compartment in a painting fashion Note Ensure the lowest aspect of the compartment has been included Avoid digitizing below the lowest anatomical point to avoid a false survey reading Register Tibia Millar Jahn Tibia Genter Lateral Compartment Tibial AP Axr Sb ISIESBET n ET 33 i4 For lateral compartment digitization CERIS follow the instructions provided above Lasoral Mallealus for the medial compartment Lateral Ci imparem 14 3 Patient Registration Register Tibia E Miter John Lon Leg Medial Malleolus Place the pointer s Tibia Ceres tip onto the most prominent aspect of the medial malleolus an
23. menu For Gap Monitoring it is mandatory to Record the distal femur cut Record the proximal tibia cut and Record the posterior femur cut Note The posterior femur cut must be recorded by using the Posterior Plane Probe For gap assessment Attach both trackers to the anchoring device With the Reactive Workflow feature the software automatically selects the Analyze Alignment screen Distract the knee in extension to assess the size of the extension gap Distract the knee in flexion to assess the size of the flexion gap Depending on the result additional measures such as ligament or capsule release may be applied to achieve an equal gap in flexion and extension Documentation Tools Screenshot The screenshot feature allows for intraoperative navigation screenshots The screenshots can be used to illustrate lectures research papers articles or promotion materials The screenshots are stored in the PNG format on hard drive D KneeData patients To create a screenshot Highlight and select the screenshot button Ruler Located on all navigation screens is a universal measurement tool enabling the surgeon to perform and document the required measurements To activate the dialog Select the ruler button Select whether the distance is measured on the femur or tibia Digitize two points Upon digitization of the two points the overall distance as well as the medial lateral anterior
24. n gans m Dotect ML overhang Cut tia first and preview insert E Esiimale mecial cond E itl Vans knee fault Register Femur E Miter John Lehi Leg Hip in Flexion Hip Center Modal Epicendyle Ye Laberal Epicondyle Facil Canter Famaeral AP Aug odin Distal Caney I II TRIB SE TE I II BIS Medial Posterior Cong Lateral Posierar Cenc Automatic Sizing and Implant Positioning Automatic femoral implant sizing and positioning can be enabled in the user settings for the following Stryker implant families and types Triathlon CR and PS Scorpio CR and PS Scorpio NRG CR and PS Based on the selected implant family and the digitized axes and bone morphology the software calculates the optimal size and position of the femoral implant The goal of the calculations is to achieve the best anterior match while keeping the implant size as small as possible Unlike the standard patient registration workflow automatic implant sizing and positioning requires a specific anterior cortex digitization and additional surface mapping of the posterior condyles Note The calculations are based on the digitized axes and digitized bone morphology only The soft tissue conditions are not considered Medial Lateral Posterior Condyle Place the pointer s tip onto the medial posterior condyle and begin digitizing by pressing the pointer s SELECT button and moving the tip over the surface of the medial
25. nal Alignment Advanced Features 8 Automatic Sizing and Implant Positioning Appendix 9 Additional Options Gap Monitoring 9 Additional Options Documentation Tools 9 Additional Options Miscellaneous 10 Part List 26 34 35 36 38 3 Patient Registration 2 Patient Preparation 1 System and Software 4 Reference System Fo Je gt fasi T2 D ab cc gt D ab gt LO 6 Resect Bones 8 Advanced Features 7 Analyze Trial and Final 9 Additional Options 10 Part List Analyze Initial Alignment Alignment Operative Technique 1 System and Software Set Up amp Ei E ii i a LJ Na woa tor System stryker Knee Navigation precisiaN Kies Navigation Hip Navegabon Spinal Navigation Fluoro Trauma Navigation iNiellect Cranial Navigaton system Start Up Note The system and software set up can be completed by the OR support staff prior to operation To ensure instrument visibility place the system opposite of the surgeon Plug in the main power cable of the navigation system Press the main power button on the front panel of the navigation system Enter the user name navigation and press enter or use the left mouse button and click OK Upon Application Manager start up use the mouse to select precisioN Knee Navigation software and Too Preparation Enter Patient Data Select the Enter Patient Data screen Re
26. portions of the anterior cortex must be covered and the digitization must represent the bone morphology properly Uneven point distribution and uneven mapping density should be avoided The digitized points should cover an area reaching at least 12 mm proximal to the final implant After digitization potential air points are displayed by the software and can be deleted Select Next to proceed Register Femur remit Verify Anterior Cortex E Miter John fe Le qq Hip in Flexion Hip Centor Medial Enicandyle Lateral Epicondyle Fastul Cente Famasi AP Aun Madian Dirstal Gangyia NI ICE Condyle Madii Pesperar Condyta Lateral Postenor Condyle Anlerior orien Basi bh Main Men ae Za on o N D co rab Li CS D c e a oe Dieipti Air Point Siete AS Paints Koop A Points 27 Miller John Flexion a Position Implant After completion of patient registration the software will calculate the size and position for the best fitting implant and place it on the virtual femur For verification the following calculated parameters are displayed graphically and in numerical value in the Position Implant dialog Femoral implant size Flexion angle Medial amp lateral distal resection level Medial amp lateral posterior resection level Downsize to 3 AP shift if applicable Modify Implant Position Uncove
27. posterior and proximal distal distance is calculated Report The report is automatically created after saving the patient file It compiles all relevant surgery data including the recorded positions of the cutting planes and all kinematics data The report is saved as a pdf file on the hard drive D KneeData patients and can be accessed via the main menu Hu Bn Resect Proximal Tibia E Miter John Left Lag ld Record Cut Exch Wig Nen Feat Measure Distance Fomu HIT precixioM Hec Nagar Surgery Report qt ry 35 Appendix 9 Additional Options Miscellaneous Note Avoid pin positions and pin orientations where any vulnerable neurovascular structures might be injured on either side of the entrance N cs ex 2 IS To lt o gt 36 or exit points Choose an Anchoring Pin with the appropriate thread length according to the insertion depth Bi cortical Anchoring Pin Fixation Position and Orientation Bi cortical Anchoring Pins are two step pins available in different thread diameters and lengths Rotational stability of bi cortical Anchoring Pins is provided by the pins bone anchor splines On the femur the Anchoring Pin can be positioned within the incision in a region of the metaphysis On the tibia the Anchoring Pin can be inserted in the midportion of the bone and distal to the tibial tubercle to avoid
28. red anterior bone resection area marked in orange Maximum gap between implant and the anterior cortex and its position orange dot if applicable Selected implant Triathlon CR Back Main Menu Next m D Varus valgus and rotational alignment as well as the reconstruction of the posterior and distal condyles are achieved in accordance with the principles of conventional surgical technique The calculated parameters are either displayed within the bone model or in the numerical value boxes in I grey see the highlighted area in the Planned Femoral Implant screenshot Position Implant In addition to the calculations the dialog provides online information on the actual leg alignment and if selected in the user settings a preview on the size of the flexion and extension gap Triathlon CR Size 4 Lett 2 Flexion 0 Orim AP shitt O Rotation mm PO shift A Wiame aja Li Wa Pai wal IUS Verify the calculated femoral implant size and position Select Next to open the Planned Femoral Implant dialog summarizing size alignment and position of the calculated femoral implant Select OK to proceed The calculated parameters are displayed in the Resect Distal Femur and Align Femoral Rotation dialog in grey numerical values suggesting the target for instrument alignment In addition the suggested resection levels are displayed as green planes If soft tissue con
29. ructions before using any Stryker product Products may not be available in all markets Product availability is subject to the regulatory or medical practices that govern individual markets Please contact your Stryker representative if you have questions about the availability of Stryker products in your area Products referenced with designation are trademarks of Stryker Products referenced with designation are registered trademarks of Stryker Literature Number MTX9100001117 MTX GS 10 07 Copyright 2007 Stryker
30. second cortex Avoid pin positions and pin orientations where any vulnerable neurovascular structures might be injured both at entry and exit points Avoid pin collisions with the implants and any external checks alignment or resection guides which may be utilized Mount Patient Tracker After anchoring device fixation is complete Mount the patient trackers to the femoral and tibial anchoring device Operative Technique 3 Patient Registration Registration ITEE With registration the positions of anatomical landmarks and axes d a A are digitized as reference for the 4 Tid V Actwate Tibia Tracker alignment of instruments bone cuts ae e MM and leg ins Setup System E Miller John Len Leg Position the Camera prm E D ab as T ab faye co Before starting with patient registration Bring the camera in line with the knee joint so that all instruments are centered in the working volume signified by the grey circles in the Setup System dialog Select the Next button to proceed With the Register Femur dialog Confirm Treatment Prior to femur registration Confirm the treatment and selected leg side by pressing the Confirm Treatment SELECT button of any navigated Miller John tool that 1s visible to the camera Left Leg 3 Patient Registration Femur Registration By digitizing femoral landmarks Seale
31. straints require the calculated implant can be quickly virtually downsized to visualize the result of using a smaller femoral component instead of the suggested one or if desired a more in depth implant modification dialog may be entered Select Downsize to or Modifiy Implant Position Position Implant selected implant Triathlon CR Z Millar Jean Lem Lag a ire 13 1 Record Cut Miter John Back Mai Mend Nea F Eecard Rotalion Bii MT Meni 2 Miller John Flexion ds Downsize to 3 Modify Implant Position Next 7 Back Main Menu 29 Implant Modification Option 1 Downsize to Downsize Implant The Downsize Implant dialog select reference v Keep Anterior F facilitates downsizing the calculated Keep Posterior implant to the next smaller one Use Average To downsize the calculated implant Selecttoxon V Keep Current 2 me a mama ew Use 1 downsizing the calculated implant Use 3 Anterior resection plane Posterior resection plane Use 5 Implant center line Select the desired flexion angle of the downsized femoral implant Select Downsize a Downsize Implant Modification Option 2 MS y Modify Implant Position The Modify Implant Position dialog allows to manually adjust the suggested femoral implant position with respect to Varus valgus Proximal distal shift
32. tive techniques and the user documentation supplied with each company s conventional instrumentation Introduction The Stryker Navigation System precisioN Knee module is an interactive operative monitoring system designed to improve the surgical performance and clinical outcome of knee replacement surgery As a PC based imageless guidance system the Stryker Knee Navigation System helps to facilitate improved decision making for alignment and orientation of instruments trials and implants as well as for balancing soft tissue Furthermore the Stryker Knee Navigation System provides surgeons with pre operative intra operative and post implantation assessments of the patient s joint kinematics and various documentation options Long term cost savings may result from possible shorter hospital stays decreased morbidity and blood loss improved joint stability and decreased rehabilitation time The Stryker precisioN Knee software as well as the dedicated instruments are compatible and represent an open platform for different implant systems 1 J M Sikorski S Chauhan Aspects of Current Management Computer Assisted Orthopedic Surgery Do We Need CAOS JBJS Br Vol 85 B No 3 April 2003 Table of Contents Operative Technique System and Software Set Up Patient Preparation Patient Registration Reference System Verify Registration Analyze Initial Alignment Resect Bones Analyze Trial and Fi
33. ulated by the software The gap is measured at its maximum in the sagittal plane perpendicular to the digitized mechanical femur axis Estimate Medial Condyle for Position Implant j Varus Knees With the Estimate medial condyle for varus knees feature activated the software alerts the user if the digitized lateral condyle is more prominent than the medial side N D 5 Co rab Li ste D 25 gt IS oe Choose Reference Level With the alert the software offers an estimation of the original medial UA SAA condyle or to continue with the Uza Lateral Alofarence 9 He more prominent lateral condyle as EST ere aa reference for distal femur resection level and for calculating the best fitting implant 32 8 Automatic Sizing and Implant Positioning Automatic Sizing and Implant Positioning Options Detect ML Overhang The Detect ML Overhang functionality can be enabled in the user settings It requires the digitization of the medial and lateral overhang region In the Position Implant dialog the average medial lateral overhang or uncovered bone cut will be displayed in numerical value The amount of overhang or uncovered bone is measured at the AP position of the digitized overhang region Note Potential medial lateral overhang or uncovered bone cut is displayed only It is not considered in the automatic sizing and positioning calculations Navigated Drill
34. xtension For analysis Bring the leg through a range of motion and apply varus and valgus stress For documentation initial alignment can be recorded Analyze Initial Alignment ae 2 Spana 29 A ge D fab m gt 4 cS ab E LO Highlight and select Next to proceed Analyze Initial Varus Valgus Malar Jone Analyze Initial Varus Valgus deua With the Analyze Varus Valgus 40 0 ppt M screen the varus valgus deformity 7 5 qum and laxity of the knee joint throughout a whole range of motion can be assessed The graph with the blue slider bars indicates the amount of varus valgus laxity and deformity with respect to the flexion angle To record the graph Activate the record button and perform a range of motion exercise at least twice while applying both varus and valgus load Press the SELECT button on any tracker to stop recording Highlight and select Next to proceed with navigating the bone cuts 18 6 Resect Bones Resect Bones Options Workflow Options Both posterior and anterior referencing techniques are supported by the Stryker precisioN Knee software Additionally two software control options for navigating bone cuts are offered Manual Workflow With the manual workflow the bone cut sequence can be configured and is displayed on sequential screens Reactive Workflow With the reactive workflow the software selects the n
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