Smith & Nephew TC-PLUS Revision User manual

Surgical Technique
Intramedullary Procedure *smith&nephew
TC-PLUS™ REVISION
Revision Knee System
Sawblade Thickness: 1.00 mm
Complex Primary Knee System

TC-PLUS™ Revision
IM Procedure
Table of Content
Introduction ............................................................................................. 3
Concept/Description ............................................................................... 4
Indications .............................................................................................. 8
Contraindications .................................................................................... 9
Case Study ............................................................................................ 10
Preoperative Planning ............................................................................ 12
Surgical Technique ................................................................................. 15
•
Femoral Preparation ......................................................................19
•
Tibial Preparation ......................................................................... 31
•
Offset Stem Option ....................................................................... 39
•
Posterior-Stabilized Option .......................................................... 43
•
Patellar Preparation ..................................................................... 46
•
Assembling the Implants-Components .......................................... 48
•
Implanting the Components ......................................................... 53
Postoperative Treatment ........................................................................ 56
Sterilization ............................................................................................ 57
Implants ................................................................................................ 59
Instruments ........................................................................................... 68
1
Product Overview ( Combination Tables ) ............................................. 90
Nota Bene
The technique description herein is made available to the healthcare professional to
illustrate the author’s suggested treatment for the uncomplicated procedure. In the final
analysis, the preferred treatment is that which addresses the needs of the patient.
Disclaimer
The following technique is for informational and educational purposes only. It is not intended
to serve as medical advice. It is the responsibility of treating physicians to determine and
utilize the appropriate products and techniques according to their own clinical judgment for
each of their patients. For more information on the TC-PLUS Revision knee system, including
its indications for use, contraindications, and product safety information, please refer to the
product's label and the Instructions for Use packaged with the product.
Prior to performing this technique, please consult the Instructions for Use documentation
provided with each device for additional health and safety information, including indications,
contraindications, warnings and precautions.

2
Introduction
The TC-PLUS™ Revision knee prosthesis, with the posterior-stabilized version, has
been developed to extend the indication range of the primary TC-PLUS knee system.
The TC-PLUS Revision knee system use the same joint design (femur/insert) and
resections as the TC-PLUS Primary knee system. Just additional stem connection and
blocks fixation have been added.

3
General Warnings and Comments
Warnings
They are written in orange. They must be followed as they relate to critical functions
or this information should be noted as it contains valuable advice which helps the
user to clinically apply the system..
Training
Only adequately trained operators should use the TC-PLUS™ Revision knee system.
This Surgical Technique must be fully read and understood as part of the training.
If any part of this documentation is not clear, please contact your Smith & Nephew
representative.
Implants
TC-PLUS Revision knee system components are only designed for use with the
indicated Smith & Nephew implants and instruments. Implants and instruments
must be used in accordance with the instructions in all other relevant Surgical
Techniques.
Responsibility
It is the responsibility of the user of the TC-PLUS Revision knee system to review all
relevant information concerning the product before use. All the information
provided in the Instructions for Use and in the Surgical Technique are to help the
user in preparing for use of the product. The user must check all recommendations
concerning the product in the Instructions for Use and in the Surgical Technique and
is responsible for all clinical decisions taken.
Cleaning and Sterilization
All instruments must be sterilized before use. Detailed information on cleaning and
sterilization of instruments is contained in the separate cleaning and sterilization
instructions No. 03389.
Additional Warnings
Warnings and comments cited in other Surgical Techniques relating to TC-PLUS
knee systems must also be followed.

Femoral Components
The femoral components are manufactured from CoCrMo
alloy and are asymmetrical. They are identical to the
primary TC-PLUS femoral components in terms of design,
kinematics properties and bone resections.
The femoral patellar groove is deeply hollowed-out and
present a 6° oblique patella tracking. The revision femoral
component has a 6° valgus connection that allows the use
of different stems.
To compensate femoral bone defects, distal and/or
posterior femoral augmentation blocks can be fixed to the
femoral component.
The femoral components, both the standard and the
posterior-stabilised version, are available in sizes 2, 4, 6, 8
and 10.
4
Concept / Description
The TC-PLUS™ Revision knee system is the revision version of the primary tricompartmental
TC-PLUS knee system. In addition, the TC-PLUS PS Revision knee system is the
„posterior-stabilized“ option of the TC-PLUS Revision and the corresponding revision
version of the primary TC-PLUS PS knee system.
As the TC-PLUS Revision implants offer the same resections as the tricompatimental
TC-PLUS Primary knee prosthesis, this permits if necessary an easy intraoperative
switchover from the resurfacing to the condylar revision knee.
The femoral and tibial components of the TC-PLUS Revision correspond, apart from the
connection for the stems and the blocks, to those of the TC-PLUS Primary knee system.
The tibia inserts are identical; therefore the femoral and tibial components of both
knee systems are fully cross compatible. The range includes femoral and tibial
components fitted with stem couplings; the corresponding Ti6Al4V stems for non-
cemented application and in CoCrMo stems for cemented application. CoCrMo blocks are
available to compensate femoral and tibial bone defects.
All stems of the TC-PLUS Revision can be combined with the femoral and tibial
components of the TC-PLUS Revision. The same applies for the femoral components of
the TC-PLUS PS Revision.
The implants are available in five sizes ( corresponding to TC-PLUS sizes 2, 4, 6, 8 and
10 ). Each size can be combined with the next size up or down ( see product overview
from page 90 ).
Product Description

5
Patellar Component
The all-poly ( UHMW-polyethylene ) patellar component
has a symmetrical biconcave surface for better tracking.
The patellar component are identical to those in the
TC-PLUS™ portfolio.
Tibial Inserts
The tibial inserts present a snapping fixation and
is additionally secured by a screw.
The tibial inserts are identical to those used in the primary
TC-PLUS knee portfolio, they are manufactured from
UHMW-polyethylene and are available in six different
heights of 9 mm, 11 mm, 13 mm, 15 mm, 17 mm and 19 mm
for the ultracongruent tibia inserts and in seven different
heights of 9 mm, 11 mm, 13 mm, 15 mm, 17 mm and 19 mm
( optionally 21 mm ) for the posterior-stabilised tibia
inserts. The target is, independent to the degree of tibial
bone substance loss, to be able to restore the joint line.
The minimum effective PE thickness in the load zone is
6 mm.
Please see the available sizes in the implant table ( on page 59 ff ).

6
Tibial Component
The femoral and tibial blocks are manufactured from
CoCrMo alloy.
In order to compensate different femoral and/or
tibial bone defects, there are distal femoral blocks
available in heights of 5 mm, 10 mm and 15 mm,
posterior femoral blocks in heights of 5 mm and 10 mm
and proximal tibial blocks in heights of 5 mm, 10 mm and
15 mm.
The same femoral blocks are used for both
standard and posterior-stabilised femoral components.
The same tibial blocks, except height of 15mm, are
used for the medial- as for the lateral-condyle of the
tibial component.
The blocks have to be assembled to the femoral and
tibial components with screws and can then be cemented.
The symmetrical tibial component is manufactured
from CoCrMo alloy.
In order to minimize polyethylene wear inside the tibial
component, the base plate is polished on the inside and
the insert is completely enclosed along its entire
circumference.
The revision tibial component has a 3° slope
connection that allows the use of different stems.
To compensate tibial bone defects, proximal tibial
blocks can be fixed on the tibial component.
The tibial component is available in sizes 2, 4, 6, 8 and 10.
Femoral and Tibial Blocks

7
Cemented Stem
The femoral and tibial components can be intramedullary
anchored in the bone by cemented conical stems,
made of forged CoCrMo alloy.
Available in lengths; 80 mm, 110 mm and 150 mm.
Zementfreie Schäfte
The femoral and tibial components can also be
stabilised into the bone by using non-cemented
cylindrical stems, made of forged Ti6Al4V alloy.
These stems are not suitable for primary anchorage;
therefore they are not designed for osseo-integration. For
matching the different patients anatomy, a wide stems
range with straight stems, 2° valgus stems (for femur
valgus of 4° or 8°) and 3.75 mm offset stems (placed 360°
on the tibia), in various diameters ( Ø 10, Ø 12, Ø 14, Ø 16,
Ø 18 and Ø 20 mm) and lengths ( 40 mm, 80 mm, 110 mm
and 150 mm ) are available.
Please see the available sizes in the implant table ( on page 59 ff ).
2° 3.75 mm

8
Indications
The principal preoperative planning factor is the correct diagnosis. It has to be
determined whether the bone and stability situation allow the implantation of an
uncoupled prosthesis.
The main indications for implantation of TC-PLUS™ Revision are :
•Degenerative or posttraumatic arthrosis
•Rheumatoid arthritis
•Avascular necrosis of the femoral condyles
•Joint destruction with restricted function and requirement for additional stabilization
with longer stems andreconstruction of bone defects
•Marked contractures and axial deformity less than 20 - 25°
•Failure after surface replacement ( e.g. infection, loosening ) - Revision of a primary
prostheses
•Trauma - induced femoral or tibial fractures
Important
Due to the design, it is possible to switch with relatively little effort, even intra-
operatively, from theTC-PLUS™ knee system ( or TC-PLUS™ PS ) to the TC-PLUS™
Revision knee system ( or TC-PLUS™ PS Revision ),since the resections and prosthesis
sizes are identical

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•Acute or chronic, local or systemic infections ( or in the case of a corresponding
anamnesis )
•Severe muscle, nerve or vascular diseases that endangers the affected extremity
•Laking bone substance or inadequate bone quality that endangers a stable seating of the
prothesis
•Distinct collateral ligament instability
•Pronounced genu recurvatum
•Axial misalignment over 25°
•All concomitant diseases that may endanger the function of the implant. These include in
particularextreme insufficiency of the knee extensor mechanism, which can lead to
excessive joint distortion; orsevere adiposity which can lead to a dorsal impingement,
which leads to instability of the components. Inthese cases it may be advisable to use a
constrained rotating or a tumor prosthesis
•Patient hypersensitivities or allergies to the materials used
•Strenuous physical activity ( e.g. competitive sport, hard physical work )
See also instructions in package insert
Contraindications
Contraindications are :

10
Preoperative situation
Case Study
Patient with varus displaced or implanted tibia, with a medial instability that must be revised because of pain and swelling.

11
Postoperative Result
Immediately postoperative; functional and pain-free reconstruction with TC-PLUS™ Revision knee.

12
Preoperative Planning
A full-leg X-ray with the patient in the standing position is recommended for preoperative
planning purposes. If this is not possible, an X-ray of the thigh, including the femoral
head, should be taken. The X-ray images of the knee joint at three levels should be
available for planning the surgery. A tangential patellar exposure, a frontal and a sagittal
to the leg axis exposure must be taken.
For preoperative planning there are X-ray templates available: with scale of 1.15:1 Lit. No.
1354 / 1355 and with scale of 1:1 Lit. No. 1511 / 1512 ( see page 89 ). The lateral view of
the condyles is decisive. If these are no longer completely intact, it is possible to switch
to the condylar width. In cases of doubt, the smaller implant should be selected to
prevent the prosthesis components from protruding. In normal cases, the size
determination and the correct positioning of the prosthesis are controlled intraoperatively
with relevant instruments and planning may also be possible on the unrestored opposite
side leg.
Important
The femoral and tibial component sizes can all be combined with the next size up
or down ( see product overview on page 90 ff ).
Large deviations of the femoral neck angle as well as severe deformities of femur and
tibia ( e.g. posttraumatic axial deformities ) must be taken into consideration during
surgical planning.
In cases of deformities away from the knee joint that adversely influence the mechanical
axis, additional corrective osteotomies may be indicated.

13
Planning the surgery using the radiograph
The following procedure is recommended
for the anterior-posterior whole leg imaging
process:
A Anatomical femoral axis
B Anatomical tibial axis
C Mechanical leg axis
D Mechanical femoral axis
E Tibial resection depth (mm)
aValgus angle
Post-op
Pre-op
1. The femoral axis A (anatomical axis) is drawn
onto the radiograph.
2. A line is drawn from the femoral head to the
center of the knee (mechanical axis D) on the
radiograph.
3. The angle measured between the anatomical
and the mechanical axis = angle adetermines
the valgus angle.
4. The tibial axis B is drawn in and the tibial
resection plane E is determined to avoid exces
sive resection, especially if defects
are present.
5. The component sizes and resection depths are
determined preoperatively using the X-Ray
templates (see page 87) in anterior/posterior
(A/P) and the lat eral planes.
6. The mechanical leg axis C should merge with
lines D and B after correction.

14

15
Positioning of the patient for the surgery
Surgical Technique
In case of an implant revision, where
components must be removed at the
beginning of the surgery, Smith & Nephew
with the RENOVATION Knee set, offers the
surgeons a knee specific implant extraction
system that contents different instrument
options to facilitate the removal of different
femur and tibia components (loose first and
then extract).
The instrument set consists of a basic set
(no. SAP 75210243 / 0944290) and sterile
packaged, single-use chisel-blades and
saw-blades (see surgical technique Lit. No.
04044 (2025)).
Surgery is performed whilst the patient is
supine. It is recommended that the blood
supply be partially blocked with the use of a
tourniquet. But this is not absolutely
necessary. The leg must be covered, so as
to allow movement and secured to the
operating table in such a way that the knee
joint is brought into a stable 90° flexion
position. Most of the surgical steps are
performed in this position.
Surgical procedure
The skin incision can be a midline incision
or a parapatellar incision. If there are scars
from skin incisions made during previous
surgery, it is advisable to use them for
access in order to reduce the risk of
cutaneous blood flow disorders. Medical
arthrotomy is recommended, or an
approach adapted to the pathological
situation.
After the usual preparation (meniscus
resection, removal of osteophytes and
synovectomy if necessary), the cruciate
ligaments are sectioned close to the bone.
Implant component removal

16
It is important that the flexion and extension gaps are identical.
1.Distal femoral resection and optional distal
augment resection
3.Chamfer and trochlea resections and cutting
out of the box if the PS version is required
Remove residual posterior condyles if
present
4.Tibial resection and optional augment
resection
5.Patellar resection ( optional )
Overview of the resections sequences for primary application
Important
For the standard instrument set, use 1.00mm saw blades for all bone resections!
For the 1.27mm instrument slot option, use the corresponding 1.27mm saw blades.
See Lit. No. 01218 for corresponding connection.
2.A/P femoral resections and optional posterior
augment resection

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The bone resections are refreshed after extraction of the primary implants.
1.Distal femoral resection and optional distal
augment resection
2.A/P femoral resections and optional posterior
augment resection
3.Chamfer and trochlea resections and cutting
out of the box if the PS version is required
Remove residual posterior condyles if
present
Overview of the resection sequences for revision application
Important
For the standard instrument set, use 1.00mm saw blades for all bone resections!
For the 1.27mm instrument slot option, use the corresponding 1.27mm saw blades.
See Lit. No. 01218 for corresponding connection.
4.Tibial resection and optional augment
resection
5.Patellar resection ( optional )

18
Use of Speed-Pins
We also offer speed-pins as an alternative
for fixing the instrument to the bone.
The speed-pins are available in different
lengths and types:
Speed-Pins with Rim Ø 3.2 / 30mm
–6x PAC (Art. Nr. 42000089/75006487)
Speed-Pins Ø 3.2 / 65mm
– 6x PAC (Art. Nr. SYS251354/75009338)
Speed-Pins Ø 3.2 / 80mm
– 6x PAC (Art. Nr. SYS251355/75009339)
Speed-Pins Ø 3.2 / 110mm
– 6x PAC (Art. Nr. SYS251356/75009340)
AO Adapter for Speed-Pins
(Art. Nr.: SYS251316/75009310)
The speed-pins are delivered non-sterile
and for multi-use (limitation of use is
defined as the standard pin and can be
used until functionality is no longer
ensured)