0612 51 506r5 Sigma HP Revision Surgical Technique

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SIGMA®

REVISION

AND M.B.T.

REVISION

TRAY

SURGICAL TECHNIQUE

TABLE OF CONTENTS

2 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Surgical Technique Key Surgical Steps Summary 4

SIGMA® Revision/M.B.T. Revision Tray Knee Surgery 6

The SIGMA Revision System Overview 7

Incision and Exposure 8

Intra-operative Evaluation 10

Initial Preparation of the Tibia 11

Preparation of the Metaphyseal Bone – Tapered Reamer 13

Proximal Tibial Resection – Tapered Reamer 14

Preparation of the Metaphyseal Bone – Broach 16

Tibial Trial Assembly 18

Joint Space Assessment 19

Preparation of Femoral Diaphysis 20

Reaming the Medullary Canal 21

Preparation of the Metaphysis – Stem Use 23

Preparation of the Metaphysis – Sleeve Use 24

Femoral Preparation – Distal Resection 27

Femoral Preparation – A/P and Chamfer Cuts 30

Femoral Preparation – Notch Resection 35

Femoral Trial Assembly 37

Femoral Trial Assembly – Sleeve and Stem Use 39

Femoral Trial Assembly – Stem-Only Use 41

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 3

Femoral Trial Assembly – Sleeve-Only Use 42

Final Preparation of the Tibia 43

Preparation of the Patella 44

Implant Assembly - Tibia 46

Tibial Implantation 47

Implant Assembly – SIGMA Femoral Adapter 48

Implant Assembly – SIGMA Femoral Augments 50

Implant Assembly – Sleeve and Stem Use 51

Implant Assembly – Stem-Only Use 53

Implant Assembly – Sleeve-Only Use 54

Final Trial with Implants 55

APPENDICES Key Surgical Steps Summary 4

Appendix 1: The Cemented Tibial Stem Extensions 56

Appendix 2: Step Wedge Preparation 59

Appendix 3: Thick Tray Preparation 62

Appendix 4: Femoral Revision and Tibial Insert Compatibility 63

Appendix 5: SIGMA Revision

Anteroposterior Chart (With Sleeve Use) 64

Instrument Glossary 65

4 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

KEY SURGICAL STEPS SUMMARY

ImplantationPatella Preparation

Final Trialing

Femoral Medullary

Canal Preparation

Distal Femoral Resection Femoral Preparation -

A/P and Chamfer Cuts

Tibial Resection

Tibial Medullary Canal Preparation

Incision and Exposure

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 5

Femoral Trial AssemblyFemoral Preparation

- Notch Resection

Tibial Trial Assembly Joint Space Assessment

6 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

SIGMA

®

REVISION / M.B.T. REVISION TRAY

KNEE SURGERY*

Introduction

In total knee arthroplasty (TKA), failure may result

from many causes including: wear, aseptic loosening,

infection, osteolysis, ligamentous instability,

arthrofibrosis and patellofemoral complications. In

approaching revision procedures, the surgeon must

address such considerations as the planning of an

incision in a previously operated site, the condition of

the soft tissue, mobilization of the extensor mechanism,

extraction of the primary prosthesis and the attendant

conservation of bone stock. Among the goals of

successful revision arthroplasty are the restoration of

anatomical alignment and functional stability, fixation

of the revision implants and accurate re-establishment

of the joint line. Careful selection of the appropriate

prosthesis is of paramount importance. Ideally, the

revision knee replacement system will offer the options

of adjunctive stem fixation and variable stem positions,

femoral and tibial augmentation, sleeve, and various

levels of prosthetic constraint.

Pre-operative Planning

Revision total knee arthroplasty begins with thorough

clinical and roentgenographic evaluation. Physical

evaluation includes the examination of the soft

tissues, taking into account previous skin incisions,

range of motion, motor strength, the condition of all

neurovascular structures, ligamentous stability and

the integrity of the extensor mechanism. Biplanar

radiographic views are obtained, as are tangential views

of the patella and full-length standing bilateral extremity

views for the assessment of alignment and bone stock,

documentation of the joint line and evaluation of the

present implant fixation. Stress views are helpful in

evaluating ligamentous instability. CAT and MRI scans

may at times be of value in cases of massive bone loss

or substantial anatomic distortion from trauma and

metabolic bone disorders. Templates are employed to

establish replacement implant size and the alignment of

bone cuts, to indicate augmentation of skeletal deficits

and to confirm the anatomic joint line.

*The SIGMA Revision Knee System is intended for cemented use only.

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 7

THE SIGMA REVISION SYSTEM OVERVIEW

The M.B.T. Revision Knee System is comprised

of the following components:

· Tibial Components are available in eight sizes

· Tibial Metaphyseal Sleeves are available in 29 mm, 37

mm, 45 mm, 53 mm and 61 mm sizes (M/L dimension)

· Tibial Wedge Augmentation Components: Step Wedge

in 5, 10 and 15 mm thicknesses

· 75, 115 and 150 mm Fluted Stem lengths in 10 to 24

mm diameters in 2 mm increments

· 30 and 60 mm Cemented Stem lengths in 13 mm

diameters. 90, 120, 150 Cemented Tapered Stem

lengths in 13 mm diameters

· Thick Trays are available in three different sizes (2, 3

and 4) and two different thicknesses

(+15 mm and +25 mm)

· Accepts Rotating Platform inserts from LCS®

Complete™, SIGMA RP, LCS Complete Revision and

SIGMA TC3 RP inserts

· Accepts rotating platform hinged insert, Universal

LPS Hinged insert, from the Orthogenesis LPS™ (Limb

Preservation System), which is compatible with the

S-ROM® NOILES™ Rotating Hinge (NRH) femoral

component and LPS femoral component

The SIGMA Revision Knee System is comprised of

the following components:

· Stabilized Femoral Component is available

in seven sizes

· TC3 Femoral Component is available in six sizes

· Modular Femoral Stem, known as the SIGMA Femoral

Adapter, which allows the use of the Universal

Femoral Metaphyseal Sleeves and Universal Stems.

The SIGMA Femoral Adapter is available in 5 and 7

degree valgus angles

· The Universal Femoral Metaphyseal Sleeves are

available in

20 mm, 31 mm, 34 mm, 40 mm and 46 mm sizes

(M/L dimension), and can be used with or without a

stem

· 4 mm, 8 mm, 12 mm and 16 mm Distal Femoral

Augmentations

· 4 mm and 8 mm Posterior Femoral Augmentations

· Three anteroposterior stem positions: 0 mm, +2 mm

and -2 mm

· 75 mm, 115 mm and 150 mm Fluted Universal Stem

lengths in 10 mm to 24 mm diameters in 2 mm

increments

· 30 mm and 60 mm Cemented Stem lengths in 13 mm

diameter

· 30 mm and 60 mm Cemented Stem lengths in 15 mm

diameter (Must be used with a sleeve)

· 90 mm, 120 mm, and 150 mm Tapered Cemented

Stem lengths in 13 mm diameter

· 90 mm Tapered Cemented Stem length in 15 mm

diameter (Must be used with a sleeve)

8 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

INCISION AND EXPOSURE

Initial Incision

When possible, follow the scar from the primary

procedure (Figure 1). Where parallel incisions are

present, the more lateral is usually preferred, as

the blood supply to the extensor surface is medially

dominant. Where a transverse patellectomy scar is

present, the incision should transect it at 90 degrees.

Where there are multiple incision scars or substantial

cutaneous damage (burn cases, skin grafting, etc.), one

may wish to consult a plastic surgeon prior to surgery

to design the incision, determine the efficacy of pre-

operative soft tissue expansion and plan for appropriate

soft tissue coverage at closure.

Capsular Incision

The fascial incision extends from the rectus femoris

proximal margin to the distal margin of the tibial

tubercle following the patella’s medial border,

maintaining a 3-4 mm cuff for reapproximation of the

vastus medialis aponeurosis at closure (Figure 2). Where

mobilization of the extensor mechanism and patella

is problematic, extend the skin and capsular incisions

proximally.

Figure 1

Figure 2

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 9

INCISION AND EXPOSURE

Figure 3

Figure 4

Occasionally an early retinacular release is indicated to

assist with patellar eversion. Where eversion difficulties

persist, a quadriceps snip, a proximal inverted quadriceps

incision (modified V-Y) or a tibial-tubercle osteotomy

may be indicated. Perform appropriate ligamentous

release based upon pre-operative and intra-operative

evaluation. Release fibrous adhesions to re-establish

the suprapatellar pouch and medial and lateral gutters

(Figure 3).

In many revision cases, the posterior cruciate ligament

will be absent or non-functional; when this is the

situation, excise any residual portion. Exercise care when

everting the patella. Frequently, subluxing the patella

laterally is adequate. Doing so will help avoid patella

tendon avulsion.

Implant Extraction from the Primary Procedure

Take care to preserve as much bone as possible.

To this end, assemble a selection of tools, including

thin Osteotomes, an Oscillating Saw, a Gigli Saw, a

highspeed Burr and various extraction devices, but many

cases will require only the thin Osteotome. Carefully

disrupt the bone/cement or bone prosthesis interface

before attempting extraction (Figure 4).

Disengage the implanted components and extract

as gently as possible, in such manner as to avoid fracture

and unnecessary sacrifice of bone stock. Where the

entire prosthesis is to be replaced, it is advantageous to

remove the femoral component first, as this will enhance

access to the proximal tibia. Clear all residual methyl

methacrylate with hand (chisels) or power tools.

10 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

INTRA-OPERATIVE EVALUATION

The surgeon should establish two anatomic conditions

to facilitate revision arthroplasty: the level of the joint

line and the disparity in the flexion and extension gaps

(Figure 5).

Joint Line Evaluation

In an average knee in full extension, the true joint line

can be approximated in reference to several landmarks.

· It lies 12–16 mm distal to the femoral PCL

attachment

· It lies approximately 3 cm distal to the medial

epicondyle and 2.5 cm distal to the lateral

epicondyle

· It lies distal to the inferior pole of the patella

(approximately one finger width)

· Level with the old meniscal scar, if available

Additional pre-operative joint line assessment

tools include:

1) Review of original pre-operative radiograph

of the TKA

2) Review of radiograph of contralateral knee

if non-implanted

Figure 5

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 11

INITIAL PREPARATION OF THE TIBIA

The Tibial Alignment System

When pre-operative evaluation and radiographs indicate

that fluted stem extensions, metaphyseal sleeves or

Wedges are required, it is recommended that the

proximal tibia be prepared with reference to the position

of the IM Rod.

Note: Where a Cemented Stem Extension is

indicated, see Appendix 1 (page 56).

Place the knee in maximal flexion with the patella

laterally retracted and the tibia distracted anteriorly and

stabilized. Release fibrosis around the tibial border or

excise as required to ensure complete visualization of its

periphery.

Approximate the location of the medullary canal with

reference to pre-operative anterior/posterior (A/P) and

lateral radiographs and to the medial third of the tibial

tubercle.

Introduce a 9 mm Drill into the canal to a depth of

2 to 4 cm. Avoid cortical contact (Figures 6 and 7).

4 cm

2 cm

Figure 6

Figure 7

12 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Reaming the Medullary Canal

Assemble the straight reamer to the T-handle.

If power reaming, it will be necessary to attach the

modified Hudson Adapter to the straight reamer. The

shaft of the Reamer contains markings in 25.4 mm

(1 inch) increments. Each marking is numbered to

use as a reference when reaming to the appropriate

depth. Fluted stem lengths are available in 75, 115

and 150 mm. Determine the length and diameter of

the Prosthetic Stem Extension with Templates (Cat. No.

2178-30-100) applied to pre-operative Radiographs.

Use the Reamer Depth Chart (Figure 8) to determine

the appropriate mark on the reamer for canal reaming

depth. Another option to determine Reamer depth is to

measure the trial assembly against the Reamer and note

the corresponding depth mark for reaming. Sequentially

open the canal with progressively larger Reamers until

firm endosteal engagement is established (Figure 9).

Note: Simple cortical contact should not be

construed as engagement.

The fixed relationship of the reamer to the cortices

ensures the secure fit of the appropriate reamer

and, subsequently, the corresponding fluted stem.

It is equally important to not over-ream osteopenic bone.

While reaming the proximal tibia, pay close attention

to the reamer to assure that it is somewhat centrally

located to the exposed proximal tibial surface. Eccentric

reaming can occur, which could lead to undersizing of

the tibial component.

The size of the final reamer indicates the diameter

of the implant stem. The fluted stems are available in

even sizes (10 through 24 mm). Perform final reaming

with an even-sized reamer. The final implant will have a

.4 mm press fit versus the reamer.

Note: Refer to Appendix 1 (page 56) for cemented

stem preparation.

T-handle

Straight

Reamer

INITIAL PREPARATION OF THE TIBIA

Figure 9

Figure 8

Reamer Depth Chart

M.B.T. Revision Tray Reamer Line Depth

Press Fit

Stems

75 mm 2

115 mm 3

150 mm 4

Cemented

Stems

30 mm 1

60 mm 2

90 mm 2.5

120 mm 3.5

150 mm 4

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 13

PREPARATION OF THE METAPHYSEAL BONE

– TAPERED REAMER

Tibial Resection Plane

Notches on the Drill

Figure 10

For Diaphyseal Engaging Stem and

Metaphyseal Filling Sleeve

Attach the appropriately sized stem trial to the end of

the M.B.T. Revision Tapered Reamer.

Note: Assembly of the stem trial may be aided by

the pre-attachment of the T-handle to the M.B.T.

Revision Tapered Reamer.

Taper ream to the planned proximal tibial resection level

(Figure 10). When finished reaming, the notches on

the drill should line up with the planned proximal tibial

resection level.

Note: Use the “cemented” taper reamer when

requiring a cement mantle or when utilizing a

sleeve. Use the press-fit tapered reamer when line-

to-line fit is desired and a sleeve will not be utilized

(Figure 10). Use End-Cutting Primary Reamer (Cat.

No. 2178-63-199) when a stem or sleeve will not be

used.

Note: To avoid stem trial disengagement, do not

reverse ream.

At this point, intra-operatively determine if a

metaphyseal sleeve will be used.

Note: Metaphyseal sleeves are ideal to provide

filling of Engh Type II or III defects in revision TKA.

The steps of the metaphyseal sleeve also provide

progressive loading of the bone with porous coating,

which enhances fixation.

If a metaphyseal sleeve is selected, see page 16 in order

to broach the metaphyseal bone.

If a metaphyseal sleeve will not be used, see the

following page to prepare for the proximal tibial

resection.

14 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

PROXIMAL TIBIAL RESECTION

– TAPERED REAMER

Attach the 2 degree Tibial Cutting Block to the I.M.

Tibial Referencing Device. Attach the I.M. Tibial

Referencing Device to the shaft of the tapered reamer.

Position the I.M. Tibial Referencing Device with the

pre-attached 2 Degree Cutting Block onto the shaft

and allow it to descend to the proximal tibial surface.

Since considerable bone stock may have been sacrificed

in the primary total knee arthroplasty, minimize the

amount resected: no more than 1-2 mm from the most

prominent condyle, managing residual defects of the

contralateral condyle with either prosthetic augment or

bone graft.

Resection is based on tibial deficiency and the level of

the joint line. Compensate deficiencies with sleeves,

wedges and/or bone grafts. Advance the cutting block

to the anterior tibial cortex and lock into position

by tightening the knurled knob on the outrigger.

Preliminary rotational alignment is based on the medial

third of the tibial tubercle. Secure the alignment device

to the reamer shaft with the lateral Setscrew (Figure 11).

Pin the Tibial Cutting Block so a minimal resection is

made from the proximal tibia. Utilize the stylus when

necessary (Figure 11).

Note: There is a slotted and non-slotted end to the

stylus. The difference between the two

is 5 mm.

Note: If a metaphyseal sleeve is to be used the tibial

resection will be performed using the Tibial Sleeve

Broach (see page 17, Figure 14).

Figure 11

Pins

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 15

Figure 12

PROXIMAL TIBIAL RESECTION

– TAPERED REAMER

Remove the I.M. device while leaving the 2 degree

Cutting Block in place. Remove the tapered reamer and

resect the proximal tibia (Figure 12).

Note: At this point determine whether a Step Wedge

is necessary on either the medial or lateral side to

augment a defect, or both sides in order to restore

the joint line. If a wedge is necessary on one side,

it is recommended that the step wedge be prepared

after rotational position of both the femoral and

tibial components have been determined. For step

wedge preparation see Appendix 2 (page 59).

PREPARATION OF THE

METAPHYSEAL BONE – BROACH

16 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

For Sleeve Utilization Only

Note: The M.B.T. Revision Tibial Tray will accept

either a tibial metaphyseal sleeve or a tibial step

wedge. Only the 29 mm Sleeve is indicated for use

with a tibial step wedge.

Attach the M.B.T. Revision Broach Handle to the smallest

broach and then attach the appropriately sized Stem

Trial. The broaches are asymmetrical, position the “ANT”

engraving on the broach anteriorly. Impact the broach

into the tibia until the top surface of the broach is at the

desired proximal tibial resection level. When broaching

the proximal metaphysis, take care to assure the

appropriate rotation of the broach.

Note: The corresponding tibial sleeve implant

allows up to +/- 20 degrees of rotation from

the centerline of the M.B.T. Revision Tray.

Check for rotational stability of the broach. If the broach

(not the handle) moves in the canal, it is not rotationally

stable.

If the broach is unstable or the defect is unfilled, repeat

with consecutively larger broaches until the desired

fit is achieved (Figure 13). Remove the broach handle,

leaving the last broach in place. Any defects remaining

can be filled with allograft or autologous bone placed in

intimate contact with the sleeve.

Two common tibial broaching techniques:

1) Chase the defect by rotating the broach to fill the

defect until reaching rotational stability of the broach.

If utilizing this technique the surgeon must be aware

that the sleeves are allowed to rotate +/-20 degrees

with respect to the M.B.T. Revision Tibial Tray.

2) Align the broach with the medial third of the tibial

tubercle and progressively broach until rotational

stability of the broach is attained.

Figure 13

Tibial Resection Plane

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 17

PREPARATION OF THE

METAPHYSEAL BONE – BROACH

Resect the proximal tibia utilizing the top of the broach

as a guide (Figure 14). The top of the broach has a 2

degree slope built in. The proximal cut should be parallel

to the top of the broach.

Note: If a cutting guide is desired for resecting

the proximal tibia with the tibial broach in place,

assemble the SP2 0 degree Tibial Cutting Block

to the SP2 IM Tibial Guide and slide over the

Broach Adapter Outrigger (2178-01-108). Slide this

assembly onto the boss of the seated tibial broach,

pin the block, remove the outrigger, and resect

through the slot of the cutting block (Figure 15).

Slide the tibial view plate which best covers the proximal

tibial over the broach post. Note the view plate size as

it will dictate the size of the M.B.T. Revision Tibial Base

Trial that will be used. The tibial view plate is transparent

to help visualize tibial coverage (Figure 16). The template

matches the implant to aid in orienting the tibial sleeve

to the tibial base during assembly.

Figure 16

Figure 15

Figure 14

18 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

18

TIBIAL TRIAL ASSEMBLY

Assemble the tibial tray trial with the stem extension and

sleeve trial, if applicable (Figure 17). Position the tibial

trial construct into the prepared tibial canal (Figure 18).

Assess proximal tibial coverage and rotation of tibial

component. The base plate should be positioned to

provide the best coverage of the tibial condylar surface.

Note: The M.B.T. Revision Tibial Keel Punch with

the Universal Handle may be utilized to assist with

seating of tibial trial construct. Once the tibial trial

construct is seated the keel punch must be removed

in order to accommodate the use of the HP Revision

M.B.T. Spacer Blocks.

Leave the trial in place and proceed to femoral

preparation, final tibial preparation will occur after

femoral preparation is complete.

Note: A 14 mm or smaller size stem implant can be

pulled through the sleeve implant. If the stem is 16

mm or greater it will not pull through the sleeve.

Figure 17

Figure 18

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 19

18

After tibial preparation has been performed you may utilize

the HP Revision M.B.T. Spacer Blocks to assess the flexion

and extension gaps (Figures 19 and 20). For common

scenarios, potential solutions are explained below.

Where flexion gap >extension gap:

· To decrease flexion gap without affecting extension gap,

apply a larger femoral component. This is particularly

important where an IM Stem Extension is indicated, as

the Stem Extension will determine the anteroposterior

positioning of the component and the consequent

flexion gap

· Where stem positioning will not permit posterior

augmentation, translate the Femoral Adapter Trial on the

TC3 Box Trial to the +2 (Fem Pos) position. This will result

in translating the femoral component 2 mm posteriorly

(Refer to page 38 for further explanation)

· Where there is insufficient stability, a cemented femoral

stem may be substituted, allowing the component to be

seated further posteriorly

· Where the joint line is elevated, the preferred correction

is posterior femoral augmentation. The alternative–

additional distal femoral resection and use of a

thicker tibial insert to tighten the flexion gap–is not

recommended, as considerable bone stock has been

sacrificed in the primary procedure, and it is important

that additional resection of the distal femur be avoided.

The possible exception is where the joint line is not

elevated and minimal distal resection will increase the

extension gap toward equivalency with the flexion gap

JOINT SPACE ASSESSMENT

Figure 19 Figure 20

20 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Flexion/Extension Balancing

Where extension gap >flexion gap:

· To decrease extension gap without affecting flexion

gap, augment the distal femur with bone graft or

prosthetic augmentation. It is important to note that

this will lower the joint line, which is usually desirable

as it is generally found to be elevated in revision cases.

This will lessen the incidence of post-operative

patella infera

Note: In the initial assessments of the joint space

the Extension Shim may be utilized to help evaluate

the flexion space. This will only be used to evaluate

gap differences. It is important to keep in mind

that the use of the Extension Shim in flexion will

be approximately 1 mm thicker than the final

flexion gap. If the Extension Shim is not used

here to evaluate flexion, the Spacer Block will be

approximately 4 mm thinner than the final

flexion gap.

JOINT SPACE ASSESSMENT

Loose Extension Tight Extension Stable Extension

Loose Flexion

Cause

Flexion and extension gaps are too

large.

Possible Solution

Thicker tibial insert.

Cause

Inadequate resection of the distal

femur (i.e. extension gap < flexion

gap).

Possible Solution

1. Recut distal femur.

2. Recut chamfers.

Cause

Extension gap < flexion gap.

Can be tolerated to a small extent,

but verify stability.

Possible Solution

1. Increase tibial bearing thickness and

reset more distal femur.

2. Upsize femoral component.

Tight Flexion

Cause

1. Extension gap > flexion gap.

2. Posterior osteophytes.

Possible Solution

1. Check for presence of

posterior femoral osteophytes.

2. Downsize femoral component.

3. Cut Posterior slope on the tibia

(not to exceed 10 degrees) and

increase tibial bearing thickness.

Cause

Flexion and extension gaps are too

small.

Possible Solution

1. Thinner tibial component.

2. If the smallest PE is still too tight,

resect more tibia.

Cause

Flexion gap is too small.

Possible Solution

1. Check for posterior femoral

osteophytes.

2. Ensure that there is no soft

tissue impingement.

3. Recut the tibia with a posterior slope.

4. Possibly downsize femoral component.

Cause

1. Extension gap > flexion gap.

Possible Solution

Upsize the tibial components. Might

be necessary to recut tibia with

biggerposterior slope (not to exceed

10 degrees) to obtain full range of

motion (ROM).

Cause

Extension gaps are too small.

Possible Solution

Recut the distal femur and chamfers.

Cause

Excellent ligament balance.

Possible Solution

You have already found it.

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 21

21

PREPARATION OF FEMORAL DIAPHYSIS

Intramedullary Femoral Alignment System

This technique is designed to flow in a logical sequence,

from reaming the diaphysis, to broaching the metaphysis

and cutting the bone. The length and diameter of the

stem extension is determined with templates applied to

pre-operative radiographs.

Begin the procedure with the preparation of the

medullary canal (Figures 21 and 22).

Enter the medullary canal with a 9 mm Drill to a depth

of 3-5 cm (Figure 23). Take care that the drill avoids the

cortices. It is helpful to palpate the distal femoral shaft

as the drill is advanced.

Where impedance of the intramedullary canal is

anticipated, adjust the entry point accordingly.

Figure 21

Figure 23

Figure 22

22 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

22

REAMING THE MEDULLARY CANAL

Connect the Reamer Handle to a small diameter M.B.T.

Revision Reamer. If power reaming, it will be necessary

to attach the modified Hudson Adapter to the Straight

Reamer.

Note: The Reamer shaft contains markings in

25.4 mm increments to accommodate the various

Universal stem/sleeve length combinations (Figure

24).

Use the Reamer Depth Chart (Figure 25) to determine

reamer depth for each combination of components.

Another option to determine reamer depth is to measure

the trial assembly against the reamer and note the

corresponding depth mark for reaming.

You may also determine the length and diameter of

the prosthetic stem extension with templates (Cat. No.

2294-99-035: SIGMA Femoral Adapter Sleeve and Stem

Template) applied to pre-operative Radiographs.

The P.F.C.® SIGMA Femoral Component accepts:

· Universal Fluted Stems available in lengths of 75, 115

and 150 mm in diameters of 10-24 mm

· Cemented Stems available in lengths of 30 and 60 mm

lengths and diameters of 13 and 15 mm (15 mm with

sleeve use only)

· Cemented Tapered Stems available in lengths of 90,

120, 150 mm (13 mm diameter) and also a 90 mm in

15 mm diameter (with sleeve use only)

Figure 24

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 23

22 23

REAMING THE MEDULLARY CANAL

In 1 mm diameter increments, sequentially open

the medullary canal with M.B.T. Revision Reamers

of progressively greater size until firm endosteal

engagement is established.

Take care to ream the canal in line with the femoral axis

to avoid putting the implant in flexion.

Note: Do not reverse ream.

It is important that simple cortical contact of the tip not

be construed as engagement as it is the fixed

relationship of the reamer to the cortices that ensures

the secure fit of the appropriate sleeve and subsequently,

the corresponding fluted or cemented stem.

Figure 25

PS Femur No

Sleeve

20 mm

31 mm

34 mm

40 mm

46 mm

Cemented

Stems

30 mm 1 2 2

60 mm 2 3 3

90 mm 4 5 5

120 mm 4 6 6

150 mm 5 7 7

Universal

Slotted

Stems

75 mm 2 4 4

115 mm 4 5 6

150 mm 5 7 7

TC3 Femur No

Sleeve

20 mm

31 mm

34 mm

40 mm

46 mm

Cemented

Stems

30 mm 1 2 2

60 mm 2 3 4

90 mm 4 5 5

120 mm 4 6 6

150 mm 6 7 7

Universal

Slotted

Stems

75 mm 3 4 4

115 mm 4 5 6

150 mm 6 7 7

24 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

24

Figure 26

Figure 27

Stem Reamer

Universal Fluted Stem Use:

As Fluted Stems are available in even sizes (10 through

24 mm diameters), perform final reaming with the

appropriate even-sized reamer.

Note: For stem-only applications, where a Fluted

Stem less than 16 mm in diameter is chosen, use the

Stem Reamer to clear the area around the adapter.

Attach the threaded shaft to the Stem Reamer and then

attach the appropriate Stem Trial to this assembly (Figure

26). Ream the canal (Figure 27).

Sink the Threaded Shaft, Stem Reamer, Stem Trial assembly

until the 20 mm, 31 mm, 34 mm mark corresponds with

the planned level of distal resection.

For trial and implant assembly with stem-only use, please

see page 41.

Cemented Stem Use:

Where a Cemented Stem Extension is indicated, perform

final reaming with a 15 mm Diameter Reamer for the

13 mm diameter stem extension; similarly, a 17 mm

Diameter Reamer is used to accommodate the 15 mm

diameter stem extension. This allows for creation of a

cement mantle.

PREPARATION OF THE METAPHYSIS – STEM USE

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 25

24

After reaming the intramedullary canal, attach the

threaded shaft to the broach reamer and then to the

appropriate Stem Trial as determined by straight reaming

(Figure 28).

Ream to the 20 mm, 31 mm, 34 mm etch mark on the

Threaded Shaft (Figure 29).

When using the broach reamer, the next smaller diameter

stem trial may be used to allow for easier reaming. The

broach reamer will be necessary when utilizing a 20

mm Sleeve and for the beginning of larger sequential

broaching when using a 31 mm or larger sleeve. After

broach reaming has been completed, attach the 31

mm broach to the broach handle (Figure 30). Attach the

appropriate stem trial to the broach as determined by

straight reaming. Give close attention to the medial

orientation of the broach.

Note: The broach is asymmetrical; and the narrow

side of the broach must point medially (Figure 31).

Note: When prepping for a 20 mm Sleeve, leave the

broach reamer and threaded shaft in the canal and

perform the subsequent femoral cuts off the reamer.

PREPARATION OF THE METAPHYSIS – SLEEVE USE

Figure 28

Figure 29

Broach

Reamer

Medial SideLateral Side

Figure 31 Figure 30

26 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Planned Level of Distal Resection

PREPARATION OF THE METAPHYSIS – SLEEVE USE

Sequentially broach to the desired TC3 or SIGMA CS

Line (Figure 32). When the appropriate etch mark on the

broach handle is at the planned distal resection level,

check the broach’s rotational stability. If the broach (not

the handle) moves in the canal, it is not rotationally

stable.

If the stability of the broach is unsatisfactory, move up

to the next broach size. The last broach used will be the

femoral sleeve size. The broach depth sets the extension

gap/joint line.

In patients with a large degree of distal femoral bow,

closely monitor the anterior progression of the broach

during impaction. Excessive anterior placement of the

broach may result in a loose flexion gap.

Figure 32

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 27

27

Figure 33

After broaching is complete, remove the broach handle

from the broach. With the broach seated in the femur,

attach the threaded shaft to the broach (Figure 33), and

continue with the distal, 4-in-1, and notch cuts.

PREPARATION OF THE METAPHYSIS – SLEEVE USE

28 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

28

Distal Resection

Set the valgus angle to 5 degrees and Left/Right on the

Distal Femoral Alignment Guide by compressing the two

triggers and lock in place by rotating the blue locking

lever clockwise. Place the Femoral Alignment Guide on

the threaded shaft and seat against the distal femur

(Figure 34).

Rotate the knob on the Femoral Resection Guide

counterclockwise until the arrow is pointing to the

padlock symbol. Slide the femoral distal connector

into the Femoral Resection Guide. Rotate the knob

on the Femoral Resection Guide clockwise. Every

click moves the Revision Distal Cutting Block 1 mm

proximal or distal. Turn the knob clockwise from

15 all the way down to 0 (which is the padlock

symbol). This will set the block up for a 0 mm

resection (Figure 35).

Slide the femoral Distal Cutting Block onto the Distal

Femoral Block attachment. The tang on the block

connector will slide into the 0 mm cutting slot on the

cutting block. The trigger should engage in the hole

behind the 0 mm slot (Figure 36).

Note: An open resection will resect 4 mm less

femur. When a 0 mm, open resection is desired, the

dial should be set to 4 mm.

Position the Resection Guide over the two legs of the

Distal Femoral Alignment Guide until the Distal Cutting

Block touches the anterior femur (Figure 37).

Note: The Revision Distal Block is equipped with 0,

4, and 8 mm saw slots. Please keep in mind that if

the resection level is not at 0 (the padlock symbol)

this will alter the resection. If the resection knob is

set at 2, for instance, the saw slots will perform 2, 6,

and 10 mm resections.

FEMORAL PREPARATION – DISTAL RESECTION

Distal Femoral

Connector

Revision Distal

Cutting Block

Figure 34

Distal Femoral

Resection Guide

Figure 35

Figure 37

Figure 36

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 29

28

FEMORAL PREPARATION – DISTAL RESECTION

Figure 39

0 mm

8 mm

4 mm

Secure the cutting block to the femur with Non-Headed

HP Pins through the holes marked with a .

Optional: A Convergent Pin can also be used to provide

better block stability/fixation (Figures 38 and 39).

Figure 38

30 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

FEMORAL PREPARATION – DISTAL RESECTION

Figure 41

An example of a medial

4 mm augment resection

Figure 40

1. Slide femoral

resection guide

upwards

2. Remove femoral

alignment guide

towards the

T-handle

Release

attachment

Once the pins are in place, unlock the Distal Cutting

Block from the distal block connector, using your thumb

and index finger to release the attachment. Slide the

Femoral Resection Guide upwards on the Alignment

Guide legs until the block connector disengages from

the cutting block and in one motion remove the Femoral

Alignment Guide by pulling the instruments distally over

the threaded shaft (Figure 40).

In many cases, little, if any, bone is removed from the

distal femur as the joint line is effectively elevated with

the removal of the primary femoral component. As the

level of resection is based on the preservation of bone

stock, each condyle is cut only to the level required to

establish a viable surface, with augmentation employed

to correct imbalance

The resection is then performed through the slot

appropriate for each condyle, using a standard 1.19 mm

Thick Blade (Figure 41).

Note: If a ½ inch wide Standard Saw Blade is used

it can complete both medial and lateral distal

femoral cuts with the entire jig still in place.

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 31

To size the femur, turn the femoral trial around so the

posterior condyles point away from the distal surface

(Figure 42). The M/L width of the trial should provide the

femoral size. Once the femoral size is determined, select

the appropriately sized Revision 4-in-1 Cutting Block.

Note: The Revision 4-in-1 Cutting Blocks may also

be used to assess the femoral size, as the block is

the same M/L width as the implant (See Figure 43).

If augment cuts were made during the distal resection,

assemble the appropriate distal spacer (4, 8, 12 or

16 mm) to the proximal side of the cutting block to

compensate for the condylar discrepancy. The distal

spacers slide in from the side using a dovetail connection

on the 4-in-1 Block (Figure 44).

Each distal spacer thickness is represented by a different

color (Figure 45).

Red = 4 mm

Black = 8 mm

Green = 12 mm

Blue = 16 mm

Figure 43

FEMORAL PREPARATION – A/P AND CHAMFER CUTS

Figure 42

Width of femoral trial

matches 4-in-1 block

16 mm

12 mm

8 mm

4 mm

Figure 45

Figure 44

32 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

The HP Revision 4-in-1 Cutting Block is fixed at a 5

degree angle. To change the block’s orientation for left

5 degrees or right 5 degrees, flip over the block’s knob

until the L is on top for Left or the R is on top for Right

Note: To assist in changing the Left or Right

orientation (L/R), the shaft of the Revision

Screwdriver may be placed lengthwise between the

two knobs of the L/R dial and rotated 180 degrees.

To set the block to the correct A/P starting position,

Insert the Revision Screwdriver into the hex head on the

block, PUSH and turn clockwise. (To change the setting,

the hex head must first be pushed in to shift the block)

(Figure 46).

Note: The block should be set up in the +2 position

(Fem Post) to begin. The lines on the side of the

knob should line up with the etched lines for the

desired position.

Once done, slide the block proximally onto the threaded

shaft with the appropriate Left/Right (L/R) orientation on

top (Figure 47).

FEMORAL PREPARATION – A/P AND CHAMFER CUTS

The Revision 4-in-1 Cutting Block

As the Screwdriver is turned

clockwise, the +2,0,-2 knob shifts

downwards

Figure 47

To adjust A/P position:

1. Push Screwdriver into Hex Head

2. Rotate Screwdriver to adjust +2,0,-2 position

Figure 46

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 33

FEMORAL PREPARATION – A/P AND CHAMFER CUTS

Figure 48

Figure 49

Rotational positioning of the Revision 4-in-1 Cutting Block

is critical to the establishment of a symmetrical flexion gap

and patellofemoral alignment. The correct block rotation

should have the posterior surface of the cutting block

parallel to the resurfaced proximal tibia under tension.

Validate symmetry with the HP Revision M.B.T. Spacer

Blocks (Figure 48).

Note: The Revision M.B.T. Spacer Blocks are

designed to rest on top of the M.B.T. Revision Tray

Trial and underneath the posterior portion of the

4-in-1 Cutting Block, providing both the appropriate

tension and the correct insert thickness.

Optional: If desired, Alignment Rods may be introduced

through the handle of the spacer block. This may be

helpful in assessing alignment. Rods can be inserted

vertically (to assess the mechanical axis) and horizontally

(to assess tibial cut accuracy) (Figure 49).

Optional: Balanced Block Handles can be used to rotate

the block and to hold the block in place during final

resection.

Where asymmetry exists, additional soft-tissue balancing

may be indicated. Confirm positioning

by assuring parallel alignment of the cutting block with

the transepicondylar axis or the proximal tibia.

Introduce the Angel Wing into the anterior saw slot

to check the anterior resection and ensure femoral

notching does not occur.

34 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Figure 50

Figure 51

FEMORAL PREPARATION – A/P AND CHAMFER CUTS

If the flexion gap is loose relative to the extension gap,

the next larger size femoral component can be used and

the posterior condyles augmented.

If the flexion gap is too tight relative to the extension

gap, the block can be moved from the +2 setting

(Femoral Posterior) to the 0 (Neutral) or -2 setting

(Femoral Anterior) (Figure 50).

Note: The block should not be shifted from one

setting to another with the spacer block, pins, or

any tensioning device in place.

With rotation and gap balancing confirmed, secure the

Cutting Block with HP Threaded Pins introduced through

the side Convergent Pin holes.

Note: If additional fixation is required use threaded

non-headed pins in the anterior pin holes. Use

caution when using headed threaded pins if a gap

exists between the distal spacers and the distal

bone.

The pins will pass through the block and then through

the Distal Spacer (if used), fixing the block in place

(Figure 51). Once locked in place perform the anterior,

posterior, and chamfer cuts.

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 35

Figure 52

Anterior resection is performed through the

anterior slot using a 1.19 mm ½ inch wide Saw Blade

(Figure 52).

Note: The blocks feature an etched line on the side

of the block. This line on the block represents the

distal joint line of the femoral component.

Posterior resection is through the slot designated 0

or, where there is posterior condylar deficiency, use

the appropriate 4 or 8 mm slot to accommodate the

projected augmentation (Figure 53).

Once Anterior and Posterior resections are complete

proceed with the Anterior and Posterior chamfer cuts

(Figures 54 and 55).

Note: If pins were used in the straight anterior pin

holes for additional fixation, they must

be removed prior to making the anterior

chamfer cut.

FEMORAL PREPARATION – A/P AND CHAMFER CUTS

Figure 53

Figure 55

Figure 54

Etch Line Represents Joint Line

36 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Select the appropriate sized Revision Notch Guide, based

upon the size of the Revision 4-in-1 Block used. If distal

spacers were used for the 4-in-1 cuts, insert the same

distal spacers into the Notch Guide on the appropriate

side (Figure 56).

Select the appropriate Notch Guide Bushing. This

corresponds to the Right/Left Block knob position and

the 0 mm (Neutral), +2 mm (Fem Pos) or -2 mm (Fem Ant)

position that was used on the 4-in-1 Cutting Block.

Assemble it onto the Notch Guide with the appropriate

Right/Left and 0, +2 or -2 designation facing up and lock

into position by rotating the tabs anteriorly to the stop

(Figure 57).

Note: The width of the Notch Guide corresponds to

the final implant width (Figure 57).

Figure 57

Distal Spacer

Notch Guide Bushing

Figure 56

FEMORAL PREPARATION – NOTCH RESECTION

Final Implant Width

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 37

FEMORAL PREPARATION – NOTCH RESECTION

Figure 59

Figure 60

Figure 58

Assemble the Notch Guide onto the threaded shaft and

advance to the prepared distal surface (Figure 58).

If assistance is needed in re-establishing the rotation of

the Notch Guide, the HP Revision M.B.T. Spacer Block

may be used between the M.B.T. Revision Tibial Trial

and the posterior side of the Notch Guide to re-establish

desired rotation from the 4-in-1 Block.

Once desired rotation is set, use Non-Headed Pins in the

convergent pin holes to lock the Notch Guide in place.

The pins will go through both the Notch Guide and the

distal spacers (if used) (Figure 59).

If necessary, introduce Non-Headed Pins in the sequence

displayed (Figure 59):

1. Anterior

2. Contralateral distal

3. Anterior

4. Distal

Note: Care should be taken not to insert pins too far

into anterior bone.

Remove the notch bushing and the threaded shaft (if

used). Ensure the Notch Guide orientation does not

change and the Notch Guide is still rigidly fixed in place.

Note: The length of the intercondylar box differs

for the P.F.C. SIGMA Stabilized and TC3 femoral

components. Care should be taken to ensure that

the appropriate cut is made through the Notch

Guide.

The TC3 box cut is made through the proximal surface

of the anterior Notch Guide (through the slot) and

the Stabilized or PS box cut is made on top of the

slot (Figure 60). Perform the resection either with

an Oscillating Saw and a ½’inch wide blade or a

Reciprocating Saw (Figure 60).

TC3 and STAB markings

3

4

2

1

FEMORAL TRIAL ASSEMBLY

38 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

3

2

1

4

Figure 61

Figure 62

Figure 63 Figure 64

The Femoral Component Box Assembly

1) Place the two outrigger tabs of the box trial into

the recesses of the posterior condyles on the

corresponding size trial femoral component (Figure

61).

2) Insert the two anterior tabs into the recesses of the

anterior flange (Figure 62). If the anterior tabs won't

fit, take the box out, insert the Screwdriver into the

hex head and rotate counter clockwise, then reinsert.

3) Using the Screwdriver, adjust the hex screw at the

posterior of the box trial until a "click" is heard from

the Screwdriver (Figure 63).

4) Adjust the Femoral adapter position to the

corresponding position 0 (Neutral), +2 (Fem Post), or

-2 (Fem Ant and Right/Left (R/L)) from the Revision

4-in-1 Cutting Block and the notch guide bushing.

(Pull up then translate to desired position (Figure

64). This can be done by hand or with the Femoral

Adaptor Shift Tool. For further instructions, see Page

38 on how to adjust this positioning).

Note: Using the Screwdriver, tighten the hex screw

until a "click" is heard from the Screwdriver. This

will ensure secure assembly of the Box Trial to the

Femoral Trial. Do not overtighten the Screw or

attempt to remove the Screw from the Box Trial as

this will result in damage to the Box Trial

attachment.

Note: Do not over-loosen the Hex Screw when

disassembling the femoral trial construct. The

Screwdriver does not limit torque in the reverse

direction.

FEMORAL TRIAL ASSEMBLY

If the box trial adapter orientation needs to be adjusted,

pull the adapter up and rotate 180 degrees to set the

orientation to left or right. The correct orientation

marking will be pointing towards the posterior condyles

of the trial femoral component and will be indicated by

an L for left and an R for right (Figure 65).

Ensure that the A/P positioning is correct. There are

indicators on the side of the box to indicate +2 (which

shifts the femoral component posteriorly/closes the

flexion space), 0 (neutral), and -2 (which shifts the

femoral component anteriorly/opens the flexion space)

(Figure 65). This positioning should match the A/P

setting established on the Revision 4-in-1 Block.

Note: To change the positioning, pull up on

the Adapter and move the Adapter forward or

backwards on the box until the desired +2, 0, or -2

location is reached. If this adjustment is difficult the

Femoral Adapter Shift Tool may be used to aid in

setting this adjustment (Figure 66).

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 39

Figure 65

2

1

2

Figure 66

To adjust the setting:

1. Pull up

2. Translate posterior

or anterior

1

To adjust the

L/R setting:

1. Pull up

2. Rotate Adapter

180 degrees

Trial assembly order

(with sleeve and stem use, see Figure 67):

· Assemble HP Revision TC3 Box Trial to the

corresponding size Femoral Trial

· Assemble sleeve trial over adapter trial

· Partially tighten HP Revision Sleeve Bolt Trial with the

Screwdriver to hold the construct in place

· Add stem trial to trial assembly

· Add posterior and distal augment trials, if needed

· Seat trial assembly on femur

· Once sleeve trial has achieved proper orientation,

completely tighten with the Screwdriver until the

"click" is heard

After assembling the HP Revision TC3 Box Trial to the

femoral trial, set the femoral adapter on the box trial to

the correct side (Left or Right) and position (+2,0,-2 mm)

from the 4-in-1 Cutting Block and Notch Guide Bushing

(Figure 67 - Step 1). Assemble the femoral sleeve trial

corresponding in size to the final broach employed to

the TC3 femoral trial assembly (Figure 67 - Step 2) and

pass the HP Sleeve Bolt Trial through the hole in the box

of the distal femoral trial and partially tighten using the

Screwdriver (Figure 67 - Step 3). Make sure to properly

orient the sleeve trial with the narrow side facing

medially. Assemble the proper stem trial to the sleeve

trial (Figure 67 - Step 4).

Note: Trial bolt lengths are different for adapter/

sleeve use than for adapter/stem-only use, the bolt

trials are marked accordingly "SLEEVE BOLT" or

"STEM BOLT".

Note: Do not completely tighten down the bolt prior

to seating the trial construct into the canal. Leave

the sleeve slightly loose so that it finds its proper

rotation/orientation as it is being inserted into the

canal.

40 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

FEMORAL TRIAL ASSEMBLY

– SLEEVE AND STEM USE

Figure 67

Step 3

Step 1

Step 2

Step 4

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 41

Figure 69

FEMORAL TRIAL ASSEMBLY – SLEEVE AND STEM USE

Figure 68

The sleeve bolt mechanical connection to the sleeve trial/

adapter/femoral trial construct helps to ensure that the

parts do not disassociate during use.

Note: Please consult the anterior width chart on

page 64 (in the Appendix) to determine the sleeve/

femoral component compatibility and the distance

between the anterior chamfer and the anterior

aspect of the sleeve.

Where augmentation is employed, assemble the

appropriate trial distal and posterior augmentation

components to the trial femoral component

(Figure 68).

Remove the sleeve broach with the broach handle.

Seat the femoral trial in the femur. The sleeve trial will

achieve the rotation and orientation of final broach

used. After the femoral trial with sleeve is seated

securely in the metaphysis, tighten the sleeve bolt trial

with the screwdriver until the "click" is heard (Figure

69).

42 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Trial assembly order (with stem-only use, Figure 70):

· Assemble HP Revision TC3 Box Trial to the

corresponding size femoral trial

· Tighten HP Revision Stem Bolt Trial

with the Screwdriver

· Add stem trial to trial assembly

· Add posterior and distal augment trials, if needed

· Seat trial assembly on femur

After assembling the HP Revision TC3 Box Trial to the

Femoral Trial, set the Femoral Adapter on the box trial to

the correct side (Left or Right) and position (+2,0,-2 mm)

from the Revision 4-in-1 Cutting Block and Notch Guide

Bushing (Figure 70 - Step 1). Pass the Stem Bolt Trial

through the hole in the box of the distal femoral trial

and tighten using the HP Revision Screwdriver (Figure 70

- Step 2). Assemble the proper stem trial to the box trial

(Figure 70 – Step 3).

Note: Trial bolt lengths are different for adapter/

sleeve use than for adapter/stem-only use, the bolt

trials are marked accordingly "SLEEVE BOLT" or

"STEM BOLT".

The stem bolt mechanical connection to the Adapter/

Femoral Trial construct helps to ensure that the parts do

not translate during use.

Where augmentation is employed, assemble the

appropriate trial distal and posterior augmentation

components to the trial femoral component.

Seat the femoral trial in the femur.

Note: The stem bolt must be used for a stem only

trial. Failure to use the stem bolt will result in an

inaccurate reading of varus/valgus stability during

trialing.

Step 2

Step 1

Step 3

Figure 70

FEMORAL TRIAL ASSEMBLY – STEM-ONLY USE

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 43

Trial assembly order (with Sleeve-only use, Figure 71):

· Assemble HP Revision TC3 Box Trial to the

corresponding size Femoral Trial

· Assemble sleeve trial over adapter trial

· Partially tighten HP Revision Sleeve Bolt Trial

with the Screwdriver to hold the construct in place

· Add posterior and distal augment trials, if needed

· Seat trial assembly on femur

· Once sleeve trial has achieved proper orientation,

completely tighten with the Screwdriver until the

"click" is heard

After assembling the HP Revision TC3 Box Trial to the

femoral trial, set the femoral adapter on the box trial to

the correct side (Left or Right) and position (+2,0,

-2 mm) from the Revision 4-in-1 Cutting Block and

Notch Guide Bushing (Figure 71 - Step 1). Assemble the

femoral sleeve trial corresponding in size to the final

broach employed to the TC3 Femoral Trial assembly

(Figure 71 - Step 2) and pass the HP Revision Sleeve Bolt

Trial through the hole in the box of the distal femoral

trial and partially tighten using the Screwdriver (Figure

71 - Step 3). Make sure to properly orient the sleeve trial

with the narrow side facing medially. Do not completely

tighten down the bolt. Leave the sleeve trial slightly

loose so that it find its proper rotation/orientation as it is

being inserted into the canal.

Note: Trial bolt lengths are different for adapter/

sleeve use than for adapter/stem-only use, the bolt

trials are marked accordingly "SLEEVE BOLT" or

"STEM BOLT".

FEMORAL TRIAL ASSEMBLY – SLEEVE-ONLY USE

Figure 71

Step 3

Step 1

Step 2

44 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

FEMORAL TRIAL ASSEMBLY – SLEEVE-ONLY USE

The sleeve bolt mechanical connection to the adapter/

femoral trial construct helps to ensure that the parts do

not disassociate during use.

Note: Please consult the anterior width chart

on page 64 (in the Appendix) to determine the

sleeve/femoral component compatibility and the

distance between the anterior chamfer and the

anterior aspect of the sleeve.

Where augmentation is employed, assemble the

appropriate trial distal and posterior augmentation

components to the trial femoral component. Remove

the sleeve broach with the broach handle. Seat the

femoral trial in the femur. The sleeve trial will achieve

the rotation and orientation of final broach used. After

the sleeve trial is seated securely in the metaphysis,

tighten the sleeve bolt trial with the screwdriver until the

"click" is heard.

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 45

FINAL PREPARATION OF THE TIBIA

Figure 73

Figure 72

Assess proximal tibial coverage and rotation of tibial

component. Impact the appropriate Keel Punch (utilize

the cemented Keel Punch if a cement mantle is desired

or the press-fit Keel Punch if line-to-line contact is

desired) (Figure 72). The base plate should be positioned

to provide the best coverage of the tibial condylar

surface.

Leave the Keel Punch in place for trial reduction and

insert the polyethylene Trial (Figure 73).

Note: PS or CR M.B.T. Insert Trials may be used at

this point to assess construct stability. Using these

trials will allow easier insertion onto the keel and

will provide a better idea on how well the gaps are

balanced.

46 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

PREPARATION OF THE PATELLA

Where replacement of the patellar component is

indicated, it is important that the anteroposterior

dimension be maintained and that adequate bone

stock be preserved. Problems arise from inadequate,

excessive or uneven resection resulting in abnormal

anteroposterior dimension to the complex, subsequent

patellar tilt and implant wear.

Free sufficient soft tissue at the prepatellar bursa to

position Calipers at the anterior cortex.

Where residual bone stock is adequate, implantation of

the replacement prosthesis is essentially routine. Where

inadequate, patelloplasty may be indicated.

Note: The normal anteroposterior patellar

dimension is 22–24 mm in the female, 24–26 mm in

the male (Figure 74).

Figure 74

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 47

PREPARATION OF THE PATELLA

Figure 75

Figure 76

Meticulous disruption of the bone/prosthesis interface

is essential. It is performed with thin Osteotomes and

thin Oscillating Saw Blades. Avoid excessive leverage to

minimize possible fracturing.

Position the Patellar Template that most adequately

covers the prepared surface along the horizontal axis

of the patella and firmly engage. Fashion the three

holes for the fixation pegs of the component with the

appropriate drill (Figure 75). Depth is governed by the

collar.

Implanting the Patellar Component

Perform patellar implantation when convenient.

Cleanse the site with pulsatile lavage, dry, and apply

methyl methacrylate cement. Insert the component into

the prepared holes and position thePatellar Clamp.

The clamp is designed to fully seat and stabilize the

implant. Position it with the silicone O-ring centered

over the articular surface of the implant and the metal

backing plate against the anterior patellar cortex,

avoiding skin entrapment. When snug, the handles are

closed and held by the ratchet until polymerization is

complete (Figure 76). Avoid excessive compression as

it can fracture osteopenic bone. Remove all extruded

cement with a Curette.

Tibial Sleeve Assembly

Note: It is imperative to assemble the sleeve prior to

stem attachment.

Note: Sleeves and step wedges can only be used

together if using a 29 mm Sleeve.

Remove trial component in one piece (use as guide for

assembly of implants).

Place the M.B.T. Revision Tray on a firm, stable, padded

surface. Set the tibial sleeve in an orientation that

matches the prepared canal. Matching the orientation of

the tray/sleeve trial is helpful in determining appropriate

rotation of the final tibial tray/sleeve implant (Figure 77).

The sleeve can rotate 20 degrees internally or externally.

Using the Sleeve Impactor and a mallet, impact the

sleeve onto the M.B.T. Revision Tray. Deliver several

strikes to engage the two components (Figure 78).

Stem Component Assembly

Attach the stem extension to the prosthetic tray using

the two appropriate wrenches to ensure full

engagement (Figure 79).

48 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

IMPLANT ASSEMBLY - TIBIA

Figure 77 Figure 78

Figure 79

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 49

Implanting the Tibial Component

Thoroughly cleanse the site with pulsatile lavage.

Perforate with small drill holes on the prepared tibial

surface to facilitate penetration of methyl methacrylate

cement (Figure 80). Pack residual small cavitary bone

defects with cancellous autograft, if available, or

allograft.

Apply methyl methacrylate cement to the proximal tibial

surface (Figure 81) or directly to the underside of the

tibial tray component.

When a fluted stem or a fluted stem with a metaphyseal

sleeve is used, ensure the medullary canal remains free

of cement. Clear all extruded cement with a curette.

Seat the tibial implant construct into the prepared tibia

by impacting the RP Tray Impactor and Universal Handle

assembly (Figure 82).

TIBIAL IMPLANTATION

Figure 82

Figure 80 Figure 81

50 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Remove the assembled femoral trial components and

clean the site thoroughly using pulse lavage before

implantation. Before prostheses implantation proceeds,

attach all augments, sleeves and modular stems to the

femoral component.

Pass the appropriate P.F.C. SIGMA Femoral Adapter

Bolt, neutral or +/-2 mm, corresponding to the position

selected for the Revision 4-in-1 Cutting Block and the

bushing for the notch guide through the hole of the

distal femoral component and into the P.F.C. SIGMA

Femoral Adapter (Figure 83).

IMPLANT ASSEMBLY – SIGMA FEMORAL ADAPTER

Figure 83

Arrow Indicator Box Trial Final Implant

+2 mm

0 mm

-2 mm

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 51

Tighten the construct until the base of the adapter is

flush with the femoral box. The three A/P etch marks

on the base of the adapter implant should face laterally.

From the posterior view of the assembly, the angle

(5 degrees) and orientation (L or R) will be legible

(Figure 84).

Attach the P.F.C. SIGMA Femoral Adapter holding

clamp to the femoral implant and tighten it. The clamp

provides the second moment arm needed to assemble

the parts. Place the torque wrench over the P.F.C. SIGMA

Femoral Adapter implant and move it clockwise to

tighten the adapter to the femoral implant

(Figure 84). The torque wrench has a deflection beam,

which indicates when sufficient torque has been applied

(Figure 85).

Note: Torque the assembly to the 270 in. lb mark on

the torque wrench to ensure proper assembly torque

(Figure 85).

IMPLANT ASSEMBLY – SIGMA FEMORAL ADAPTER

Figure 84

Figure 85

52 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

IMPLANT ASSEMBLY – SIGMA FEMORAL AUGMENTS

Figure 87

Figure 86

Attach the femoral augments using the wobble bits

included in the augment package. Attach the femoral

augments to the femoral component using the augment

T-handle provided (Figures 86 and 87).It may be

necessary to use the T-handle extension in conjunction

with the T-handle to attach the augments.

Fully seat the augments on the component before

tightening the screw thread mechanism. Carefully

tighten with the large T-handle Torque Driver until an

audible "click" is discerned.

The augment assembly sequence is shown below. For

implant assembly: sleeve and stem proceed to page 51,

stem-only proceed to page 53, and sleeve-only proceed

to page 54.

Assembly Rules for Femoral Augmentation

1. For Size 1.5 Femoral Components

· Distal augmentation component augments in

4, 8 and 12 mm thicknesses

· Assemble last

2. For Size 4n PS Femoral Components

· Use size 2 distal and posterior augments

3. For 4 mm/8 mm Augments

· They are fully interchangeable

· If using 4 mm or 8 mm distal with posterior augment,

install distal first

4. For 12 mm/16 mm Distal Augment

· Use 16 mm distal augment with TC3 femoral only

· Femoral stem is indicated

· On size 2, 2.5 and 3 femoral component, use

4 mm posterior only

· On size 4, 5 femoral component, may use 4

or 8 mm posterior

(Note: No size 6 augments available - use size 5

distal augments and size 3 posterior augments

with size 6 femoral component)

· If using with posterior augment, install posterior

augment first

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 53

Implant Assembly - Sleeve and Stem Use

Implant assembly order (with sleeve and stem use):

· Femoral adapter-to-femoral component

· Add posterior and distal augments, if necessary

· Sleeve-to-stem

· Sleeve construct-to-femoral adapter construct

To attach the Universal Stem to the universal femoral

sleeve, thread the stem onto the sleeve. Grasp the sleeve

with the tibial sleeve clamp and use the stem Extension

Wrench to grasp the Universal Stem and tighten

(Figure 88).

Apply sufficient force to both wrenches to ensure that

the stem is secure.

Place the femoral component with the femoral adapter

on a firm, stable surface. Place the appropriate sleeve

and stem construct on top of the femoral adapter

assembly (Figure 89).

Use the sleeve and femoral trial construct trial to help

set the final sleeve and femoral component implant

rotation.

Figure 88

IMPLANT ASSEMBLY – SLEEVE AND STEM USE

Figure 89

54 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

IMPLANT ASSEMBLY – SLEEVE AND STEM USE

Slide the femoral stem/sleeve impactor on top of the

stem and forcefully apply three strikes with a mallet to

engage the two component assemblies (Figure 90).

Note: The femoral stem/sleeve Impactor has two

uses, one end for use of a sleeve without a stem

extension and one end for a sleeve and stem

combination.

The definitive components are implanted in the

following order:

· Tibial tray (with stem, sleeve and/or wedges)

· Femoral component (with stem, sleeve and/or

augments)

· SIGMA Rotating Platform PS or TC3 inserts

Implant the femoral component using the Femoral

Impactor (Figure 91).

Figure 91

Figure 90

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 55

IMPLANT ASSEMBLY – STEM-ONLY USE

Figure 93

Figure 92

Implant Assembly - Stem Only

Implant assembly order (with Stem-only use):

· Femoral adapter-to-femoral component

· Add posterior and distal augments, if necessary

· Stem-to-femoral adapter

To attach the Universal Stem to the P.F.C. SIGMA

Femoral Adapter, thread the stem onto the adapter.

With the P.F.C. SIGMA Femoral Adapter holding clamp

in place, use the Stem Extension Wrench to grasp the

Universal Stem and tighten (Figure 92). Apply sufficient

force to both the P.F.C. SIGMA Femoral Adapter holding

clamp and Stem Extension Wrench to ensure that stem

is secure.

The definitive components are implanted in

the following order:

· Tibial Tray (with stem, sleeve and/or wedges)

· Femoral component (with stem and/or augments)

· SIGMA Rotating Platform PS or TC3 inserts

Implant the femoral component using the Femoral

Impactor (Figure 93).

56 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

IMPLANT ASSEMBLY – SLEEVE-ONLY USE

Implant Assembly - Sleeve Only

Implant assembly order (with sleeve-only use):

· Femoral adapter-to-femoral component

· Add posterior and distal augments, if necessary

· Sleeve-to-femoral adapter

Slide the femoral stem/sleeve Impactor on top of

the sleeve and forcefully apply three strikes with a Mallet

to engage the two components (Figure 94).

Note: The femoral stem/sleeve impactor has

two uses, one end for the sleeve without a stem

extension and one end for a sleeve and stem

combination.

The definitive components are implanted in

the following order:

· Tibial tray (with stem, sleeve and/or wedges)

· Femoral component (with sleeve and/or augments)

· SIGMA Rotating Platform PS or TC3 inserts

Implant the femoral component using the femoral

impactor.

Figure 94

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 57

Place the Revision Trial Post into the cone of the M.B.T.

Revision implant. Seat the appropriate trial insert in the

trial post/tray (Figure 95).

Assemble the appropriate femoral implant construct

(see pages 51-54), apply the appropriate cementation

technique and impact the femoral implant construct into

the prepared femur.

Fully extend the knee to maintain pressure as the cement

polymerizes (Figure 96).

Note: With constrained femoral and tibial

components in trial reduction, it may be

appropriate to cement the tibial tray implant and

the femoral implant using the insert trial. This will

allow visibility of final rotation.

Note: PS or CR M.B.T. Insert Trials may be used in

the place of TC3 insert trials during this step. Using

these trials will allow easier insertion onto the keel

and will provide a better idea on how well the gaps

are balanced.

FINAL TRIAL WITH IMPLANTS

Revision Trial Post

Figure 95

Figure 96

58 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

APPENDIX 1: THE CEMENTED TIBIAL

STEM EXTENSIONS

Cemented Stem Reamer

Align the tibial tray and secure with two Fixation Pins

inserted through the holes designated (Figure 1).

Seat the M.B.T. Revision Drill Bushing onto the tibia trial.

Place in the posterior holes.

Place the cemented drill bushing into the M.B.T. Revision

Drill Bushing (Figure 2).

Use the “cemented” reamer to ream to the

predetermined selected depths for tray only or the tray

with a 30 or 60 mm cemented stem.

Remove the reamer and “cemented” bushing, leaving

the tray trial and M.B.T. Revision Drill Bushing in place

(Figure 3).

Note: Only a 13 mm diameter cemented stem should

be used in conjunction with the M.B.T. Revision Tray

to avoid a step off at the stem/tray junction.

Cemented

Drill Bushing

M.B.T. Revision

Drill Bushing

Figure 1

Figure 2 Figure 3

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 59

APPENDIX 1: THE CEMENTED TIBIAL

STEM EXTENSIONS

Tapered Reamer

Assemble the revision reamer adapter onto the

cemented tapered reamer.

Next, attach the modified Hudson Adapter to the

tapered reamer, if power reaming.

Attach the appropriately sized cemented stem trial

(13 x 30 mm or 13 x 60 mm) to the tapered reamer, if

utilizing a cemented stem extension (Figure 4). Ream

until the revision reamer adapter is flush with the M.B.T.

Revision Drill Bushing (Figure 5).

Note: To avoid stem trial disengagement,

do not reverse ream.

Figure 4

Figure 5

Modified Hudson Adapter

Revision Reamer Adapter

60 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

APPENDIX 1: THE CEMENTED

TIBIAL STEM EXTENSIONS

Tapered Cemented Stems

Note: Tapered cemented stem sizes 13 x 90/120/150

mm are compatible with M.B.T. Revision Trays.

Ream the canal with a reamer two sizes larger than the

stem. Ream the medullary canal with a 15 mm reamer

to implant a 13 mm tapered cemented stem, which

allows for a 1 mm circumferential cement mantle at the

proximal end of the stem. The cement mantle will be

greater around the distal end of the cemented tapered

stem (3 mm per side).

This provides the following benefits:

· Thicker cement mantle distally helps assure that a

circumferential mantle is present and reduces the

possibility of thin or non-existent cement coverage of

the stem distally

· Stresses are greatest at the tip of the stem. A larger

cement mantle is advantageous in dissipating these

stresses. Thinner cement mantles are more prone to

breakdown when exposed to higher stresses

Tibial Keel Preparation

Place the knee in full extension and determine

appropriate rotation of the tibial tray. Mark the

appropriate rotation with electrocautery on the anterior

tibial cortex at the center and sides of the alignment

handle.

Assemble the appropriate stem trial to the M.B.T.

Revision Tray Trial and seat in the prepared bone bed.

Impact the cemented keel punch (Figure 6).

Disconnect the Universal Handle leaving the Keel Punch

in place for trial reduction (if appropriate).

It is recommended that a Cement Restrictor be placed at

the appropriate level prior to cementing the component.

Use a Cement Gun to fill the canal with methyl

methacrylate.

Figure 6

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 61

Step Wedge Augmentation

Resection for supplementary tibial augmentation

may be based on the established position of the

trial tray. Remove the femoral trial to provide greater

access. Confirm rotational alignment of the Tibial Tray

Stem Trial. Secure the tray with two Fixation Pins.

Attach the tray trial wedge cutting attachment with the

Step Wedge Cutting Guide to the trial tray. The Step

Wedge Cutting Block allows for a 5, 10, or 15 mm step

wedge preparation, as necessary. Slide the block forward

to the anterior proximal tibia and secure in place with

two Steinmann Pins through the holes marked with

(Figure 1).

Unlock the block and slide the assembly out of the

block. Disconnect the handle from the trial tray

(Figure 2).

Figure 2

APPENDIX 2: STEP WEDGE PREPARATION

Figure 1

62 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

APPENDIX 2: STEP WEDGE PREPARATION

Trim the tibia accordingly with an Oscillating Saw so the

cut does not extend beyond the central riser (Figure 3).

Remove the block and pins.

Assemble the trial wedge to the appropriate tibial tray

trial (Figure 4) and introduce into the prepared site.

Perform minimal correction with a Bone File where

indicated to ensure maximal contact.

Figure 3

Figure 4

Step Wedge

Cutting Block

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 63

Figure 7

Figure 5 Figure 6

APPENDIX 2: STEP WEDGE PREPARATION

Confirm positioning, alignment and security of the tray

assembly. If there is old cement or sclerotic bone, remove

this first with a saw blade or burr prior to punching.

Position the M.B.T. Revision Tibial Keel Punch at the tray

and cancellous bone interface and impact into the keel

configuration (Figure 5). Leave the punch in place and

perform a final trial reduction if necessary.

Note: Utilize the “cemented” keel punch when a

cement mantle is desired.

Alternative Step Wedge Preparation

This is a “free-hand” resection. Assemble the wedge

trial and stem trial to the tibial tray trial. Position the

device slightly proximal to the planned resection level.

Make a conservative “free-hand” wedge resection and

then check cuts with the trials (Figure 6).

Wedge Implant Assembly

Note: To aid wedge implant assembly, attach wedge

prior to stem attachment.

Assemble the designated wedge to the tray and secure

using the appropriate screw. Carefully tighten with the

large T-handle torque driver until an audible "click" is

discerned, ensuring a full and permanent interlock

(Figure 7).

64 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

After impacting the cement or press-fit keel punch,

remove the keel punch. Insert the M.B.T. Thick Tray Trial

Adapter (15 or 25 mm) onto the tibial tray trial (Figures

1 and 2).

Note: The tibial tray trial must be used with the

thick tray adapters as the two pieces equal the

appropriate sizing – 15 or 25 mm.

Perform the final trial reductions utilizing the same

technique as the standard M.B.T. Revision Tray. Implant

assembly and implantation is also the same as with the

standard M.B.T. Revision Tray. If utilizing a wedge, refer

to the step wedge preparation in Appendix 2.

Note: A tibial wedge can be used with all thick tray

sizes, except for size 2. Sleeves may be used with all

thick trays.

Note: Due to the taper, trial with appropriate tray

trial size. For example, a size 4 thick tray tapers

down to a size 2. Use the size 2 tray trial with the

size 4 thick tray adapter. The size 3 thick tray

tapers down to a size 1. And the size 2 thick tray

tapers down to a size 0. The size 0 tray trial can be

found in the M.B.T. thick tray instrument set. Figure 1

Figure 2

APPENDIX 3: THICK TRAY PREPARATION

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 65

APPENDIX 4: FEMORAL REVISION AND

MBT REVISION TRAY COMPATIBILITY

FEMORAL COMPONENTS

Size 1.5

53AP/57ML

Size 2

56AP/60ML

Size 2.5

59AP/63ML

Size 3

61AP/66ML

Size 4N

65AP/66ML

Size 4

65AP/71ML

Size 5

69AP/73ML

Size 6

74AP/78ML

PS TC3 PS TC3 PS TC3 PS TC3 PS ** PS TC3 PS TC3 PS **

M.B.T

REVISION TRAYS

Size 1

39AP/59ML X X

Size 1.5

41AP/62ML XXXX

Size 2

43AP/65ML XXXXXX

Size 2.5

44AP/67ML XXXXXX

Size 3

46AP/70ML XXXXX XX

Size 4

49AP/75ML XXX XXXX

Size 5

53AP/81ML X XXXXX

Size 6

57AP/87ML XXX

**TC3 FEMURS ARE NOT AVAILABLE IN SIZE 4N OR 6

Note: RP insert must match femur size for size.

Note: For a size 4N femur, use a size 4 RP insert.

M.B.T. Revision Trays

· Made of Cobalt Chrome

· Tray thickness is 4.8 mm

M.B.T. Revision Thick Trays

· Made of Cobalt Chrome

· Tray thickness is 15 mm and 25 mm

· All thick trays taper distally by two sizes

to match tibial anatomy.

M.B.T. Revision Thick Tray Sizing Chart

Size 2 Size Three Size Four

Proximal size two size three size four

Distal size zero

(38ap/54ml) size one size two

66 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

APPENDIX 5: SIGMA REVISION

ANTEROPOSTERIOR CHART (WITH SLEEVE USE)

The following chart shows the distance (mm) between

the anterior flange of a femoral component and the

sleeve, based on the size of the component and the

anteroposterior option chosen. Fields with an X denote

that the sleeve, femoral component and offset option is

not possible.

Femoral Size and A/P Position

1.5

Ant

1.5

Neut

1.5

Post

2

Ant

2

Neut

2

Post

2.5

Ant

2.5

Neut

2.5

Post

3

Ant

3

Neut

3

Post

Size of sleeve (M/L)

20 mm 0.9 2.7 4.7 1.8 3.8 5.8 2.6 4.6 6.6 3.2 5.2 7.2

31 mm 2.1 4.5 5.8 2.7 5.0 7.0 3.8 5.8 7.8 4.6 6.7 8.6

34 mm X 3.4 4.6 2.1 4.4 5.9 3.2 5.2 7.0 3.6 5.7 7.6

40 mm X 2.4 3.9 1.2 3.2 5.6 2.0 3.9 6.0 2.7 4.6 6.5

46 mm X 2.6 3.6 X 2.6 4.8 1.5 3.6 5.5 2.4 4.6 6.4

Femoral Size and A/P Position

4

Ant

4

Neut

4

Post

5

Ant

5

Neut

5

Post

6

Ant

6

Neut

6

Post

Size of sleeve (M/L)

20 mm 4.9 6.9 8.9 6.4 8.4 10.4 8.5 10.5 12.5

31 mm 6.3 8.3 10.2 7.8 9.7 11.8 9.9 11.9 13.9

34 mm 5.3 7.3 9.3 6.8 8.9 10.8 8.8 10.9 13.0

40 mm 4.2 6.1 8.1 5.6 7.6 9.6 7.8 9.9 11.8

46 mm 4.3 6.2 8.2 5.7 7.6 9.6 7.9 9.9 11.7

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 67

SIGMA HP REVISION FEMORAL PREP INSTRUMENT

CASE CAT. NO. 2011-03-049

Description Cat. No.

A SIGMA HP Revision 4-in-1 Cutting Block Size 2 2011-03-000

SIGMA HP Revision 4-in-1 Cutting Block Size 2.5 2011-03-001

SIGMA HP Revision 4-in-1 Cutting Block Size 3 2011-03-002

SIGMA HP Revision 4-in-1 Cutting Block Size 4 2011-03-003

SIGMA HP Revision 4-in-1 Cutting Block Size 5 2011-03-004

B SIGMA HP Revision Notch Guide Size 2 2011-03-005

SIGMA HP Revision Notch Guide Size 2.5 2011-03-006

SIGMA HP Revision Notch Guide Size 3 2011-03-007

SIGMA HP Revision Notch Guide Size 4 2011-03-008

SIGMA HP Revision Notch Guide Size 5 2011-03-009

C SP2 Femoral Notch Guide Bushing 5 degree +2L/-2R 96-6531

SP2 Femoral Notch Guide Bushing 5 degree 0 mm offset 96-6532

SP2 Femoral Notch Guide Bushing 5 degree +2R/-2L 96-6533

D SP2 Removable Handles 96-6147

E Pin Caddy

F SIGMA HP Power Pin Driver 9505-02-071

G Distal Spacer Caddy

SIGMA HP Revision Distal Spacer 4 mm 2011-03-021

SIGMA HP Revision Distal Spacer 8 mm 2011-03-022

SIGMA HP Revision Distal Spacer 12 mm 2011-03-023

SIGMA HP Revision Distal Spacer 16 mm 2011-03-024

A

B

FG E D C

Top Tray

68 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Bottom Tray

SIGMA HP REVISION FEMORAL PREP INSTRUMENT

CASE CAT. NO. 2011-03-049

Description Cat. No.

A Visualization Wing 96-6530

B Completion Revision Femoral Tapered Reamer 2178-60-030

C Universal Revision Femoral Broach Reamer 96-1671

D Universal Revision Femoral Broach 31 mm 96-1683

E Universal Revision Femoral Broach 34 mm 96-1684

F Universal Revision Femoral Broach 40 mm 96-1685

G Universal Revision Femoral Broach 46 mm 96-1686

H SIGMA HP Revision Adapter Removable Shaft 2011-03-029

I SIGMA HP Distal Femoral Resection Guide 9505-01-235

J SIGMA HP Distal Femoral Connector 9505-01-238

K SIGMA HP Revision Distal Femoral Block 9505-01-239

L SIGMA HP Distal Femoral Alignment Guide 9505-01-234

M Universal Revision Femoral Broach Handle 96-1682

A

B C D

M

E F G

I

K

J

L

H

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 69

SIGMA HP REVISION FEMORAL TRIAL INSTRUMENT

CASE CAT. NO. 2011-03-050

Top Tray

Description Cat. No.

A LCS/SIGMA Revision Femoral Sleeve Trial 20 mm 2294-53-100

B LCS/SIGMA Revision Femoral Sleeve Trial 31 mm 2294-53-110

C LCS/SIGMA Revision Femoral Sleeve Trial 34 mm 2294-53-120

D LCS/SIGMA Revision Femoral Sleeve Trial 40 mm 2294-53-130

E LCS/SIGMA Revision Femoral Sleeve Trial 46 mm 2294-53-140

F Modular Plus Torque Driver 86-0284

G SIGMA HP Revision TC3 Box Trial Size 2 2011-03-011

H SIGMA HP Revision TC3 Box Trial Size 2.5 2011-03-012

I SIGMA HP Revision TC3 Box Trial Size 3 2011-03-013

J SIGMA HP Revision TC3 Box Trial Size 4 2011-03-014

K SIGMA HP Revision TC3 Box Trial Size 5 2011-03-015

L SIGMA HP Revision Femoral Adapter Shift Tool 2011-03-057

M SIGMA Femoral Adapter Sleeve Bolt Trial Neutral 2011-03-052

N SIGMA Femoral Adapter Stem Bolt Trial Neutral 2011-03-051

O Femoral Augment Plug Puller 86-5151

P SP2 Torque Driver Handle Extension 96-6301

Q Large Fragment Screwdriver Shank 8242-19-000

R 2.0 Nm Torque-limiting Screwdriver 2141-18-001

S Femoral Adapter Torque Wrench 96-1673

T Femoral Adapter Holding Clamp 96-1674

A B C

O

Q

P

R

N

M K

L

S

T

ED

F G H I J

70 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Bottom Tray

SIGMA HP REVISION FEMORAL TRIAL INSTRUMENT

CASE CAT. NO. 2011-03-050

Description Cat. No

A PFC SIGMA C/R Femoral Left Size 2 Trial 96-1002

PFC SIGMA C/R Femoral Right Size 2 Trial 96-1012

B Size 2 Femoral Augment Trial Caddy

PFC SIGMA Distal Femoral Augment Trial 4 mm Size 2 96-1820

PFC SIGMA Distal Femoral Augment Trial 8 mm Size 2 96-1822

PFC SIGMA Posterior Femoral Augment Trial 4 mm Size 2 96-1826

PFC SIGMA Posterior Femoral Augment Trial 8 mm Size 2 96-1828

PFC SIGMA Distal Femoral Augment Trial 12 mm Size 2 96-1830

PFC SIGMA Distal Femoral Augment Trial 16 mm Size 2 96-1832

C PFC SIGMA C/R Femoral Left Size 2.5 Trial 96-1008

PFC SIGMA C/R Femoral Right Size 2.5 Trial 96-1018

D Size 2.5 Femoral Augment Trial Caddy

PFC SIGMA Distal Femoral Augment Trial 4 mm Size 2.5 96-1840

PFC SIGMA Distal Femoral Augment Trial 8 mm Size 2.5 96-1842

PFC SIGMA Posterior Femoral Augment Trial 4 mm Size 2.5 96-1846

PFC SIGMA Posterior Femoral Augment Trial 8 mm Size 2.5 96-1848

PFC SIGMA Distal Femoral Augment Trial 12 mm Size 2.5 96-1850

PFC SIGMA Distal Femoral Augment Trial 16 mm Size 2.5 96-1852

E PFC SIGMA C/R Femoral Left Size 3 Trial 96-1003

PFC SIGMA C/R Femoral Right Size 3 Trial 96-1013

B

A D E H I

C F J

G

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 71

SIGMA HP REVISION FEMORAL TRIAL CASE

CAT. NO. 2011-03-050

Bottom Tray

Description Cat. No

F Size 3 Femoral Augment Trial Caddy

PFC SIGMA Distal Femoral Augment Trial 4 mm Size 3 96-1860

PFC SIGMA Distal Femoral Augment Trial 8 mm Size 3 96-1862

PFC SIGMA Posterior Femoral Augment Trial 4 mm Size 3 96-1866

PFC SIGMA Posterior Femoral Augment Trial 8 mm Size 3 96-1868

PFC SIGMA Distal Femoral Augment Trial 12 mm Size 3 96-1870

PFC SIGMA Distal Femoral Augment Trial 16 mm Size 3 96-1872

G PFC SIGMA C/R Femoral Left Size 4 Trial 96-1004

PFC SIGMA C/R Femoral Right Size 4 Trial 96-1014

H Size 4 Femoral Augment Trial Caddy

PFC SIGMA Distal Femoral Augment Trial 4 mm Size 4 96-1880

PFC SIGMA Distal Femoral Augment Trial 8 mm Size 4 96-1882

PFC SIGMA Posterior Femoral Augment Trial 4 mm Size 4 96-1886

PFC SIGMA Posterior Femoral Augment Trial 8 mm Size 4 96-1888

PFC SIGMA Distal Femoral Augment Trial 12 mm Size 4 96-1890

PFC SIGMA Distal Femoral Augment Trial 16 mm Size 4 96-1892

I PFC*SIGMA C/R Femoral Left Size 5 Trial 96-1005

PFC SIGMA C/R Femoral Right Size 5 Trial 96-1015

J Size 5 Femoral Augment Trial Caddy

PFC SIGMA Distal Femoral Augment Trial 4 mm Size 5 96-1900

PFC SIGMA Distal Femoral Augment Trial 8 mm Size 5 96-1902

PFC SIGMA Posterior Femoral Augment Trial 4 mm Size 5 96-1906

PFC SIGMA Posterior Femoral Augment Trial 8 mm Size 5 96-1908

PFC SIGMA Distal Femoral Augment Trial 12 mm Size 5 96-1910

PFC SIGMA Distal Femoral Augment Trial 16 mm Size 5 96-1912

B

A D E H I

C F J

G

72 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Top Tray

SIGMA HP REVISION TC3 RP INSERT TRIAL

AND SPACER BLOCK CASE CAT. NO. 2011-03-070

Description Cat. No.

A TC3 RP Tibial Insert Trial Size 2 10 96-3321

TC3 RP Tibial Insert Trial Size 2 12.5 96-3322

TC3 RP Tibial Insert Trial Size 2 15 96-3323

TC3 RP Tibial Insert Trial Size 2 17.5 96-3324

TC3 RP Tibial Insert Trial Size 2 20 96-3325

B TC3 RP Tibial Insert Trial Size 2.5 10 96-3331

TC3 RP Tibial Insert Trial Size 2.5 12.5 96-3332

TC3 RP Tibial Insert Trial Size 2.5 15 96-3333

TC3 RP Tibial Insert Trial Size 2.5 17.5 96-3334

TC3 RP Tibial Insert Trial Size 2.5 20 96-3335

C TC3 RP Tibial Insert Trial Size 3 10 96-3341

TC3 RP Tibial Insert Trial Size 3 12.5 96-3342

TC3 RP Tibial Insert Trial Size 3 15 96-3343

TC3 RP Tibial Insert Trial Size 3 17.5 96-3344

TC3 RP Tibial Insert Trial Size 3 20 96-3345

D TC3 RP Tibial Insert Trial Size 4 10 96-3351

TC3 RP Tibial Insert Trial Size 4 12.5 96-3352

TC3 RP Tibial Insert Trial Size 4 15 96-3353

TC3 RP Tibial Insert Trial Size 4 17.5 96-3354

TC3 RP Tibial Insert Trial Size 4 20 96-3355

E TC3 RP Tibial Insert Trial Size 5 10 96-3361

TC3 RP Tibial Insert Trial Size 5 12.5 96-3362

TC3 RP Tibial Insert Trial Size 5 15 96-3363

TC3 RP Tibial Insert Trial Size 5 17.5 96-3364

TC3 RP Tibial Insert Trial Size 5 20 96-3365

A B C D E

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 73

Bottom Tray

A B C D E

F

G H I

K

J

Description Cat. No.

A TC3 RP Tibial Insert Trial Size 2 22.5 96-3326

TC3 RP Tibial Insert Trial Size 2 25 96-3327

TC3 RP Tibial Insert Trial Size 2 30 96-3328

B TC3 RP Tibial Insert Trial Size 2.5 22.5 96-3336

TC3 RP Tibial Insert Trial Size 2.5 25 96-3337

TC3 RP Tibial Insert Trial Size 2.5 30 96-3338

C TC3 RP Tibial Insert Trial Size 3 22.5 96-3346

TC3 RP Tibial Insert Trial Size 3 25 96-3347

TC3 RP Tibial Insert Trial Size 3 30 96-3348

D TC3 RP Tibial Insert Trial Size 4 22.5 96-3356

TC3 RP Tibial Insert Trial Size 4 25 96-3357

TC3 RP Tibial Insert Trial Size 4 30 96-3358

E TC3 RP Tibial Insert Trial Size 5 22.5 96-3366

TC3 RP Tibial Insert Trial Size 5 25 96-3367

TC3 RP Tibial Insert Trial Size 5 30 96-3368

F HP Alignment Rod 9505-01-207

G SIGMA HP Revision M.B.T. Spacer Block 10/12.5 2011-03-017

H SIGMA HP Revision M.B.T. Spacer Block 15/17.5 2011-03-018

I SIGMA HP Revision M.B.T. Spacer Block 20/22.5 2011-03-019

J SIGMA HP Revision M.B.T. Spacer Block 25/30 2011-03-020

K SIGMA HP Revision Extension Shim 2011-03-061

SIGMA HP REVISION TC3 RP INSERT TRIAL

AND SPACER BLOCK CASE CAT. NO. 2011-03-070

74 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Top Tray

A

C

D F

G

B

H

NM

L

I

E

J

K

Description Cat. No.

A M.B.T. Revision Cemented Stem Reamer, 13 mm 2178-63-185

B Tibial Cutting Block, 2 Degree 2178-40-086

C M.B.T Revision Reamer Adapter 2178-63-128

D M.B.T. Revision Press-fit Tibial Punch 2178-63-118

E M.B.T. Revision Cemented Tibial Punch 2178-63-120

F Pin Driver 2490-94-000

G M.B.T. Revision Drill Bushing 2178-63-100

H Pin Puller 96-6515

I SP2 IM Rod, 400 mm 96-6120

J SP2 IM Rod Handle 99-2011

K M.B.T. Revision Cemented Bushing, 13 mm 2178-63-196

L M.B.T. Revision Tapered Press-fit Reamer 2178-63-104

M M.B.T. Revision Tapered Cemented Reamer 2178-63-106

N Steinman Pins (Package of 10) 86-9117

M.B.T. REVISION PREPARATION CASE

CAT. NO. 2178-64-100

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 75

M.B.T. REVISION PREPARATION CASE

CAT. NO. 2178-64-100

Bottom Tray

A B C

E

DH

FI J

G

Description Cat. No.

A M.B.T. Revision 2-Degree Tibial Broaches 29 mm 2178-63-109

M.B.T. Revision 2-Degree Tibial Broaches 37 mm 2178-63-111

M.B.T. Revision 2-Degree Tibial Broaches 45 mm 2178-63-113

M.B.T. Revision 2-Degree Tibial Broaches 53 mm 2178-63-115

M.B.T. Revision 2-Degree Tibial Broaches 61 mm 2178-63-117

B M.B.T. Tray Sleeve Trials 29 mm 2294-54-000

M.B.T. Tray Sleeve Trials 37 mm 2294-54-100

M.B.T. Tray Sleeve Trials 45 mm 2294-54-110

M.B.T. Tray Sleeve Trials 53 mm 2294-54-120

M.B.T. Tray Sleeve Trials 61 mm 2294-54-130

C LCS Completion Tibial Stylus 2178-40-045

D M.B.T. Revision Tibial Broach Handle 96-6521

E Revision Sleeve Impactor 2178-63-124

F Revision Femoral Sleeve/Stem Impactor 2178-63-126

G SP2 Universal Handle 96-6520

H SP2 IM Tibial Alignment Device 96-6315

I M.B.T. Tibial Impactor 9505-01-558

J M.B.T. Revision Tibial View Plate, Size 1 2178-65-110

M.B.T. Revision Tibial View Plate, Size 1.5 2178-65-115

M.B.T. Revision Tibial View Plate, Size 2 2178-65-120

M.B.T. Revision Tibial View Plate, Size 2.5 2178-65-125

M.B.T. Revision Tibial View Plate, Size 3 2178-65-130

M.B.T. Revision Tibial View Plate, Size 4 2178-65-140

M.B.T. Revision Tibial View Plate, Size 5 2178-65-150

M.B.T. Revision Tibial View Plate, Size 6 2178-65-160

76 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

M.B.T. REVISION STEM TRIALS AND INSTRUMENTS

CASE CAT. NO. 2178-64-110

Top Tray

Description Cat. No.

A Revision Femoral/Tibial Sleeve Clamp 2178-63-134

B SIGMA Tibial Cemented Stem Trial, Sizes 2-3, 13 x 60 mm 86-6502

C SIGMA Tibial Cemented Stem Trial, Sizes 1.5-3, 13 x 30 mm 86-6501

D Stem Trial Extractor 86-5226

E Fluted Tibial Stem Trials – 75 mm

75 x 10 mm 86-6874

75 x 12 mm 86-6875

75 x 14 mm 86-6876

75 x 16 mm 86-6877

75 x 18 mm 86-6878

75 x 20 mm 86-6879

75 x 22 mm 86-6880

75 x 24 mm 86-6881

A

B F GE

C

D

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 77

M.B.T. REVISION STEM TRIALS AND INSTRUMENTS

CASE CAT. NO. 2178-64-110

Top Tray

Description Cat. No.

F Fluted Tibial Stem Trials – 115 mm

115 x 10 mm 86-6882

115 x 12 mm 86-6883

115 x 14 mm 86-6884

115 x 16 mm 86-6885

115 x 18 mm 86-6886

115 x 20 mm 86-6887

115 x 22 mm 86-6888

115 x 24 mm 86-6889

G Fluted Tibial Stem Trials – 150 mm

150 x 10 mm 86-6890

150 x 12 mm 86-6891

150 x 14 mm 86-6892

150 x 16 mm 86-6893

150 x 18 mm 86-6894

150 x 20 mm 86-6895

150 x 22 mm 86-6896

150 x 24 mm 86-6897

A

B F GE

C

D

78 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

M.B.T. REVISION STEM TRIALS AND INSTRUMENTS

CASE CAT. NO. 2178-64-110

Bottom Tray

Description Cat. No.

A Press-fit Rod Wrench 86-5189

B SIGMA Tibial Cemented Stem Trial, Sizes 2-3, 13 x 60 mm 86-6502

C SIGMA Tibial Cemented Stem Trial, Sizes 1.5-3, 13 x 30 mm 86-6501

D Fluted Tibial Stem Trials – 75 mm

75 x 10 mm 86-6874

75 x 12 mm 86-6875

75 x 14 mm 86-6876

75 x 16 mm 86-6877

75 x 18 mm 86-6878

75 x 20 mm 86-6879

75 x 22 mm 86-6880

75 x 24 mm 86-6881

A

B D E F

C

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 79

M.B.T. REVISION STEM TRIALS AND INSTRUMENTS

CASE CAT. NO. 2178-64-110

Bottom Tray

Description Cat. No.

E Fluted Tibial Stem Trials – 115 mm

115 x 10 mm 86-6882

115 x 12 mm 86-6883

115 x 14 mm 86-6884

115 x 16 mm 86-6885

115 x 18 mm 86-6886

115 x 20 mm 86-6887

115 x 22 mm 86-6888

115 x 24 mm 86-6889

F Fluted Tibial Stem Trials – 150 mm

150 x 10 mm 86-6890

150 x 12 mm 86-6891

150 x 14 mm 86-6892

150 x 16 mm 86-6893

150 x 18 mm 86-6894

150 x 20 mm 86-6895

150 x 22 mm 86-6896

150 x 24 mm 86-6897

A

B D E F

C

80 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

M.B.T. REVISION REAMERS CASE

CAT. NO. 2178-64-105

Description Cat. No.

A Press-fit Rod Wrench 86-5189

B IM Rod Sleeve Guide, 12 mm 2178-63-187

C IM Rod Sleeve Guide, 14 mm 2178-63-188

D LCS Reamer Depth Scale 2178-63-102

E Revision Femoral/Tibial/Sleeve Clamp 2178-63-134

F I.M. Reamer, 9 mm 2178-56-045

G M.B.T. Revision Reamers

M.B.T. Revision Reamer, 10 mm 2178-63-170

M.B.T. Revision Reamer, 11 mm 2178-63-171

M.B.T. Revision Reamer, 12 mm 2178-63-172

M.B.T. Revision Reamer, 13 mm 2178-63-173

M.B.T. Revision Reamer, 14 mm 2178-63-174

M.B.T. Revision Reamer, 15 mm 2178-63-175

Top Tray

A

D

G

F E

B C

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 81

Description Cat. No.

A M.B.T. Revision Reamers

M.B.T. Revision Reamer, 16 mm 2178-63-176

M.B.T. Revision Reamer, 17 mm 2178-63-177

M.B.T. Revision Reamer, 18 mm 2178-63-178

M.B.T. Revision Reamer, 19 mm 2178-63-179

M.B.T. Revision Reamer, 20 mm 2178-63-180

M.B.T. Revision Reamer, 21 mm 2178-63-181

M.B.T. Revision Reamer, 22 mm 2178-63-182

M.B.T. Revision Reamer, 23 mm 2178-63-183

M.B.T. Revision Reamer, 24 mm 2178-63-184

B IM Rod Sleeve Guide, 16 mm 2178-63-189

C IM Rod Sleeve Guide, 18 mm 2178-63-190

D IM Rod Sleeve Guide, 20 mm 2178-63-

191

E IM Rod Sleeve Guide, 22 mm 2178-63-192

F IM Rod Sleeve Guide, 24 mm 2178-63-193

G IM Rod Sleeve Guide, 26 mm 2178-63-194

H M.B.T. Revision T-Handle 2178-63-137

I Modified Hudson Adapter 2178-63-136

M.B.T. REVISION REAMERS CASE

CAT. NO. 2178-64-105

Bottom Tray

A

H

I

B

C

DF

EG

82 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

M.B.T. REVISION WEDGE TRIALS AND INSTRUMENTS

CAT. NO. 2178-64-115

Top Tray

Description Cat. No.

A Size 1, 5 mm 2294-56-110

Size 1, 10 mm 2294-56-111

Size 1, 15 mm 2294-56-112

B Size 1.5, 5 mm 2294-56-115

Size 1.5, 10 mm 2294-56-116

Size 1.5, 15 mm 2294-56-117

C Size 2, 5 mm 2294-56-120

Size 2, 10 mm 2294-56-121

Size 2, 15 mm 2294-56-122

D Size 2.5, 5 mm 2294-56-125

Size 2.5, 10 mm 2294-56-126

Size 2.5, 15 mm 2294-56-127

E Size 3, 5 mm 2294-56-130

Size 3, 10 mm 2294-56-131

Size 3, 15 mm 2294-56-132

F Size 4, 5 mm 2294-56-135

Size 4, 10 mm 2294-56-136

Size 4, 15 mm 2294-56-137

G Size 5, 5 mm 2294-56-140

Size 5, 10 mm 2294-56-141

Size 5, 15 mm 2294-56-142

H Size 6/7, 5 mm 2294-56-145

Size 6/7, 10 mm 2294-56-146

Size 6/7, 15 mm 2294-56-147

A B C D E F G H

Size 1

5 mm

10 mm

15 mm

5 mm

10 mm

15 mm

Size 1.5 Size 2 Size 2.5 Size 3 Size 4 Size 5 Size 6/8

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 83

M.B.T. REVISION WEDGE TRIALS AND INSTRUMENTS

CAT. NO. 2178-64-115

Bottom Tray

Description Cat. No.

A M.B.T. Revision Tray Trial, Size 1 2294-36-110

M.B.T. Revision Tray Trial, Size 1.5 2294-36-115

M.B.T. Revision Tray Trial, Size 2 2294-36-120

M.B.T. Revision Tray Trial, Size 2.5 2294-36-125

M.B.T. Revision Tray Trial, Size 3 2294-36-130

M.B.T. Revision Tray Trial, Size 4 2294-36-140

M.B.T. Revision Tray Trial, Size 5 2294-36-150

M.B.T. Revision Tray Trial, Size 6 2294-36-160

B M.B.T. Revision Tray Trial with Stem, Size 1 2294-35-110

C M.B.T. Revision Tray Trial with Stem, Size 1.5 2294-35-115

D M.B.T. Revision Tray Trial with Stem, Size 2 2294-35-120

E M.B.T. Revision Tray Trial with Stem, Size 2.5 2294-35-125

F M.B.T. Revision Cutting Block 2178-63-122

G Tibial Wedge Trial Screwdriver 86-0277

H M.B.T. Wedge Cutting Attachment 2178-63-130

I SP2 Alignment Rods 99-1016

J Tibial Trial Alignment Handle 96-6330

K M.B.T. Revision Trial Post 2178-63-132

L Modular Plus Torque Driver 86-0284

M M.B.T. Tray Trial Fixation Pins 2178-30-123

N M.B.T. Revision Tray Trial with Stem, Size 3 2294-35-130

O M.B.T. Revision Tray Trial with Stem, Size 4 2294-35-140

P M.B.T. Revision Tray Trial with Stem, Size 5 2294-35-150

Q M.B.T. Revision Tray Trial with Stem, Size 6 2294-35-160

A

B C

F

G

HIK

J

D E

M

QPON

L

84 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 85

86 SIGMA Revision and M.B.T. Revision Tray Surgical Technique

Surgical Technique SIGMA Revision and M.B.T. Revision Tray 87

DePuy Orthopaedics, Inc.

700 Orthopaedic Drive

Warsaw, IN 46582

T. +1 (800) 366-8143

www.depuysynthes.com

0612-51-506 (Rev. 5) 3M 10/13