Smith & Nephew LEGION Cones User manual

Surgical Technique

Indications
The LEGION Cones System is intended to be used with the LEGION Revision and LEGION Hinge
knee systems. The LEGION Cones are indicated for the following:
1. Rheumatoid arthritis
2.Post-traumatic arthritis, osteoarthritis, or degenerative arthritis.
3.Failed osteotomies, unicompartmental replacement, or total knee replacement.
4.Posterior stabilized knee systems are designed from use in patients in primary and revision
surgery, where the anterior and posterior cruciate ligaments are incompetent and the collateral
ligaments remain intact.
5.Constrained knee systems are designed for use in patients in primary and revision surgery,
where the posterior cruciate ligament and one or both of the collateral ligaments (i.e. medial
collateral and/or lateral collateral ligament) are incompetent.
6.Hinge knee systems are designed for use in patients in primary and revision surgery, where the
posterior cruciate ligament and one or both of the collateral ligaments (i.e. medial collateral and/
or lateral collateral ligament) are absent or incompetent.
These are single use implants and are intended for use with and without bone cement.
Nota bene
The technique description herein is made available to the healthcare professional to illustrate
the suggested treatment for the uncomplicated procedure. In the nal analysis, the preferred
treatment is that which addresses the needs of the patient.
LEGION™ Cones
Surgical Technique
Contents
Introduction ...................................................................................... 1
LEGION Cone Handle description ............................................. 1
Cone Handle – Sleeve Assembly.............................................. 2
Cone Handle – Broach Assembly ............................................. 3
Cone Handle Alignment ............................................................ 4
Implant and Trial deployment .................................................... 5
Surgical Technique
Tibial Cones .............................................................................. 6
Femoral Cones .......................................................................... 14
Appendix
Tibial Cones without Offset Couplers........................................ 20
Tibial Cones with Variable Positioning ...................................... 25

1
Figure 1
Figure 2
Introduction
The standard LEGION™ Tibial Cones surgical
technique is provided in the rst section followed
by the standard Femoral Cones surgical technique
in the second section. Two additional tibial surgical
technique variations are provided in the Appendix
to maximize the benets of using LEGION Cones.
Tibial Cone usage with Oset Couplers is often
associated with Presst Stems. In this technique,
emphasis is placed on controlling the placement
of the Cone’s internal diameter relative to an
intramedullary stem location and the Tibial
Tray location.
The Appendix contains additional techniques
for Tibial Cone usage without Oset Couplers,
as seen more commonly with the use of
Cemented Stems. These techniques will
take advantage of the size of the Cone’s
internal diameter to maximize the Cone’s
positional exibility.
The labeled sizes of the LEGION Cones are the
functional internal diameters (ID). The IDs are
relative to the functional diameters of LEGION
Press-Fit Stems including the 1mm diametrically
oversized cutting utes. For example, a size
22 ID LEGION Tibial Cone can accept up to a
22mm LEGION Press-Fit Stem without oset.
LEGION Cone Handle Description
All cone surgical techniques utilize the Cone
Handle (Figure 1). The Cone Handle ts over the
LEGION Revision Reamers or LEGION Trial Stem
Connection Rod and positions the broaches,
trials and nal implants in the proper positioning.
Various Cone Handle Sleeves are inserted into
the Cone Handle and oriented depending on the
surgical technique being utilized.
Seven Cone Handle Sleeves provide the variable
positioning control of the Cone Handle, which
allows the variations in surgical techniques for
the tibia. The Neutral Sleeve (Figure 2) aligns the
Cone Handle directly to the intramedullary canal.
This sleeve is used in the standard Femoral Cone
technique and the Tibial Cone without Oset
Couplers technique in the Appendix.

2
For Tibial Cones with Oset Couplers, the 2mm,
4mm and 6mm Oset Sleeves (Figure 3) are
used. These sleeves mimic the positioning
of the Oset Bushings in the LEGION RK and
LEGION HK surgical techniques.
In the Variable Positioning Technique, the 2mm,
4mm and 6mm Variable sleeves (Figure 4) are
utilized to provide additional positioning
freedom with Tibial Cones without the use
of oset couplers.
Figure 4
b
a
Figure 6
Figure 5
Figure 3
Cone Handle Assembly
Insert the desired sleeve into the Cone Handle
(Figure 5 and 6). Press the Sleeve capture button
(Figure 6a) to release the sleeve for orientation
or removal. The Cone Handle Oset Sleeves have
an orientation arrow to align to the appropriate
clocking line (Figure 6b) on the Cone Handle
referencing the clocking position of the Tibial
Sizing guide from the LEGION™ RK/HK technique.

3
b
a a
On the bottom end of the Cone Handle, align the
gold locking pin to the selected broach (Figure 7).
Retract the gold slide (Figure 8a) and engage the
Cone Handle with the Broach (Figure 8b).
Rotate the Broach a ¼ turn following the black
line (Figure 9). Release the gold slide (Figure 10).
Note: The Cone Broach Handle will only engage
in the direction described above.
To remove the Broach, reverse this method by
retracting the gold slide and reversing the ¼
turn following the black line.
Figure 7
Figure 9
Figure 8
Figure 10
Cone Handle – Broach Assembly

4
+/-10°
a
Figure 12
Figure 11
Cone Handle Alignment
The Cone Handle rotational alignment platform
indicates the anterior direction for both LEGION™
Tibial and Femoral Cones (Figure 11a). Additionally,
a LEGION Quick ConnecT-Handle and optional
drop rod can be used for anterior alignment of the
Cone Handle (Figure 11).
A maximum of 25° of rotational freedom is
provided between the Tibial Cone and the
Tibial Tray ns/keel with no oset. Using osets
or variable positioning reduces the amount of
rotational freedom.
A maximum of 20° of rotational freedom is
provided between the Femoral Cone and the
Femoral component’s anterior ange (Figure 12).
Oset Coupler usage is independent from this
freedom on Femoral Cones.
25°

5
Trial and Implant deployment
The LEGION™ Cone Handle is designed to deploy
both the Tibial and Femoral Cone Trials and
Implants. Separate Tibial and Femoral Cone
Impactor Heads (Figure 13, 14 respectively) are
used with the LEGION Cone Handle to connect
to and control orientation of the Tibial and
Femoral Cone Trials and Implants.
The Impactor Heads assemble to the Cone
Handle in the same ¼ turn locking method as
the broaches (Figure 15). The Cone Trials and
Implants snap onto the Impactor Heads.
Figure 15
Figure 13 Figure 14

6
Tibial Cones Surgical Technique
The LEGION™ Tibial Cones were designed to be
used with the LEGION Revision (RK) and LEGION
Hinge (HK) Tibial Baseplates and the range of
oset couplers. There is a maximum of 25° of
rotational freedom between the Tibial Baseplate
ns and the Tibial Cone.
If utilizing oset couplers, reference the below
sizing guide and the following technique.
Minimum Tibial Cone Size with Oset Couplers
Note: The labeled sizes of the LEGION Cones are
the functional internal diameters (ID). The IDs are
relative to the functional diameters of LEGION
Press-Fit Stems including the 1mm diametrically
oversized cutting utes. For example, a size 22
ID LEGION Tibial Cone can accept up to a 22mm
LEGION Press-Fit Stem without oset.
1. With the oset amount and Stem size desired,
reference the chart for the minimum Tibial Cone
Size needed to accommodate the desired
implant construct.
Stem Diameter
<18 18 20 22 24
Max Oset
018 18 20 22 24
2mm 20 20 22 24 26
4mm 22 22 24 26 28
6mm 24 24 26 28 30
Minimum Tibial Cone Size
2.To calculate the minimum Cone internal diameter
needed, add the Stem size or 18mm (whichever
is greater) to the desired oset.
Example: If you have used a 22mm reamer with
a 4mm oset coupler, the minimum size Tibial
Cone required (or larger) is 26.
Example: If a 15mm Reamer is used with a 2mm
oset, the minimum size Cone required is 20.
18 is greater than the 15mm Reamer, therefore
18+2 = 20 minimum.

7
Tibial Cones Surgical Technique continued
Proximal Tibia
Resection
a
Size and Oset
Position
Ream
Tibial Preparation
Follow the standard surgical technique for either
LEGION™ Revision (RK) or LEGION Hinge (HK)
through tibial reaming, proximal resection, and
tibial sizing and oset placement, noting stem/
reamer size, length and the oset amount
and clocking orientation. Before the tibial tray
counterbore step, determine the maximum
Cone size needed to ll the defect to ensure
the desired oset is compatible.
Tip: Hemi-wedge resections can be performed
using the Distal Femoral Cutting Block (Figure 18).
Completing these resection(s) prior to Cone
preparation assists in determining minimum
Cone depth requirements.
Figure 16
Figure 17
Figure 18
Figure 19

8
Short
Long
Figure 21
Figure 20
Initial Ream
1. With the LEGION™ Reamer (or Trial Stem and Trial
Stem Connection Rod) remaining in the canal,
place the Initial Cone Reamer over the shaft
of the Reamer (Figure 20) and ream to the
short or long depth markings depending on
Tibial Cone length desired.
Note: The depth should be below any additional
hemi-augments planned.
Note: There are two lengths of Tibial Cones, Short
(25mm) and Long (40mm). The minimum depths
are represented in Figure 20 on the Initial Reamer.
Initial Cone Handle Assembly
1. Insert the appropriate Oset Tibial Cone Sleeve
into the Cone Broach Handle oriented to the
same clock position as with the Oset Bushing
and Tibial Drill Guide (Figure 21), and lock
in place.

9
Tibial Cones Surgical Technique continued
Figure 22
Tray
Counterbore Coupler
Counterbore
Figure 23
Figure 24
Figure 25
Cone Sizing
1. Invert and place the minimum size Tibial
Cone Broach that covers the defect over the
Reamer shaft (Figure 22).
Tip: Ensure the anterior mark on the Cone
Broach faces anterior (Figure 22a).
2. With the minimum size Tibial Cone Broach
inverted, assemble the Cone Handle with the
desired Oset Sleeve over the Reamer. Position
the inverted broach assembly in the desired
orientation (Figure 23).
3.If the selected minimum size Tibial Cone
Broach with the desired oset covers or
is smaller than the defect, proceed with
sequential broaching using the selected Cone
Oset Sleeve and Cone Handle Assembly.
If the cone size is larger than desired or than
the anatomy allows, reassess tray coverage
with a reduced amount of oset and repeat
the Minimum Cone Size evaluation and
subsequent Cone Sizing steps.
4.Once a minimum Tibial Cone size, including
an oset amount and orientation, are
determined, complete the LEGION™ Counterbore
steps from the standard LEGION RK or
LEGION HK surgical technique (Figures 24
and 25).
a

10
Figure 32
a
Figure 27
Figure 26
Sequential Broaching
1. With the LEGION™ Reamer (or Trial Stem and Trial
Stem Connection Rod) remaining in the canal,
place the Cone Handle with appropriate oset
sleeve assembled with the 18mm Tibial Broach
of the desired length, ‘Short’ or ‘Long’, over the
shaft of the Reamer (Figure 26).
Note: A maximum of 25° of rotational freedom
is provided between the Tibial Cone and the
Tibial Tray ns/keel with no oset. Using osets
reduces the amount of rotational freedom.
2.With attention to rotational alignment, lightly
impact the Cone Handle Assembly with a mallet
until the desired depth is reached (Figure 27).
Caution: If excessive force is used, fracture
may occur. It is advised to broach in and out
to relieve stresses on the bone.
Note: The depth should be at or below the cut
tibial surface including below any additional hemi
augments planned.
Tip: 5mm depth marks are provided on the Cone
Handle for additional depth referencing against
planned augment thickness (Figure 27a).
3.While utilizing the same alignment orientation as
the previous broach, sequentially broach with the
next larger size until the desired size and stability
is reached.

11
b
a
Tibial Cones Surgical Technique continued
Figure 30
Figure 28
Figure 29
Tibial Cone Trialing
1. Remove the last Tibial Cone Broach from the
Cone Handle, noting the broach size and
length, and assemble the corresponding
size Tibial Cone Impactor Head and Tibial
Cone Trial (Figure 28).
2.Insert the Cone Trial into the prepared tibia
utilizing the same alignment orientation
as the previous broach (Figure 29).
Note: The Tibial Cone Trials are the same
external size as their corresponding Tibial
Cone Broaches, therefore, little to no
impaction should be required for the
Tibial Cone Trial placement.
3.Complete the remaining steps in the
LEGION™ RK or LEGION HK surgical technique
after the Counterbore section up to Implant
Assembly (i.e. trial placement, trial ROM,
set rotation, n punch and hemi-augment
resections if not previously completed).
Cone Trial Removal
1. Insert the cone removal tool into the trial
until the hooks are just past the distal edge
of the trial. Attach the T-Handle to the removal
tool (Figure 30a) and rotate until the arms
expand to grip the Cone Trial.
2. Attach the Slap Hammer to the Cone
Removal Tool and remove the Cone
Trial (Figure 30b).

12
Figure 31
Figure 32
Tibial Cone Implantation
1. To insure proper Cone Implant placement and
orientation, insert the appropriate LEGION™ Reamer
(or Trial Stem and Trial Stem Connection Rod
Assembly) into the canal.
Caution: Without LEGION Reamer or Trial Stem/Trial
Stem Connection Rod in the canal, the nal cone
implant may be malaligned.
2.Assemble the previously used Tibial Cone Impactor
Head and Oset Sleeve to the Cone Handle
maintaining the same clocking orientation.
3. Using the previous orientation used with the nal
Tibial Cone Broach and Tibial Cone Trial, lightly
impact the selected Cone Implant into the Tibia
to the desired depth and orientation (Figure 31).
Caution: If excessive force is used, fracture
may occur.
Tip: After the Cone implant is placed, ll any
existing voids between the Cone and the
endosteal of the tibia with grafting material
(Figure 32).

13
a
a
Figure 33
Tibial Cones Surgical Technique continued
Figure 34
Cementing
1. If using a hybrid cementing technique, ensure
a sucient amount of cement is applied to
Tibial Tray/Stem Implant construct to ll the
area between the Cone’s internal diameter
and the Tibial Tray/Stem Implant Assembly
prior to insertion of the Tibial Tray/Stem
Implant Assembly.
Tip: A nal depth measurement of the cone
can be taken using the Cone Removal Tool
(Figure 33a) and transferred to the implant
construct (Figure 34a).

14
Femoral Cones Surgical Technique
The LEGION™ Femoral Cones were designed to
be used with the LEGION Constrained Femoral
Component or the LEGION HK femoral component
and the complete range of oset couplers
depending upon the stem size, oset needed and
the Femoral Cone size permitted by the anatomy.
There is a maximum of 20° of rotational freedom
between the anterior ange of the Femoral
Component and the Femoral Cone (+/- 10°
each side).
The ability to oset is built into the Femoral Cone
instead of in the instrumentation. Depending on
stem size and cone size, there is the ability to oset
up to 6mm between 3 and 9 o’clock. Reference the
sizing guide below to determine which size cone
can accommodate the various levels of oset.
Minimum Femoral Cone Size with Oset Couplers
Note: The labeled sizes of the LEGION Cones are
the functional internal diameters (ID). The IDs are
relative to the functional diameters of LEGION Press-
Fit Stems including the 1mm diametrically oversized
cutting utes. For example, a size 22 ID LEGION
Femoral Cone can accept up to a 22mm LEGION
Press-Fit Stem without oset.
1. With the oset amount and Stem size desired,
reference the chart for the minimum Femoral
Cone Size needed to accommodate the desired
implant construct.
Example: If you have used a 22mm reamer with
a 6mm oset coupler, the minimum size Femoral
Cone required is 24.
Minimum Femoral Cone Size (per oset)
Max Oset
018
2mm 20
4mm 22
6mm 24

15
Femeral Preparation
Follow the standard surgical technique for
either LEGION™ Revision (RK) or LEGION
Hinge (HK) through the femoral reaming
(Figure 35) and distal resection, including
any distal wedge resections, noting
stem/reamer size and length.
Tip: Although distal hemi-augment resections
can be performed using the Femoral Trials,
completing these resection(s) prior to Cone
preparation assists in determining minimum
Cone depth requirements (Figure 36).
Ream
Distal Femoral
Resection
Femoral Cones Surgical Technique continued
Figure 35
Figure 36

16
b
a
Figure 38
Figure 37
b
Initial Ream
1. With the LEGION™ Reamer (or Trial Stem and
Trial Stem Connection Rod) remaining in the
canal, place the Initial Femoral Cone Reamer
over the shaft of the LEGION Reamer (Figure 37).
Ream to the desired depth.
Note: The minimum femoral depth mark on
the Initial Reamer (Figure 44b) should be at or
below the primary distal resection (Figure 37a).
Note: Depth accommodations should be
considered when using distal augments.
Sequential Broaching
1. Assemble the Neutral Sleeve into the Cone
Broach Handle. Assemble the 18mm Femoral
Broach onto the Cone Handle.
2.Rotationally align the anterior references
of the Cone Handle anteriorly (Figure 38a).
Note: Medial/Lateral reference lines are on
the Femoral Broaches, Trials and Implants
for additional rotational referencing.
3. Visually verify the anterior cone ange surfaces
surfaces are within +/- 10° of the femoral
component’s anterior ange/resection
(Figure 38).
+/-10°
a

17
Femoral Cones Surgical Technique continued
a
ba
b
a
b
a
b
Figure 40
Figure 39
Sequential Broaching continued
Caution: If excessive force is used, fracture may
occur. It is advised to broach in and out to relieve
stresses on the bone.
4.With attention to rotation, lightly impact the Cone
Handle Assembly with a mallet until the desired
depth is reached.
Tip: 5mm Depth marks are provided on the Cone
Handle for additional canal depth referencing (Figure
39a) when a deeper cone position is required.
Tip: If distal augments are used on both the medial
and lateral condyles broach until the corresponding
augment reference line on the Femoral Broaches
(Figure 39b) aligns with the distal cut surface.
For example, if no wedge is present on the lateral
side and a 10mm wedge is present on the medial
side, broach to the depth shown in Figure 39.
5.While utilizing the same alignment orientation
as the previous broach, sequentially broach
with the next larger size until the desired size
and stability is reached.
Femoral Cone Trial
1. Remove the last Femoral Cone Broach from
the Cone Handle, noting the broach size and
assemble the corresponding size Femoral Cone
Impactor Head and Femoral Cone Trial.
Note: The Femoral Cone Impactor Heads are
symmetric and have the same depth markings
as the Femoral Broaches on the medial side
(Figure 40b).
2.Insert the Cone Trial into the prepared femur
utilizing the same alignment orientation and
canal depth referencing on the Cone Handle
Assembly (Figure 40a).
Note: The Femoral Cone Trials are the same
external size as their corresponding Femoral Cone
Broaches, therefore, little to no impaction should
be required for the Femoral Cone Trial placement.