Zimmer Biomet Vanguard ID Total Knee User manual

Vanguard®ID Total Knee
Surgical Technique

Overview................................................................................................................... 2
Preoperative Planning .............................................................................................. 4
Incision...................................................................................................................... 4
Patella Preparation ................................................................................................... 5
Patella Resection
Femoral Preparation................................................................................................. 8
Distal Femoral Resection
Femoral Sizing
4-in-1 Femoral Cuts
Tibial Preparation ................................................................................................... 14
Tibial Resection
Stem Preparation
Sizing Chart ............................................................................................................ 22
Trial Reduction ........................................................................................................ 23
Bearing Compatibility Chart .................................................................................. 24
Implant Reduction .................................................................................................. 26
Tibial Tray Implantation
Femoral Component Implantation
Patellar Component Implantation
Tibial Bearings and Locking Bar Implantations
Table of Contents

2 | Vanguard®ID Total Knee Surgical Technique
Overview
The Vanguard ID Surgical Technique consists of:
• Vanguard XP®Femoral Component
• One tibial tray: XP-CR Interlok®Tibial Tray
• Two bearing designs: XP-XP and XP-AS
The components can be used in dierent combinations, depending on the patient’s soft tissue status
(see table below).
Level of Constraint Options
Intact, Functioning PCL Intact, Partially Functioning PCL
Femoral Component XP Femoral XP Femoral
Tibial Component XP-CR (ID) Tibia XP-CR (ID) Tibia
Bearing Combinations
(maximum 2 mm
thickness dierence)
Medial Plateau Lateral Plateau Medial Plateau Lateral Plateau
XP-XP Medial XP-XP Lateral XP-AS XP-AS
XP-XP Medial XP-XP Medial XP-XP Medial XP-AS
XP-XP Medial XP-AS XP-AS XP-XP Medial
XP-AS XP-XP Medial XP-AS XP-XP Lateral
XP-AS XP-XP Lateral
Warning: Only use the above combinations. The use of XP-XP Lateral Bearings on the medial side has not been
evaluated and could lead to premature failure of the device.
If additional implant constraint is desired, the Vanguard®PS or PS+ System can be utilized.
Note:
• Femoral Pegs: The Vanguard XP Femoral Component has two modular distal pegs. To help address minor
bone deficiencies, the pegs can be removed and distal femoral augments attached using an augment bolt
or an augment peg.
• Femoral Augments: The use of femoral augments does not necessarily change the recommended implant
combinations (table above) – the appropriate implant combination should be chosen based on the intact
soft tissues.

3 | Vanguard®ID Total Knee Surgical Technique
Description
Zimmer Biomet manufactures a variety of knee joint
replacement prostheses intended for application
with or without bone cement. Knee joint replacement
components include: femoral, tibial, and patellar
components. Components are available in a variety
of designs and size ranges intended for both primary
and revision applications. Specialty components are
available including: femoral stems, femoral screws,
femoral augments, tibial stems, tibial screws, tibial
augments, tibial cement plugs, and modular pegs.
• The Vanguard ID Total Knee is designed to oer the
flexibility to individually treat the medial and lateral
compartments to match the patient’s soft tissue
envelope.
• The transition between each constraint level can be
made with ease, allowing the physician to evaluate soft
tissue and bone deficiencies intraoperatively without
making a preoperative commitment to the level of
constraint.

4 | Vanguard®ID Total Knee Surgical Technique
Figure 1 Figure 2
Perpendicular Resection
Mechanical Axis Anatomic
Valgus Angle
Preoperative Planning
Assess bone stock and potential ligament instability
and the anatomical axis with 36 inch long standing
A/P X-rays.
Measure valgus angle (angle between anatomic and
mechanical axis) to assure the distal femoral cut is
perpendicular to the mechanical axis (Figure 1).
Estimate femoral component size using lateral view
X-ray.
Note: Confirmation of the appropriate size
component intraoperatively is critical for normal
kinematics.
Incision
The Vanguard ID Knee utilizes the Vanguard XP Total
Knee Instrumentation, which is also designed for
standard surgical approaches (Figure 2).
Ensure that the patella tendon tibia interface is released
so the patella can easily sit in the lateral gutter of the
knee. Take care to not release medial collateral ligament
(MCL) during initial exposure.
Note: If multiple scars from previous surgeries exist,
evaluate skin incision placement and elements of
scarring, which may decrease soft tissue mobility.

5 | Vanguard®ID Total Knee Surgical Technique
Figure 3 Figure 4
Patella Preparation
Patella Resection
Vanguard ID Tip: Preparation of the patella at
this time frees up the joint capsule and facilitates
exposure for the remainder of the case.
Option 1: Surface Clamp
Tilt the patella for patella preparation.
Remove the osteophytes and peripatellar tissues down
to the level of the quadriceps and patellar tendon
insertion.
Determine the patella thickness and resection amount
by using the patella caliper (Figure 3).
The patella saw guide stylus can be utilized to determine
the appropriate resection level (Figure 4).
Use the patella clamp surface cut guide to perform the
initial, flat patellar resection.
Note: Care should be taken to restore original patella
thickness to prevent overstung or under tensioning
of the patellofemoral joint.

6 | Vanguard®ID Total Knee Surgical Technique
Figure 6Figure 5
Patella Resection (cont.)
Option 1: Surface Clamp (cont.)
1-peg patellar component:
– Use the 1-peg patellar drill guide to locate the
placement of the central peg.
– Drill the central hole using the ⁄ inch Series
A™ Patellar Drill.
– Select a trial patellar component to optimize
coverage without increasing patellar thickness
beyond pre-resection height.
3-peg patellar component:
– Place the appropriately sized 3-peg drill guide
onto the resected patella and use the ¼ inch
patellar drill to prepare for the component pegs
(Figure 5).
Option 2: Patella Milling
Tilt the patella for patella preparation.
Remove the osteophytes and peripatellar tissues down
to the level of the quadriceps and patellar tendon
insertion.
Determine the patella thickness and resection amount
by using the patella caliper.
Size the patella using the mill bushings (Figure 6).
Attach the size-specific bushing to the mill handle.

7 | Vanguard®ID Total Knee Surgical Technique
Figure 7
Patella Resection (cont.)
Option 2: Patella Milling (cont.)
Note: The patella size and thickness will determine
if a standard or thin patella should be used.
Firmly clamp the patella with the mill handle paying
careful attention not to tilt the patella.
Attach the appropriate size-specific 3-peg or 1-peg
patella reamer to the reamer shaft (Figure 7).
Attach the proximal shaft to a power drill.
Insert the reamer basket into the mill bushing and allow
the reamer’s central bit to rest on the apex of the patella
bone.
Attach the appropriate thickness magnetic spacer
(marked, “Bit”) to the adjustable depth stop.
Set the adjustable stop by depressing the button on
its side and slide the stop down until the bottom of the
spacer touches the mill bushing.
Note: The magnetic spacer bit includes the depth
of the peg. Do not sink the drill bit prior to setting
the adjustable stop.
Remove the magnetic spacer and ream until the
adjustable stop touches the mill bushing.
Remove the reamer assembly. Then, disengage the mill
handle by pulling the thumb trigger towards the handle.
3-peg patellar component:
– Prepare the inset surface using the appropriate
sized surface reamer.
– Establish the resection depth using the magnetic
spacer marked with a red dot.
– The 3-peg drill guide is tapped into the prepared
patella inset and the ¼ inch patellar drill is used
to make the holes for the component pegs.

8 | Vanguard®ID Total Knee Surgical Technique
Figure 8 Figure 9
A
B
Distal Femoral Resection
Utilize the .375 inch intramedullary (IM) drill to
penetrate the intercondylar notch of the distal femur
to a depth of approximately 1.5–2 inch (3.5–5 cm)
(Figure 8).
Place the canal entry location 1 cm above the insertion of
the posterior cruciate ligament (PCL) and slightly medial
in the intercondylar notch.
Note: Irrigation and suction of the femoral canal
can be performed to decrease canal contents.
Option 1: Adjustable Distal
Femoral Resection Guide
Set the adjustable distal cut guide to the desired valgus
angle by pressing and turning the valgus angle dial
(Figure 9A).
Select the depth of distal resection by turning the
resection level dial (Figure 9B).
Femoral Preparation
1 mm
9
0
11 mm
9

9 | Vanguard®ID Total Knee Surgical Technique
Figure 10 Figure 11
Distal Femoral Resection (cont.)
Option 1: Adjustable Distal
Femoral Resection Guide (cont.)
Assemble the IM rod and adjustable distal cut guide
by inserting the IM rod through the central hole of the
adjustable distal cut guide.
Slowly introduce the IM rod to the femoral canal to
depressurize the canal.
Slide the adjustable distal cut guide until it rests flush
with the distal femur.
Attach the distal cut block to the adjustable distal
adaptor by sliding the magnetized distal cut block into
the adjustable distal adaptor.
Attach the adjustable distal adaptor and distal cut block
to the adjustable distal cut guide by sliding the two legs
on the adjustable distal adaptor through the anterior
holes of the adjustable distal cut guide (Figure 10).
Continue sliding the adjustable distal adaptor until the
block is sitting against the anterior cortex.
Pin the distal cut block into place using ⅛ inch quick
release drill pins in the center pinholes of the block
(Fig ure 11).
Note: To confirm the valgus angle, the alignment
handle can be inserted into the adjustable distal
adaptor and a ¼ inch alignment rod can be inserted
and extended to the center of the femoral head.

10 | Vanguard®ID Total Knee Surgical Technique
Figure 13Figure 12
Note: To confirm the valgus angle, the alignment
handle can be inserted into the adjustable distal
adaptor and a ¼ inch alignment rod can be inserted
and extended to the center of the femoral head.
Remove the valgus wing by removing the IM rod and
pulling the valgus wing and valgus block adaptor
distally away from the distal cut block, leaving the
distal cut block in place.
Use a 1.37 mm saw blade to complete the distal
resection through the selected 0 slot (Figure 13).
Check the resected distal femur using a flat instrument
surface to confirm a flat resection.
Recut or file as necessary to achieve proper resection.
Note: Avoid over-resecting the distal femur to
prevent raising the joint line. Aim to resect 1 to 2
mm into the femoral notch.
Distal Femoral Resection (cont.)
Option 2: Fixed Distal Femoral Resection
Guide (cont.)
Choose the appropriate left or right valgus wing and
assemble it onto the IM rod by sliding it through the
central hole.
Slowly introduce the IM rod to the femoral canal to
depressurize the canal.
Slide the valgus wing until it rests flush with the distal
femur.
– The “left” or “right” engraving on the block
must face distally corresponding to the leg
being prepared.
Slide the distal cut block and valgus block adaptor into
the anterior holes of the valgus wing until the resection
block contacts the anterior femur.
Pin the distal cut block into place using ⅛ inch quick
release drill pins in the center pinholes of the block
(Figure 12).
9 mm

11 | Vanguard®ID Total Knee Surgical Technique
Figure 14 Figure 15
Fixed
Femoral Sizing
Assemble the selected right or left A/P sizer feet to
the A/P sizer body.
Feet options include:
– Adjustable A/P sizer dial feet, left and right
with the ability to set external rotation from 0
to 10 degrees (Figure 14).
– Fixed three degree A/P sizer feet, left and right
(Figure 15).
^00

12 | Vanguard®ID Total Knee Surgical Technique
Figure 16
B
A
B
Femoral Sizing (cont.)
Note: Assessing the A/P femoral axis, the
epicondylar axis, flexion gap and the tibial shaft
axis can further optimize femoral rotation.
Due to the tight space, hyperflex the knee to place
the A/P sizer flush with the resected femoral distal
surface.
Drill the two 4-in-1 cutting block location holes
utilizing the ⅛ inch quick release drill pins (Figure 16A).
Leave the pins in place.
The femoral component size can now be read from
the central scale (Figure 16B).
Vanguard ID Tip: If the size indicated is in-
between sizes, use the smaller of the two sizes,
in order to not overstu the patellofemoral joint
space.
Remove the pins and the A/P sizer.

13 | Vanguard®ID Total Knee Surgical Technique
Figure 17
A
4-in-1 Femoral Cuts
Choose the Vanguard XP Femoral 4-in-1 Block that
matches the selected size (Figure 17).
Place the block into the ⅛ inch distal femur holes.
Note: A 1.37 mm feeler blade can be used to
determine the amount of anterior bone resection.
Ensure the block is sitting flush against the distal
femur.
If additional stability is required, ⅛ inch quick release
drill pins or the threaded headed pins can be placed in
the angled side holes provided on the femoral 4-in-1
block (Figure 17A).
Once the block position is satisfactory, resect the
anterior and posterior bone and the anterior and
posterior chamfers with a 1.37 mm thick saw blade in
a standard configuration (Figure 17).
After making the anterior resection, assess the anterior
resection relative to the anterior cortex.
If downsizing is possible, the initial block can be
removed and the smaller sized block applied. The
anterior and posterior femur and chamfers then can
be resected.
Note: Take care not to stretch the soft tissues by
over-retracting the ligaments.

14 | Vanguard®ID Total Knee Surgical Technique
Figure 19
Posterior slope is adjusted by depressing the button
on the side of the EM tibial guide base and moving the
base forwards or backwards to allow the tibial cutting
block (with 7 degrees of slope) to increase or decrease
posterior slope.
EM tibial guide shift being parallel to the long axis of
the tibia gives seven degrees of posterior slope.
Adjust the initial guide height accordingly by placing the
universal tibial cutting block against the proximal tibia
at the estimated resection level (Figure 19).
Figure 18
Tibial Resection
Resection
Attach the tibial universal cutting block (which has a 7
degrees posterior slope built-in) to the EM tibial guide.
Position the EM tibial guide on the tibia and place the
spring-loaded arms of the ankle clamp around the distal
tibia just above the malleoli (Figure 18).
Tibial Preparation

15 | Vanguard®ID Total Knee Surgical Technique
Figure 21
Secure the EM tibial guide body to the tibia with one
pin (headed threaded), placed in either the medial or
lateral hole in the EM tibial guide yoke (not through
the cutting block) (Figure 21).
Figure 20
Tibial Resection (cont.)
Resection (cont.)
Attach the tibial stylus to the universal tibial cutting
block by placing the appropriate stylus tongue into the
slot on the universal tibial cutting block (Figure 20):
• Select 4 mm o the medial low or 12 mm o
the lateral high.
• When measuring the depth of resection, aim
for a loose 4 mm or 12 mm to ensure the tibia is
not over-resected.
• The center of the universal tibial cutting block
should approximately align with the center of
the tibia.

16 | Vanguard®ID Total Knee Surgical Technique
Figure 22 Figure 23
Fine-tune
Adjustment
Tibial Resection (cont.)
Fine Tuning Tibial Resection Height
Bring the knee into extension and place the tibial
resection spacer tongue into the slot of the tibial
cutting block and allow the paddles to loosely rest
against the distal cut surface of the femur (Figure 22).
Apply traction to the leg to replicate appropriate
tension on the knee ligaments.
Gently apply pressure to the lever toward the body
of the handle. Adequate extension space will allow
the lever to rest easily on the body of the handle. If
moderate to excessive force is needed to fully depress
the lever, adjust the depth of the tibial cutting block
by using the height adjustment thumb wheel to resect
more tibial bone, and confirm the extension space by
easily depressing the lever to the paddle body.
Repeat previous step at 90 degrees of flexion to ensure
that flexion and extension spaces match.
Fine-tune the tibial resection level by using the height
adjustment thumb wheel (Figure 23).

17 | Vanguard®ID Total Knee Surgical Technique
Figure 24
Standard
Pin
Headed/
Threaded Pin
Figure 25
Tibial Resection (cont.)
Fine Tuning Tibial Resection Height (cont.)
Remove the tibial resection spacer.
After the horizontal resection level is set, place one ⅛
inch quick release drill pin in the middle hole of one
side of the universal tibial cutting block and another
one on the opposite side (Figure 24).
To create a captured cut slot, secure the tibial cutting
block insert onto the universal tibial cutting block
(Figure 25).

18 | Vanguard®ID Total Knee Surgical Technique
Figure 27Figure 26
Using the flat rasp, fine-tune the resected tibia to ensure
flatness and to remove any rough edges by using the
universal tibial cutting block as a reference (Figure 27).
Tibial Resection (cont.)
Fine Tuning Tibial Resection Height (cont.)
The cut block may be used as a surface block by not
attaching the tibial cutting block insert (Figure 26).
Resect the tibial plateau.
Note: To preserve the integrity of the soft tissues,
avoid dislocating the tibia while making the resection.
At the same time, take care to protect the insertion
point of the PCL.