ATTUNE® REVISION

KNEE SYSTEM
FIXED BEARING
SURGICAL TECHNIQUE
Introduction

This surgical technique provides guidelines for the implantation

of the ATTUNE® Revision Knee System.

ATTUNE Revision Knee System Fixed Bearing (FB) Implants

include the following components:

• ATTUNE Revision Femoral Component

• ATTUNE Revision Fixed Bearing Insert

• ATTUNE Revision Fixed Bearing Tibial Base

• ATTUNE Revision Press-Fit and Cemented Stems

• ATTUNE Revision Femoral Augments

• ATTUNE Revision Tibial Augments

• ATTUNE Revision Offset Adaptors

• ATTUNE Revision Femoral Sleeves

i INFORMATION i INFORMATION

Use of supplemental fixation components (Stems The ATTUNE Revision Femoral Component is
and/or Sleeves) is recommended when using Augments compatible with the ATTUNE PS Fixed Bearing Tibial
or a constrained (Revision) Insert. Use of the Revision Insert and the ATTUNE Revision Fixed Bearing Tibial
Insert or Augments without supplemental fixation Insert. The ATTUNE PS FB Insert can be used with the
may lead to a loss of construct fixation. ATTUNE Revision Femoral Component when less
constraint is desired.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    3
Contents

Abbreviations 6
Icons 7
Key Surgical Steps Summary 8
Pre-operative Planning 10
1. Incision and Exposure
Initial Incision, Capsular Incision and Implant Extraction from the Primary Procedure 11

2. ATTUNE Revision General Instrumentation

Pinning 12
Touch-points 13
Angled Pin Holes 14
Reamer Reference Tools 15
Canal Reamers 18
Torque Limiting Screwdriver and System Hex Attachment 21
Modular Stop 22
Stem Trial Assembly 23
Stem Trial Extraction 24

3. Tibial Preparation
Tibial Trial Assembly 25
Anterior Pins 26
Tibial Preparation - Solutions 27
Solution 1: Revision Fixed Bearing (FB) Base alone or with Short Cemented Stem Preparation
(Extramedullary Preparation) 28
Solution 2: Revision Fixed Bearing (FB) Base with Straight Stem or Offset Stem Preparation
(Intramedullary Preparation) 40

4. Revision Femoral Preparation

General Femoral Instrumentation 54
Revision Femoral Preparation - Solutions 62
Solution 1: Revision Femoral Component with Short Cemented Stem (With Cut Through Trials) 63
Solution 2: Revision Femoral Component with Short Cemented Stem (With Solid Femoral Trials) 68
Solution 3: Revision Femoral Component with Intramedullary Preparation (With Conventional Cut Guide) 74
Solution 4: Revision Femoral Component with Intramedullary Preparation (With Cut Through Trials) 74

5. Trialing and Final Preparation

Setting Tibial Base Rotation 147
Tibial Augment Preparation 151
Keel Preparation 153

6. Patella Resection and Preparation

Patella Resection and Preparation – Instrument Assembly 154
Patella Resection 156
Patella Implant Options 158
Patella Drill Trialing 159
Lug Hole Preparation 161

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7. Final Trial Assessment
Final Trial Assessment 162

8. Trial Removal
Femoral Trial Removal 163
Tibial Trial Removal 164

9. Implant Assembly
Implant Assembly 165
Augment Assembly 166
Tibial Augment Assembly 167
Femoral Augment Assembly 168
Revision FB Tibial Base and Straight Stem Implant Assembly 169
Revision Femoral Component and Straight Stem Implant Assembly 172
Alternative Revision Femoral Component and Straight Stem Implant Assembly 176
Revision FB Tibial Base and Offset Stem Implant Assembly 178
Revision Femoral Component and Offset Stem Implant Assembly 186
Revision Femoral Component and Femoral Sleeve Assembly 195

10. Cementing Technique

Cementing Technique 199
Revision FB Tibial Construct alone or with Cemented Stems or Augments 200
Revision FB Tibial Construct with Press-Fit Stems or Augments 201
Revision Femoral Construct with Cemented Stems, Augments, and/or Cemented Sleeves 202
Revision Femoral Construct with Press-Fit Stems and Augments 203
Revision Femoral Construct with Press-Fit Stems and Porous Coated Sleeves and Augments 204

11. Final Implantation

Seating the Tibial Construct 205
Seating the Femoral Construct 206
Solid Tibial Trial Extraction 207
Tibial Insert Implantation 208
PS or CR Tibial Insert Implantation 209
Final Patella Preparation 210
Patella Component Implantation 211
Final Cement Curing 212

12. Sleeve Disassembly

Femoral Sleeve Disassembly 213

Compatibility Information 215

Symbols on Surgical Instruments 216

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Abbreviations

Abbreviations used in the surgical technique:

FB - Fixed Bearing

TKA - Total Knee Arthroplasty

MRI - Magnetic Resonance Imaging

CT - Computerized Tomography

M/L - Medial/Lateral

V/V - Varus/Valgus

A/P - Anterior/Posterior

EM - Extramedullary

IM - Intramedullary

CR - Cruciate Retaining

CS - Cruciate Sacrificing

PS - Posterior Stabilized

PCL - Posterior Cruciate Ligament

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Icons

The below icons are utilized within the different preparation

solutions to indicate the type of preparation that is being
described on the specific page. These are an aid to navigate
through a given workflow solution.

Straight Stem Conventional Cut Guide

Femoral Sleeve and Stem Cut Through Trial

Offset Stem Solid Femoral Trial

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Key Surgical Steps Summary

General Revision Tibial Preparation

Instrumentation Information
Two Solutions:
Revision Fixed Bearing (FB) Base alone or
with Short Cemented Stem Preparation
(Extramedullary Preparation)

Revision Fixed Bearing (FB) Base with

Straight Stem or Offset Stem Preparation
(Intramedullary Preparation)

Final Trial Assessment Implant Assembly

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Revision Femoral Preparation Trialing and Final Preparation

Four Solutions:
Revision Femoral Component with Short
Cemented Stem (With Cut Through Trials)

Revision Femoral Component with Short

Cemented Stem (With Solid Femoral Trials)

Revision Femoral Component with Intramedullary

Preparation (With Conventional Cut Guide)

Revision Femoral Component with Intramedullary

Preparation (With Cut Through Trials)

Cementing Technique Final Implantation

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Pre-operative Planning

Revision Total Knee Arthroplasty begins with thorough

clinical and X-ray evaluation. Templates are employed
to establish replacement implant size and the alignment
of bone resections, to indicate augmentation of skeletal
deficits, and to confirm the joint line.

Pre-operative X-ray evaluation for the long-axis of

tibial and femoral curvature is recommended prior
to determining the surgical path for appropriately
addressing the needs of the patient. Anatomical
curvature should be taken into consideration when
determining the Stem length with or without
augmentation. The construct length and/or offset
should be selected to avoid the area where extreme
curvature occurs.

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Initial Incision, Capsular Incision and Implant

1. INCISION AND EXPOSURE

Extraction from the Primary Procedure
Incision and exposure should be performed using the
surgeon’s preferred surgical technique. When removing/
extracting an implant from previous procedure, take care
to preserve as much bone as possible.

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Pinning
2. ATTUNE REVISION GENERAL INSTRUMENTATION

The ATTUNE Revision Instrument System is designed to be used

with the ATTUNE Pinning System that contains Universal Pins
and Threaded Headed Pins. Threaded Non-Headed Pins are also
shown but are not available in the Pin Pack.

The Universal Pin can be drilled in or hammered

in, and drilled out or pulled out using the Pin Jack.

Universal Pin
The Threaded Headed Pin is designed to be
inserted and removed with a Power Driver. These
Pins are best used to secure blocks against a flat
surface such as resected bone. !

Threaded Headed Pin

The Threaded Non-Headed Pin is also available

and is designed to be inserted and removed with
a Power Driver.
Threaded Non-Headed Pin

! CAUTION

Care should be taken to not over tighten these

Pins with the ATTUNE Revision Knee System
Instrumentation as it may change the angle of
the Cut Block. Additionally, care should be taken
to be aware of the position of the Pin with respect
to cortical bone, as cortical perforation with a Pin
can be the source of a stress riser. Pin Jack

i INFORMATION

Steinmann Pins are compatible with all Pin holes

throughout the ATTUNE Revision Instrumentation but Power Driver
should be utilized with caution.

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Touch-points

2. ATTUNE REVISION GENERAL INSTRUMENTATION

The Revision Instrumentation System has identified touch-points
through a number of methods: Instruments may have the touch-points
highlighted red or black.

In some instances a marking pattern has been applied to metal components to indicate the touch-points.

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Angled Pin Holes
2. ATTUNE REVISION GENERAL INSTRUMENTATION

The following symbol has been applied over holes

to indicate the angled orientation of the Pin hole.

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Reamer Reference Tools

2. ATTUNE REVISION GENERAL INSTRUMENTATION

Reamer Reference Tools come in three lengths in order
!
to differentiate the various construct configurations for:
• Tibia (shortest Reference Tool)
• Femur (medium length Reference Tool)
• Offset (longest Reference Tool)

The Reference Tools are dual sided:

• Tibia: Fixed Bearing
• Femur: 1) Cemented Stem 2) Press-Fit Stem
• Offset: 1) Tibia 2) Femur
-T
he Offset Adaptor adds an additional 25 mm
to the overall construct length

The Reference Tools have general depth indication

lines sequentially numbered and spaced 25 mm apart.

• The Canal Reamers have grooves that correspond

with the depth indication lines

The 3rd, 6th and 9th depth lines are wider in both the
Canal Reamers and the Reference Tools to aid in visual
identification while reaming.

! CAUTION

It should be noted that depth lines do not represent the

exact construct lengths but rather the ream depth to
prevent underpreparation.

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Reamer Reference Tools
2. ATTUNE REVISION GENERAL INSTRUMENTATION

Select the appropriate side of the desired Reamer

Reference Tool to prepare the canal.

Align the Canal Reamer with the scribed image on

the Reference Tool. Using the scale, identify the
appropriate engraved mark and corresponding
number on the Reamer as reference for reaming the
canal. If the construct is between Reamer markings,
ream to the next deeper groove.

If it is determined that Femoral Sleeve Preparation

is appropriate to manage the defect, utilize the
indicated depth from the Sleeve and Stem markings
on the Femur Reference Tool. An example of the
Femoral Sleeve and Stem markings are on the
!
following page.
Ream to
Next Groove

i INFORMATION

For the Femur Preparation, the Femoral Box is

variable in depth and therefore the depth of ! CAUTION
reaming is dependent on the size of the femur
used. To avoid under-reaming, the Femur Reamer Always ream to the next largest groove. If a stem
Reference Tools indicate a reaming depth that length is very close to or just past or just before a
corresponds to the largest Femoral Box size, and groove, ream to the next groove; as in the example
thus for smaller femurs, this could result in slight above, which reams to Groove 4 when anticipating
over-preparation of approximately 9 mm. a 110 mm Tibial Stem.

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Reamer Reference Tools

2. ATTUNE REVISION GENERAL INSTRUMENTATION

Example of Reamer Reference Tool use for Press-Fit Stem
and Femoral Sleeve:

Either

1. Pre-operative Planning suggested use of 55 mm

Sleeve with 60 mm Stem. Ream to Groove 6.
or

2. The Cut Through Trial assessment was performed

with a 110 mm Stem Trial and Pre-operative Planning
suggested use of a 55 mm Sleeve. To accommodate
the Sleeve within the overall construct length, a
60 mm Stem should now be used instead of the
110 mm Stem. Ream to Groove 6. The resultant
implant construct (Femoral Component, 60 mm Stem,
55 mm Femoral Sleeve) will align with the Femoral
Sleeve Trial construct but will be slightly longer than
the 110 mm Stem Trial without Sleeve as can be seen
by comparing the position of the 55 mm Sleeve and
60 mm Stem versus the 110 mm Stem without Sleeve
on the Reamer Reference Tool. Refer to page 136
!
for more information on the Cut Through Trial to
Femoral Sleeve workflow.

! CAUTION

Ensure that the Sleeve scale is being referenced. The

appropriate ream depth is dependent on the final
Sleeve size. If it is not apparent what the final Sleeve
size is, ream to the depth corresponding to the largest Reference Tool
Sleeve to avoid not having the canal fully prepared. on Press-Fit Side

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Canal Reamers
2. ATTUNE REVISION GENERAL INSTRUMENTATION

The Canal Reamers come in alternating designs:

the odd diameters are fully fluted and the even
diameters are stepped down. The even diameter
Reamers correspond with definitive Stem Implants
(10, 12, 14, 16, 18, 20, 22, 24 mm) and allow the
Tibial Cutting Block instruments to be adjusted
along the length to set the desired resection height.

The canal may be opened with the fully fluted, !

end cutting, 9 mm Canal Reamer.

Canal Preparation
The Canal Reamers have a standard Hudson
connection and can attach to the Reamer T-Handle
9 mm
for Hand Reaming or can be used with standard Canal
power equipment. Reamer

9 mm Fully Stepped
Introduce the Canal Reamer into the canal to the Fluted Down
appropriate depth.

! CAUTION i INFORMATION

The 9 and 10 mm Canal Reamers in the system are end Reaming should be done based on bone anatomy and size.
resecting. Be cautious to avoid eccentric reaming or
Hand reaming is recommended, however, power reaming
extensive engagement of the cortex.
is available. If power reaming, some tactile feel may
be hindered.

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Canal Reamers

2. ATTUNE REVISION GENERAL INSTRUMENTATION

For Cemented Stem Preparation

Cemented Stems are available in the following sizes:

• 14 mm diameter x 30, 50, 80, 130 mm length

• 16 mm diameter x 80 and 130 mm length

Sequentially open the canal to the same depth with

progressively larger Reamers until reaching the
14 mm or 16 mm diameter Reamer for the 14 or
16 mm Cemented Stem respectively to prepare for
a line-to-line cement mantle.

Avoid cortical contact.

The 80 and 130 mm long Cemented Stems are

tapered 4 mm diametrically, with the 14 mm
diameter Stems tapering to 10 mm and the 16 mm
diameter Stems tapering to 12 mm.
14 x 80 mm
Cemented Stem

16 x 80 mm
Cemented Stem

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Canal Reamers
2. ATTUNE REVISION GENERAL INSTRUMENTATION

For Press-Fit Stem Preparation

Press-Fit Stems are available in the following sizes:

• 10 - 24 mm diameter (2 mm increments) x 60, 110,

160 mm length

Sequentially open the canal to the same depth with

progressively larger Reamers until firm endosteal
engagement is established. Remove any native/
sclerotic bone at the joint surface that could influence
the orientation of the reaming in to the isthmus of Press-Fit Stem
the femur or tibia. Canal reaming should end on an even
diameter to correspond with the Stem Implant offering.
The same diameter final Press-Fit Stem Implant is
designed to have a 1.25 mm diametric press-fit with
respect to the Reamer.

For Offset Stem Preparation Offset Stem Construct

Sequentially open the canal with progressively larger
Reamers to the indicated depth from the Offset Reamer
Reference Tool. For a Press-Fit Stem, ream until firm
cortical engagement is established. Remove any native/
sclerotic bone at the joint surface that could influence
the orientation of the reaming in to the isthmus of
the femur or tibia. Canal reaming should end on an
even diameter Reamer to correspond with the Stem
Implant Offering.

i INFORMATION

Simple cortical contact should not be construed

as engagement.

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Torque Limiting Screwdriver and

2. ATTUNE REVISION GENERAL INSTRUMENTATION

System Hex Attachment
The Torque Limiting Screwdriver attaches to the
System Hex Attachment via an AO connection.

System Hex
Attachment

Torque Limiting
Screwdriver

The Torque Limiting Screwdriver Assembly applies

a 2 Nm torque to aid in assembly of various
instruments throughout the ATTUNE Revision
Instrumentation set.

Tighten to “click” when assembling instruments with !

the Torque Limiting Screwdriver Assembly to ensure
solid assembly throughout preparation and trialing.

“click”

! CAUTION

Not torquing to the “click” may result in trial

components loosening during use or extraction.

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Modular Stop
2. ATTUNE REVISION GENERAL INSTRUMENTATION

The Modular Stop attaches to the Reamers of the

Revision System (excluding Canal Reamers) to aid
in controlling depth when reaming through a
Tower or Bushing. Hudson
End

Slide the Stop over the Hudson end of the Reamer.

Modular Stop

Depress the button on the Modular Stop and place

the Stop at the desired preparation indication on
the Reamer, where it “clicks” into place. Ensure
Modular Stop engages the appropriate groove on
the Reamer before use.

Optionally, the Reamers may be utilized through

the Towers or Bushings without the Modular Stop.
In that application progress the Reamer until the
center of the desired depth line is flush with the
proximal feature of either the Tower or Bushing.

i INFORMATION

Avoid contacting the sharp edges of the Reamer

flutes when attaching the Modular Stop.

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Stem Trial Assembly

2. ATTUNE REVISION GENERAL INSTRUMENTATION

The Stem Trials thread on to their connecting parts.

Stem Trial

To Aid in Disassembly
If necessary, the Stem Trial Driver Bit may be
attached to the end of the Stem Trial and
rotated counter clockwise by hand.

Stem Trial
Driver Bit

Care should be taken not to reverse ream as !

the Stem Trial may become disengaged from
the Reamer.

! CAUTION

Do not reverse ream.

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Stem Trial Extraction
2. ATTUNE REVISION GENERAL INSTRUMENTATION

If the Stem Trial disengages from the Reamer, use the

female end of the Stem Trial and Stabilizer Extractor
Tool to engage the threads of the Stem Trial and
extract it from the canal.

Stem Trial Retrieval

The threaded female (hole) end of the Stem Trial and

Stabilizer Extractor Tool connects with the threaded
male (post) feature on the Stem Trial.

Stem Stabilizer Retrieval

The threaded male (post) end of the Stem Trial and

Stabilizer Extractor Tool connects with the threaded
female (hole) feature on the Stem Stabilizer.

Drop the appropriate end of the Stem Trial and

Stabilizer Extractor Tool into the medullary canal,
turn the handle clockwise until a secure engagement
is acquired to the Stem Trial or Stem Stabilizer, and
pull to extract.

To aid in extraction, there is a through hole in the

Stem Trial and Stabilizer Extractor Tool to allow a
general surgical instrument, such as forceps, to pass
through and create a “T-Handle”.

“pull to extract”

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Tibial Trial Assembly

3. TIBIAL PREPARATION
Revision FB Base Trial
The Revision FB Tibial Base Trial attaches to the FB Adaptor
Trial, FB Stem Adaptor Trial, and the FB Offset Adaptor
Trials via a temporary snap feature.

The FB Adaptor Trial is utilized when the Revision FB Tibial

Base will be implanted without the addition of a Stem
Extension.

The FB Stem Adaptor Trial is utilized when the Revision

FB Tibial Base will be implanted with a Straight Stem
Extension.

The FB Offset Adaptor Trial is utilized when the Revision

FB Adaptor Trial
FB Tibial Base will be implanted with an Offset Adaptor
and Stem Extension. FB Stem
Adaptor Trial

FB Offset
Adaptor Trial

The Trial Assembly must be tightened with the Torque

Limiting Screwdriver Assembly until it “clicks” prior to
handing off the instrument assembly.

“click”

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Anterior Pins
3. TIBIAL PREPARATION

The Revision Cemented Tibial Prep Plates and

Revision FB Base Trials have anterior bump-outs to
receive the Anterior Low-Profile Tibial Pins.

Anterior
Pin Holes

The Anterior Pin Holes are optional and may aid in

fixing Tibial Base Rotation.

The Anterior Low-Profile Tibial Pins are inserted and

extracted using the Low-Profile Tibial Pin Puller.

The Anterior Pins may be used with the 5 mm Tibial

Augment Trial in place, however the 10 and 15 mm
Tibial Augment Trials do not have through holes to
accept the Pins.

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Tibial Preparation - Solutions

3. TIBIAL PREPARATION
Solution 1: Revision Fixed Bearing (FB) Base alone or with Short Cemented
Stem Preparation (30 or 50 mm lengths) (Extramedullary Preparation) go to page 28

Solution 2: Revision Fixed Bearing (FB) Base with Straight Stem or Offset Stem Preparation
(Intramedullary Preparation) go to page 40

Straight Stem

Offset Stem

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Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

Tibial Alignment and Resection - Instrument Assembly

This is the Extramedullary Tibial Preparation of the

Revision Fixed Bearing (FB) Tibial Base, alone (with
the pre-assembled End Cap) or with a 30 or 50 mm
Cemented Stem.

With the Height Adjustment Knob fully unscrewed on

the Tibial Proximal Uprod, attach the Tibial Distal Uprod
to the Proximal Uprod. Then attach the Tibial Ankle
Clamp to the Distal Uprod. Assemble the appropriate
Cutting Block to the Tibial Proximal Uprod. Tibial Jig Assembly

Right Revision
Tibial
Revision Tibial Cutting Block Options Cutting Block
Proximal Central Marking

Extramedullary Tibial
Proximal Uprod

Posterior Slope
Left Revision Tibial Right Revision Tibial
Adjustment
Cutting Block Cutting Block

Height Adjustment Knob

Complete Assembly Extramedullary Tibial

Ankle Clamp

Indicator Line
Anterior Posterior
(A/P) Adjustment
Mechanism

V/V Adjustment
A/P Ratchet
Mechanism

Extramedullary Tibial
Distal Uprod

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Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
Tibial Alignment and Resection

Pinch Lever Correct Placement of Tibial Jig

Set the tibial posterior slope as depicted on

the Proximal Uprod of the Tibial Jig, according i INFORMATION

to the recommendations depending on the Tibia Slope Recommendations: Revision Tibial Base
appropriate implant configuration. constructs will follow the Posterior Stabilized (PS) Slope
recommendation. The Revision Tibial Bases have a 2
degree posterior slope of the Stem with respect to the
Place the knee in 90 degrees of flexion. Place the
tibial plateau. For a PS configuration it is recommended
Ankle Clamp around the malleoli. Set Varus/ to set the tibial posterior slope at 3 degrees.
Valgus (V/V) rotation by aligning the proximal
When using Cruciate Retaining or Cruciate Sacrificing
central marking on the Tibial Cutting Block with
(CR/CS) configuration, with the ATTUNE CR Tibial Insert
the medial one third of the tibial tubercle.
and the ATTUNE CR Femoral Component, it is
recommended to use 5 - 7 degrees of tibial posterior
The axis of the Proximal Uprod should be slope. Surgeons should pre-operatively template a
positioned with reference to the tibial axis. stemmed tibial construct when using a CR/CS
configuration to assess the impact of slope upon Stem

Note that the figures on the Jig will only deliver orientation and fit within the canal.

that angle if the rest of the Jig is set up correctly. If

the slope adjustment is changed after the Cutting
Block is resting against bone, the surgeon should
re-align the Uprod to be parallel to the tibial axis by
i INFORMATION

moving the A/P adjustment mechanism. The Revision Tibial Cutting Blocks slot are set at
0 degrees similar to the ATTUNE Primary INTUITION™
Tibial Cutting Block, the slope is adjusted through the
Extramedullary Tibial Proximal Uprod.

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Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

!
When checking and setting the sagittal alignment, be
careful to prevent anterior slope. This could happen if
the A/P Boss on the Distal Uprod is translated too far
Through-Slot
towards the ankle, exposing the Through-Slot. Posterior
slope adjustment is the equivalent to using Cutting
Blocks with slope built into them.
A/P Boss

A/P Ratchet Side Slot

V/ V Adjustment

Use the V/ V Adjustment Mechanism to align the

Tibial Proximal Uprod parallel to the long axis of the
tibia. For many patients, this involves translating the
V/ V Adjustment Mechanism until the second line
from the lateral side of the ankle clamp lines up with
the indicator line.

Indicator Line
Stylus Attachment

Attach the Adjustable Tibial Stylus to the Cutting

Resection Knob
Block through the slot feature.
Pointer

! CAUTION

Adjustment of the A/P Boss such that the Through- Foot

Slot is visible (as shown) could result in anterior slope.

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Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
Resection through the Slot

When utilizing the Revision Tibial Cutting Block,

resection through the slot is recommended. Position
the foot of the Stylus marked “SLOT” into the “0”
slot of the Cutting Block.

Rotate the Resection Knob to set the resection level

on the Stylus (0 to 10). Each number corresponds to
resection amount in millimeters.

For resection off the top of the block, see the CAUTION
box below for the Stylus. !

Rest the pointer of the Adjustable Tibial Stylus on

the bone according to the presented tibial plateau.

Considerations for tibial plateau resections:

• If a defect is present, the Adjustable Tibial

Stylus may be used to reference the defect and
provide a minimal resection to clean up a
revision tibial plateau, with the option of
augmenting where required

• For a Revision Tibial Plateau, use the Revision

Tibial Cutting Blocks with a minimal resection,
with the option of resecting for augments
where required

Then lock the Height Adjustment Knob on the

Proximal Uprod.

! CAUTION

If resection off the top of the Revision Tibial Cutting

Block is desired, and the “NON SLOT” setting on the
Stylus is used, the resection will be 1 mm less than
indicated with the Stylus due to the saw capture of
the Revision Tibial Cutting Block being 5 mm vs 4 mm
in the INTUITION Instrument set. The subsequent
Augment Slots will be 5 mm deeper than indicated
by the marking on the Block.

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Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

Proximal Tibial Resection

After the height has been set, pin the Revision Tibial
Cutting Block using two Universal Pins.

If necessary, remove the Stylus for better access,

ensuring that the Height Adjustment Knob on the
Tibial Proximal Uprod is locked.

There are multiple Pin hole options in the Revision

Tibial Cutting Block to ensure fixation of the Block.

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Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
Optional: To assess tibial slope prior to
performing the tibial resection, place the
Alignment Handle into the slot feature of
the Revision Tibial Cutting Block, and insert
the Alignment Rod. Alignment can be checked Alignment Handle
by ensuring that the Alignment Rod remains
parallel with the tibial axis.

Additionally, the two Alignment Rods may

be assembled with the Alignment Handle
to assess long leg alignment from hip center
to ankle.

A second Alignment Rod may be inserted

through the Alignment Handle in the M/L
direction to help ensure that the tibia is not
resected in Varus or Valgus.
Alignment Rod
Resect the tibia.

If desired, Medial Augments may be prepared at

this point.

Should Lateral Augments be required, if exposure

permits, utilize the Tibial Cutting Block for the
opposite leg. Vertical Slot

i INFORMATION

The vertical slot in the central aspect of the Tibial

Cutting Block may aid in initiating the center line of
the Tibial Augment resection.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    33
Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

Tibial Sizing

Attach the Alignment Handle to the appropriate

size Revision Tibial Prep Plate based on pre-operative
templating and place onto the resected tibial surface.

Rotation should be set per surgeon preference.

One suggested technique follows:

The rotation of the Tibial Base Trial is typically centered

on the junction between the medial and central
third of the tibial tubercle. Assess the position of
the Base at the proper rotation to maximize tibial
coverage while avoiding overhang. Optionally, a
mark may be made on the anterior cortex of the !
tibia for future reference to tibial rotation.

When using Pins, be careful not to deflect the

Base position. !

Only utilize Non-Headed Pins through the parallel

or angled Pin Hole options on the Prep Plate.

Additionally, the Anterior Pin Holes may be utilized

with the Low Profile Anterior Pins inserted with
the Low Profile Tibial Pin Puller to aid in fixating
the Prep Plate.

Tibial Prep Plates for Sizes 1 - 3 have an anterior Angled Pinning Parallel Pinning
protrusion with an indicated line for the anterior
profile of the definitive implant.

! CAUTION Anterior Profile

Care should be taken when seating the Pins so as to
Example of anterior protrusion for Sizes 1 - 3
not perforate the Tibial Cortex.

i INFORMATION
i INFORMATION
The Revision Tibial Prep Plates are 6 mm thick and are
Final Tibial Base Rotation can also be determined not reflective of the actual Tibial Base Implant or Tibial
during trialing with the Femoral Trial and Revision Base Trial thicknesses. The Prep Plates should not be
Tibial Insert Trial in place. Refer to page 147. utilized to determine definitive Insert thickness.

33    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
With the Revision Tibial Prep Plate in place, attach Revision Tibial
Prep Tower
the Revision Tibial Prep Tower by inserting the spikes
of the Tower through the two inside holes on the
anterior aspect of the Plate.

Revision Cemented
Reamer Bushing

Insert the Revision Cemented

Reamer Bushing into the Tower.

The Revision Tibial Cemented Stem

Reamer includes markings for the
various Short Cemented Stems and
Tibial Base construct depths.

i INFORMATION

The Tibial Cemented Stem Reamer prepares for a

line-to-line fit with the pre-assembled End Cap or the
short (30 mm and 50 mm) Cemented Stem Implants.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    33
Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

Assembly of
Modular Stop
Assemble the Modular Stop to align with the desired to Reamer
FB construct depth on the Revision Tibial Cemented
Stem Reamer and advance the Reamer until the Stop
is flush with the top of the Reamer Bushing.

Revision Tibial
Cemented Stem Reamer

Modular Stop

Revision Cemented
Reamer Bushing

Revision Prep Tower

Modular Stop assembled to the

Cemented Stem Reamer at
the FB with 50 mm Stem mark

The Cemented Stem Reamer may be utilized through

the Reamer Bushing without the Modular Stop.
In that application, progress the Reamer until the
desired depth line is flush with the proximal feature
of the Reamer Bushing.

Remove the Cemented Stem Reamer and

Cemented Reamer Bushing.

i INFORMATION

If preparing for a Revision FB Tibial Base without a

Stem Extension, ream to the “FB-0” mark on the
Cemented Stem Reamer to prepare for the End Cap
on the Tibial Implant.

33    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
Assemble the corresponding Stem Trial to the end of the
Revision Cemented Conical Reamer. If preparing for a FB Line
Revision Base without a Stem Extension utilize the
Conical Reamer without any Stem Trials.

Assemble the Modular Stop to align with the “FB” line

on the Revision Cemented Conical Reamer.

To prepare for the conical section of the Tibial Base,

advance the Conical Reamer through the Tower and
seat to the Stop. The Conical Reamer can be used
without the Modular Stop. In that application, progress
the reamer until the "FB" line on the Reamer is flush
with the proximal surface of the Revision Prep Tower. !

With the tibial canal prepared, remove the Tibial

Preparation Instruments.

! CAUTION

Avoid contacting the sharp edges of the Reamer

flutes when attaching the Modular Stop.

Do not reverse ream.

i INFORMATION

Do not apply excessive force to the Conical Reamer.

If approaching the cortex, stop reaming and consider
a slightly different position on the tibial plateau,
readjustment of tibial slope and the use of cement
to fill any resulting bone voids.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    33
Tibial Preparation
3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION

Straight Tibial Trial Assembly

Choose the appropriate size of FB Base Trial that corresponds to the Tibial
Preparation Plate and assemble the FB Stem Adaptor Trial utilizing the
temporary snap attachment.

Tighten the construct using the Torque

Limiting Screwdriver Assembly.

FB Base Trial construct with a

14 x 50 mm Cemented Stem Trial

“click”

Assemble the Cemented

Stem Trial to the end of the
FB Stem Adaptor Trial.

If preparing for a Revision FB Tibial Base without a Stem

Extension, assemble the FB Adaptor Trial to the appropriate
FB Base Trial and tighten the construct with the Torque
Limiting Screwdriver Assembly.

i INFORMATION

FB Base Trial with FB Adaptor Trial is utilized when the Revision FB

FB Adaptor Trial Tibial Base will be implanted without the addition
of a Stem Extension.

33    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FIXED BEARING (FB) BASE ALONE OR WITH SHORT CEMENTED STEM PREPARATION
Seat the Tibial Base Trial construct into the prepared
bone using the Revision System Handle attached directly
to the FB Base Trial.

Proceed to Revision Femoral Preparation on page 54

prior to setting the final FB Tibial Base Rotation and
preparing for the Keels.

Tibial Base Trial

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    33
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Canal Preparation

This is the Intramedullary Tibial Preparation of the

Revision FB Tibial Base, with the following Stems:
- Cemented Stem: 80 or 130 mm lengths,
- Press-Fit Stems: 60, 110, 160 mm lengths,
- Offset Adaptor with a Press-Fit Stem.

When pre-operative evaluation indicates that

Press-Fit or Long (>50 mm) Cemented Tibial Stem
Extensions are required, it is recommended to
prepare the proximal tibia with reference to the
position of the IM canal.

Straight Stem Offset Stem

Utilize the Tibial Reamer Reference Tool. Utilize the Tibial side of the Offset Reamer
Refer to pages 15 - 17. Reference Tool. Refer to pages 15 - 17.

Assemble the Canal Reamer to either the Reamer

T-Handle or standard power. Sequentially straight
canal ream to the appropriate depth and diameter
and leave the Reamer in place, remembering to finish
on an even diameter Reamer, refer to pages 18 - 20.

44    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Select the appropriate sided Block, and assemble

the Cutting Block Mount to the Revision Tibial
Cutting Block.

Cutting Block Mount

IM Mount

Assemble to the IM Mount.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    44
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Lock Knob

Assemble the Revision IM Mount to the Canal

Reamer.

Adjust the Tibial Cutting Block Assembly to

the desired level of proximal tibial resection.

An Angel Wing, or the “Slot” Foot of the

ATTUNE Primary INTUITION Tibial Stylus !
may be used to assist with setting depth.

Angel Wing
Lock Knob

Lock the Jig in place by tightening the Lock

Knob over the IM Mount.

Stylus with Slot Foot

! CAUTION

If resection off the top of the Revision Tibial Cutting

i INFORMATION

Block is desired, and the “NON SLOT” setting on the The Revision Tibial Bases have a 2 degree posterior slope
Stylus is used, the resection will be 1 mm less than of the Stem with respect to the tibial plateau.
indicated with the Stylus due to the saw capture of
the Revision Tibial Cutting Block being 5 mm vs 4 mm The 2 degree posterior resection is built into the
in Primary Tibial Cutting Block. The subsequent IM Mount and will provide a fixed angle of resection
Augment Slots will be 5 mm deeper than indicated when assembled to the Intramedullary based
by the marking on the Block. Canal Reamers.

44    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Tibial Resection

Straight Stem Offset Stem

Pin the Tibial Cutting Block.

Make tibial resection. Vertical Slot

If desired, Medial Augments may be prepared at this

point.

Should Lateral Augments be required, if exposure

permits, utilize the Tibial Cutting Block for the
opposite leg.

Remove Tibial Cutting Block and Pins

(and other tibial instruments).

i INFORMATION

The Canal Reamer and Tibial Jig Assembly may be

i INFORMATION

removed from the canal in order to complete the The vertical slot in the central aspect of the Tibial Cutting
tibial resection. To do so, move both levers on the Block may aid in initiating the center line of the Tibial
Cutting Block Mount to the unlock position, slide Augment resection.
the Cutting Block Mount anteriorly and then remove
the assembly proximally while leaving the Cutting
Block pinned in place.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    44
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Attach the Alignment Handle to the appropriate size

Revision Tibial Prep Plate and place onto the resected
tibial surface.

Rotation should be set per surgeon preference.

One suggested technique follows:

The rotation of the Tibial Base Trial is typically

centered on the junction between the medial and
central third of the tibial tubercle. Assess the position
of the Base at the proper rotation to maximize tibial
coverage while avoiding overhang. Optionally, a mark
may be made on the anterior cortex of the tibia for
future reference to tibial rotation.

Tibial Prep Plates for Sizes 1 - 3 have an anterior

protrusion with an indicated line for the anterior
profile of the definitive implant.

Anterior Profile

Example of anterior protrusion for Sizes 1 - 3

i INFORMATION i INFORMATION

Final Tibial Base Rotation can also be determined The Revision Tibial Prep Plates are 6 mm thick and are
during trialing with the Femoral Trial and Revision not reflective of the actual Tibial Base Implant or Tibial
Tibial Insert Trial in place. Refer to page 147. Base Trial thicknesses. The Prep Plates should not be
utilized to determine definitive Insert thickness.

44    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

If required, reintroduce the final Canal Reamer

to the previously prepared depth.

Introduce the Revision Tibial Prep Plate over the

Canal Reamer.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    44
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Perform a preliminary assessment of canal

position with a Neutral (0 mm) Offset Guide.

If desired rotation and coverage is achieved with

Neutral position, proceed to the next page. If not
the following strategies could be used:

Straight Stem Offset Stem

• Reassess Tibial sizing • Evaluate the 2, 4, 6 mm offset positions via the

corresponding Tibial Offset Guides

For Straight Stem preparation, proceed to page 47. For Offset Stem preparation, proceed to page 48.

i INFORMATION i INFORMATION

The Neutral (0 mm) Tibial Offset Guide is equivalent The Offset Adaptor extends the length of the
to using a Straight Stem and is available for initial construct by 25 mm which should be considered
Canal-to-Plateau assessment. There is no 0 mm Offset when addressing anatomy with significant bow.
Adaptor Implant. If this 0 mm provides better
coverage, proceed with Straight Stem preparation.

44    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Canal Preparation

Straight Stem

Attach the appropriately sized Stem Trial to the

FB Conical Reamer.

Top of the
Reamer Flutes

Ream the tibia until the top of the Reamer flutes

are level with proximal tibial plateau.
!

For Straight Tibial Trial Assembly, proceed to page 52.

! CAUTION

Do not reverse ream.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    44
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Offset Base Preparation

Offset Stem

Once the desired offset amount and orientation is

determined, pin the Tibial Prep Plate in place through
the Parallel Pin Holes.

Parallel Pin Hole

Note the number value aligned with the front,
central mark on the Tibial Prep Plate, this is what
will be used to set the initial Trial orientation.

Offset Guide
number value

Central mark

Remove the Tibial Offset Guide.

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Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Offset Base Preparation

Offset Stem

Translate the Tibial Prep Plate vertically along the

Parallel Pins, remove the Canal Reamer, and
reintroduce the Tibial Prep Plate onto proximal
tibia via the Parallel Pins.

If Pins become dislodged from the tibia when

extracting the Prep Plate, reintroduce them to their
original position prior to reintroducing the Tibial
Prep Plate to ensure proper placement of the Prep
Plate for subsequent surgical steps.

i INFORMATION

For smaller magnitude offsets and/or smaller

diameter Canal Reamers, the Canal Reamer may be
extracted from the tibia without first having to
remove the Tibial Prep Plate.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    44
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Offset Base Preparation

Tibial Prep Tower

Offset Stem

Next, locate the spikes of the Revision Tibial Prep

Tower in the anterior holes of the Prep Plate and
seat the Tower until it is flush with the Prep Plate.

Tibial Prep Tower

Offset Bushing

Assemble the Tibial Prep Tower Offset Bushing

to the Tower.

55    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Offset Base Preparation

Offset Stem

Assemble the Modular Stop to the TIB marking on the

Offset Drill.

Introduce the Offset Drill to the Offset Bushing and

seat the Drill to the TIB marking or when the Stop is
flush with the proximal aspect of the Offset Bushing.

Tibial
Prep
Stop Tower

Tibial Offset
Bushing

Offset Drill

!
Angled Pin
Holes

For Offset Tibial Trial Assembly, proceed to page 52.

i INFORMATION ! CAUTION

Angled Pin Holes are available in the Prep Plate for If cortex is reached when advancing the Offset Drill,
added stability. Utilize the Angled Pin Holes after the stop drilling to avoid cortical perforation, and
Canal Reamer has been removed from the tibia. reassess the required offset magnitude and/or
rotation, or consider the use of a Straight Stem.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    55
Tibial Preparation
3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Assemble the FB Base Trial with the FB Stem Assemble the FB Base Trial with the appropriate
Adaptor and appropriate Stem Trial. magnitude Tibial Offset Adaptor Trial (2, 4, or 6 mm).

To set the preliminary offset orientation, rotate the

Tibial Offset Adaptor Trial to the offset orientation
noted from the Tibial Offset Guide.

Offset Guide
Orientation

Tibial Offset
“click” Adaptor Trial

Central mark

Lock the preliminary orientation using the

Torque Limiting Screwdriver Assembly.

FB Stem Adaptor Trial

“click”

Stem Trial Tibial Offset

Adaptor Trial

Assemble the appropriately sized Stem

Trial to the Tibial Offset Adaptor Trial.

55    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Preparation

3. REVISION FB BASE WITH STRAIGHT STEM OR OFFSET STEM PREPARATION

Straight Stem Offset Stem

Seat the Tibial Base Trial construct into the prepared

bone using the Revision System Handle attached
directly to the FB Base Trial.

Proceed to Revision Femoral Preparation on page 54

prior to setting final FB Tibial Base Rotation and
preparing for the Keel.

FB Tibial Base Trial Assembly with Straight Stem FB Tibial Base Trial Assembly with Offset Stem

i INFORMATION

Temporary anterior fixation holes and corresponding

Pins are available to lock rotation during and after
trialing if desired.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    55
General Femoral Instrumentation
4. REVISION FEMORAL PREPARATION

Torque Driver and 6 mm Hex Driver

Torque Driver

The Torque Driver Assembly is utilized when

tightening instruments to Femoral Broaches,
6 mm Hex Driver
Boss Trials, and Femoral Offset Adaptor Trials. The
Assembly applies a torque to the constructs to aid
in maintaining a tight connection throughout the
surgical process and to aid in setting final implant
rotation based off of the Femoral Trial construct.

Tighten to “click” when assembling Femoral

!
Instruments and associated constructs with the
Torque Driver Assembly to ensure solid assembly
throughout preparation and trialing.

“click”

! CAUTION

Not torquing to the “click” may result in Trial

components loosening during use or extraction.

55    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
General Femoral Instrumentation

4. REVISION FEMORAL PREPARATION

Femoral Trial Assembly - Boss Trial

Cut Through Trial Boss Trial

Box Trial

Straight Stem

Stem Trial Bolt

The Boss Trial attaches to the proximal side of the

Femoral Trial utilizing the Stem Trial Bolt passed
through the Box region of the Femoral Trial. The Stem Trial Bolt
Stem Trial then threads on to the Boss Trial.

The Cut Through Trial can be assembled with the IM

Connector for the Cut Through Trial workflows in
cases where it is desired to use the Cut Through Trial
prior to final box preparation. Otherwise it should be
assembled to the Box Trial (shown below).
“click”

Torque Driver Assembly

Tabs

Box Trial and Boss Trial

Stem Trial

i INFORMATION

The distal surface of the Boss Trial has a recess to

interface with the tabs on the box of the Femoral
Trial components.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    55
General Femoral Instrumentation
4. REVISION FEMORAL PREPARATION

Femoral Trial Assembly - Boss Trial

Solid Femoral Trial Boss Trial

Box Trial

Straight Stem

Stem Trial Bolt

The Boss Trial attaches to the proximal side of the

Femoral Trial utilizing the Stem Trial Bolt passed
through the Box region of the Femoral Trial. The Stem Trial Bolt
Stem Trial then threads on to the Boss Trial.

“click”

Torque Driver Assembly

Tabs

Stem Trial

i INFORMATION

The distal surface of the Boss Trial has a recess to

interface with the tabs on the box of the Femoral
Trial components.

55    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
General Femoral Instrumentation

4. REVISION FEMORAL PREPARATION

Femoral Trial Assembly - Offset Adaptor Trial for Offset Stem

Offset Stem

The Femoral Offset Adaptor Trial attaches to the proximal

side of the Femoral Trial utilizing the Stem Trial Bolt passed
through the Box region of the Femoral Trial. The Stem Trial
threads on to the Femoral Offset Adaptor Trial.

Cut Through Trial Solid Femoral Trial

Stem Stem
Trial Bolt Trial Bolt

Stem Trial Bolt Stem Trial Bolt

Torque Driver Assembly Torque Driver Assembly

“click” “click”

Orientation Feature

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    55
General Femoral Instrumentation
4. REVISION FEMORAL PREPARATION

Femoral Trial Assembly - Broach Trial for Femoral Sleeve

Sleeve and Stem

The Femoral Broach attaches directly to the Box of the

Femoral Trial via the Broach Bolt.

The Femoral Trial will generally be assembled to the

Broach when it is in situ on the bone. Broach Bolt

Cut Through Trial Solid Femoral Trial

“click” “click”

Torque Driver Assembly Broach Bolt Torque Driver Assembly Broach Bolt

Orientation Feature

55    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
General Femoral Instrumentation

4. REVISION FEMORAL PREPARATION

Femoral Boss Reamer
Stem Trial
Boss Reamer

When reaming with the Femoral Boss Reamer the

appropriate Stem Trial should always be assembled to
the end of the Boss Reamer.

There are different depth indications on the Femoral

Modular Stop
Boss Reamer:

1) T
he single engraved line closest to the Hudson
Connection:
Ream to this line any time the Boss Reamer is going
through a Reamer Guide.
Additionally, the Modular Stop may be assembled to
this line to aid in controlling the depth of the Reamer
Single Line
and should be seated flush against the Reamer Guide.

2) The grouping of three lines closest to the cutting flutes

of the Boss Reamer:
In preparations where the Boss Reamer is being Guided
by a Stem Trial (not passing through a Reamer Guide),
seat the Boss Reamer until the appropriate femoral size
marking group is aligned with the distal surface of the
femur (or distal surface of any prepared Augments). No Modular Stop

The size groupings on the Boss Reamer represent the

distal bone surface and not the anticipated joint line.

The Modular Stop will NOT connect to these positions.

Three Lines

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    55
General Femoral Instrumentation
4. REVISION FEMORAL PREPARATION

Femoral Augment Trial Assembly

The Femoral Augment Trials slide in from the side of

the Femoral Trials and have a magnet for retention.

When assembling the Augment Trials to the Femoral

Trial while on the bone, it may be necessary to
slightly distract the Femoral Trial to allow clearance
for assembly.

To remove the Femoral Augment Trial:

1. G
ently press on the posterior aspect of the Distal
Augment Trial.
1
2. Slide to the exterior of the Femoral Component.
2

For the Posterior Augment Trial:

1. G
ently press on the distal aspect.

2. Slide exteriorly.

i INFORMATION

Where appropriate, Femoral Augment resections may

be made through the Conventional Cut Guide, Notch
Guide, or Cut Through Trial. 1

i INFORMATION
2
Femoral Augment Trials are shared across 2 sizes:
1 - 2, 3 - 4, 5 - 6, 7 - 8, and 9 - 10 and may be utilized ! CAUTION
on the “Left or Right” medial or lateral for the
corresponding Distal or Posterior Augment Trials; The ATTUNE Revision Femoral Augment Trials contain
the Femoral Augment Implant sizes correspond to the magnets. These devices should be kept at a safe
Femoral Implant size and are not shared across sizes. distance from a patient’s active implantable medical
Additionally, each Augment Trial is marked with two device(s) (i.e. pacemaker) in order to avoid adversely
colored dots which correspond to the size and color affecting the device. The Femoral Augment Trials
markings for the compatible Femoral Component. should be kept at an appropriate location when not in
The Compatibility Chart can be found on Page 216. use in the surgical site.

66    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
General Femoral Instrumentation

4. REVISION FEMORAL PREPARATION

Distalizing Gauge

The Distalizing Gauge may be utilized to provide an additional

reference to the epicondyles and ultimately joint line placement.
There are reference marks on the Distalizing Gauge in 5 mm
increments to allow for assessment of the distance of the joint Distalizing Gauge
line from the medial or lateral epicondyle, as desired.

The "0" line indicates the joint line of the Femoral Component
and is level with:

• The articular surface of the Revision Femoral Trials

• The distal surface of the Conventional Cut Guide

The Distalizing Gauge slides into:

• The channels for the Distal Spacers in the Conventional

Cut Guide

• The channels for the Femoral Augment Trials in the

Femoral Trials

• Or the channels in the Medial and Lateral sides

of the Broach Stop

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    66
Revision Femoral Preparation - Solutions
4. REVISION FEMORAL PREPARATION

Solution 1: Revision Femoral Component with Short Cemented Stem With Cut Through Trials
(go to page 63)

Cut Through Trial

This workflow positions the Femoral Component with a Short Cemented Stem relative to the femoral
bone resections as determined using the ATTUNE Primary INTUITION A/P Chamfer Block from the
ATTUNE Primary INTUITION Instruments Surgical Technique.

Solution 2: Revision Femoral Component with Short Cemented Stem With Solid Femoral Trials
(go to page 68)

Conventional Cut Guide

This workflow positions the Femoral Component with a Short Cemented Stem relative to the femoral
bone resections as determined using the ATTUNE Primary INTUITION A/P Chamfer Block from the
ATTUNE Primary INTUITION Instruments Surgical Technique.

Revision Femoral Component with Intramedullary (IM) Preparation

Solutions 3 and 4 position the Femoral Component relative to the IM Canal with the positioning
being driven by the fixation achieved through Long Stems or Femoral Sleeves.

Femoral Sleeve
Straight Stem Offset Stem
and Stem

Solution 3: Revision Femoral Component with Intramedullary (IM)

Preparation with Conventional Cut Guide (go to page 74)

Conventional Cut Guide

Solution 4: Revision Femoral Component with Intramedullary (IM)

Preparation with Cut Through Trials (go to page 74)

Cut Through Trial

66    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH CUT THROUGH TRIALS)
Cut Through Trial

This is the Extramedullary Preparation of the

Revision Femoral Component with a 30, 50, or
80 mm Cemented Stem.

When using an 80 mm long Cemented Stem (14 mm or

16 mm in diameter) and based on pre-operative
templating, the size of the Femoral Stem and bow of the
femoral canal should be taken into consideration when
determining if the longer Stem is suitable for the patient.

This technique positions the Stem based on the

femoral bone cuts rather than the patient’s Femoral Finishing - Cut Through Trial
intramedullary canal.
Take the corresponding size Revision Cut Through
Follow the femur preparation stages described in Femoral Trial (without any attachments assembled)
the ATTUNE Knee System ATTUNE Primary INTUITION and place on the prepared distal femur. Locate the
Instruments Surgical Technique. Once the chamfer Cut Through Trial in the desired M/L position on the
resections are made, remove the ATTUNE Primary prepared distal femur.
INTUITION A/P Chamfer Block.
Pin the Cut Through Trial in place.
Delay resecting the Femoral Box as the Revision Box
will be prepared using the Cut Through Trial to set
If Augments are required, make the appropriate
the M/L position.
resections through the Distal and/or Posterior

i
v INFORMATION
Augment slots ensuring that Pins are not in the
way. Femoral Augment Trials may be loaded from
Reference the ATTUNE Knee System ATTUNE Primary the side. !
INTUITION Instruments Surgical Technique for femur
preparation.
Pins can pass through the Augment Trials after
they are in place, however, the Pins must be
! CAUTION removed to perform the resection and to allow
for the trials to slide into position.
The ATTUNE Revision Femoral Augment Trials contain
magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
i INFORMATION

affecting the device. The Femoral Augment Trials The Cut Through Trials are available in Sizes 3 - 10.
should be kept at an appropriate location when not in The Conventional Cut Guide must be utilized to prepare
use in the surgical site. femurs of sizes 1 or 2.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    66
Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH CUT THROUGH TRIALS)

Femoral Finishing - Cemented Stem Preparation

Cut Through Trial

Introduce the correct side “Left or Right” and size

(3, 4 - 7, or 8 - 10) Femoral Trial Reamer Guide and
attach to the Cut Through Trial by tightening the
Hexes using the Torque Limiting Screwdriver Assembly.

Introduce the 14 mm Femoral Reamer Bushing to

the Reamer Guide. Femoral Trial Reamer Guide

Femoral Reamer Bushing

Attach the Modular Stop to the desired 30, 50, or

80 mm line of the 14 mm Cemented Femoral Reamer.

Seat the Reamer to the Stop. !

Proceed to Boss Preparation on page 65.

50 mm Line

If a 16 mm x 80 mm Cemented Stem is desired,

introduce the 16 mm Femoral Reamer Bushing to
the Reamer Guide.

Ensure the 80 mm long Stem is appropriate for the

!
patient's anatomy as previously described on page 63.

Attach the Modular Stop to the 80 mm line of

the 16 mm Cemented Femoral Reamer.

Seat the Reamer to the Stop. ! Femoral

Reamer Bushing
Proceed to Boss Preparation on page 65.

! CAUTION
16 mm Cemented
Avoid cortical contact. Femoral Reamer

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Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH CUT THROUGH TRIALS)
Femoral Finishing - Boss Preparation

Cut Through Trial

To prepare for the Femoral Boss, remove the Femoral

Boss Reamer
Reamer Bushing and prepare the femoral canal with
the Femoral Boss Reamer.

Modular Stop

Assemble the appropriate Cemented Stem Trial to

the Femoral Boss Reamer and attach the Modular
Stop to the most proximal line on the Femoral Boss
Reamer.

Seat the Reamer to the Stop.

Remove all instruments except the Cut Through

Trial and Pins.

! CAUTION

Do not reverse ream.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH CUT THROUGH TRIALS)

Femoral Finishing - Box Resection

Cut Through Trial

A Reciprocating Saw is recommended for resecting the

sides of the Femoral Box. Use the side walls of the box
opening on the Cut Through Trial as a guide.

Attach the Box Cut Platform to the anterior flange

of the Cut Through Trial and proceed to resect
the top of the box with the Reciprocating Saw or
Narrow Saw Blade. A groove is machined into the
bridge between the posterior condyles, once the
top of the box resection has been completed this
groove is fully visible.

Check completeness of the box resection with the

Angel Wing against the Box Cut Platform and along
the sides of the box opening in the Cut Through Trial. !

Remove the Box Cut Platform.

Groove
! CAUTION

If the box resection is not complete, the connecting

components of the Cut Through Trial may not seat.

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Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH CUT THROUGH TRIALS)
Femoral Trial Assembly

Cut Through Trial

Assemble the Cut Through Femoral Trial with

the Box Trial, Boss Trial, Stem Trial Bolt, Stem
Trial, and any appropriate Augment Trials. !

“click”

“click”

Torque Limiting Torque Driver Assembly

Screwdriver Assembly

Boss Trial
Introduce the Femoral Trial Assembly to the
prepared femur. Utilize the ATTUNE System !
Impactor to seat the Femoral Trial Assembly.

Introduce the Revision Tibial Insert Trial and proceed

to setting Tibial Base Rotation on page 147.

! CAUTION
The Box Trial is size and side specific.

! CAUTION
ATTUNE System Impactor
The ATTUNE Revision Femoral Augment Trials contain
magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical ! CAUTION
device(s) (i.e. pacemaker) in order to avoid adversely
If Femoral Trial Assembly does not seat to the
affecting the device. The Femoral Augment Trials
should be kept at an appropriate location when not in intended depth, verify that the depth of the box
use in the surgical site. resection was correct.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)

Conventional Cut Guide

This is the Extramedullary Preparation of the Revision

Femoral Component with a 30, 50, or 80 mm
Cemented Stem.
Revision Notch Guide

When using an 80 mm long Cemented Stem (14 mm

or 16 mm in diameter) and based on pre-operative
templating, the size of the Femoral Stem and bow
of the femoral canal should be taken into consideration
when determining if the longer Stem is suitable for
the patient.

This technique positions the Stem based on the

femoral bone cuts rather than the patient’s
intramedullary canal.

Follow the femur preparation stages as described Conventional Cut Guide

in the ATTUNE Knee System ATTUNE Primary
INTUITION Instruments Surgical Technique. Once
the chamfer resections are made remove the
ATTUNE Primary INTUITION A/P Chamfer Block.
Delay resecting the Femoral Box as the Revision
Box will be prepared with the Conventional Cut
Guide and Revision Notch Guide.

Take the corresponding Conventional Cut Guide

and Revision Notch Guide and place on the prepared
distal femur. Locate the Assembly in the desired M/L
position on the prepared distal femur.

Pin the Conventional Cut Guide and Revision Notch

Guide in place.

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4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)
Augment and Cemented Stem Preparation

Conventional Cut Guide

If Augments are required, make the appropriate

resections through the Distal and/or Posterior Augment
slots ensuring that the Pins are not in the way.

Insert the appropriate Distal Spacers by loading from

the side of the Conventional Cut Guide.

Distal Spacer

Introduce the Conventional Cut Guide Reamer Guide

so that the correct text "LEFT" or "RIGHT" is legible
when assembled to the Conventional Cut Guide and
the 14 mm Femoral Reamer Bushing.

Conventional Cut Guide

Reamer Guide
Femoral Reamer
Bushing

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)

Cemented Stem Preparation

Conventional Cut Guide

Attach the Modular Stop to the desired 30, 50,

or 80 mm line of the 14 mm Cemented Femoral
Reamer.

Modular Stop 50 mm Line

Seat the Reamer to the Stop.

Proceed to Boss Preparation on page 71.

Femoral Reamer Bushing

If a 16 mm x 80 mm Cemented Stem is desired, 16 mm Cemented

introduce the 16 mm Femoral Reamer Bushing ! Femoral Reamer
to the Reamer Guide. Ensure the 80 mm long
Stem is appropriate for the patient’s anatomy
as previously described on page 63.

Attach the Reamer Stop to the 80 mm line of the

16 mm Cemented Femoral Reamer.

Seat the Reamer to the Stop.

Proceed to Boss Preparation on page 71.

! CAUTION

Avoid cortical contact.

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4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)
Boss Preparation

Conventional Cut Guide

To prepare for the Femoral Boss, remove the Femoral

Reamer Bushing.

Boss Reamer

Assemble the Stem Trial to the Femoral Boss Reamer

and attach the Reamer Stop to the most proximal line
on the Femoral Boss Reamer.

Modular Stop

Seat the Reamer to the Stop.

With the Femoral Boss prepared, remove the Boss

Reamer and the Conventional Cut Guide Reamer
Guide Assembly.

! CAUTION

Do not reverse ream.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)

Box Resection and Femoral Trialing

Conventional Cut Guide

Resect the sides and top of the Femoral Box with a

Reciprocating Saw. Use the side walls and top ledge
of the box as a guide.

With the femoral preparation complete, remove the

Conventional Cut Guide Assembly.

Solid Femoral Trial

Femoral Trialing Boss Trial

Assemble the Solid Femoral Trial with the Boss Trial, Stem Stem Bolt

Bolt, Stem Trial, and any appropriate Augment Trials. !

“click”

Torque Driver Assembly

Stem Trial
! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely Augment Trial
affecting the device. The Femoral Augment Trials
should be kept at an appropriate location when not in
use in the surgical site.

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4. REVISION FEMORAL COMPONENT WITH SHORT CEMENTED STEM (WITH SOLID FEMORAL TRIALS)
Femoral Trialing

Conventional Cut Guide

!

Introduce the Solid Femoral Trial Assembly to the

prepared femur. Utilize the ATTUNE System Impactor
to seat the Femoral Trial Assembly.

ATTUNE System Impactor

Introduce the Revision Tibial Insert Trial

and proceed to Setting Tibial Base Rotation
on page 147.

! CAUTION

If Femoral Trial Assembly does not seat to the

intended depth, verify that the depth of the box
resection was correct.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

According to user preference and amount of distal femoral bone loss,

choose one of the following to perform the femoral bone preparation:

For either workflow, proceed to pages 75 - 79 prior to progressing

to Conventional Cut Guides or Cut Through Trials.

Solution 3 Solution 4

Conventional Cut Through Trials

Cut Guide These should only be used when
there is femoral bone loss that allows for
(Pages 80 - 120) a sliding fit of the Cut Through Trial before
A/P and chamfer resections. Cut Through
OR Trials are available in Sizes 3 - 10.
(Pages 121 - 146)

Straight Stem Femoral Sleeve Offset Stem Straight Stem Femoral Sleeve Offset Stem
and Stem and Stem

i INFORMATION

Regardless of the instruments used for these remaining femoral bone

preparation steps, either the Cut Through Trial or Solid Femoral Trial
can be used for trialing and range of motion evaluation.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Canal Reaming

Cut Through Trial Conventional Cut Guide

Straight Stem Offset Stem

Utilize the “With Stem” indications on Utilize the Femoral side of the
the Femoral Reamer Reference Tool. Offset Reamer Reference Tool.
Refer to pages 15 - 17. Refer to pages 15 - 17.

Femoral Sleeve and Stem

Utilize the “With Sleeve and Stem”

indications on the Femoral Reamer
Reference Tool. Refer to pages 15 - 17.

Assemble the Canal Reamer to either the Reamer

T-Handle or standard power. During canal
preparation for Femoral Sleeves, care should be
taken to posteriorize the Reamer in the distal
femoral bone and not allow for the hard posterior
bone to drive the femoral position anteriorly
i.e. so that the Femoral Component is not extended. 16 mm Canal Reamer

Straight canal ream to appropriate depth and desired

canal fit, remembering to finish on an even diameter
Reamer. Refer to pages 18 - 20.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Distal Resection

Cut Through Trial Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

It is possible to use the INTUITION Distal Femoral

Guide to perform a distal clean up cut.
Use the Jig prior to canal reaming and follow the
instructions in the ATTUNE Knee System ATTUNE
Primary INTUITION Instruments Surgical Technique,
setting the instrument to 5 degrees valgus and set
for a minimal amount of resection. Distal Femoral Outrigger

Alternatively, the distal femoral resection can be

made off of the Canal Reamer as described. After
progressively reaming, retain the even diameter
Canal Reamer in the femoral canal. Distal Femoral Mount

Assemble the Revision Distal Femoral Mount to

the Revision Distal Femoral Outrigger. Ensure the
correct “R5” for Right, 5 degrees valgus or “L5”
for Left, 5 degrees valgus is legible on the Distal
Femoral Mount.

Assemble the INTUITION Distal Femoral Cutting

Block to the Revision Distal Femoral Outrigger.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Distal Resection

Cut Through Trial Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

Slide the Distal Femoral Jig Assembly over the shaft

of the Canal Reamer until the Distal Femoral Mount Distal Femoral
rests on the most prominent distal femoral bone. Outrigger

The Cutting Block is positioned so that it takes a

2 mm clean up resection from the bone contacting
surface of the Distal Femoral Mount.

Distal Femoral Mount

If the Distal Femoral Jig Assembly does not rest on

the most prominent distal bone, an Angel Wing may
be utilized through the slot of the Cutting Block to
reference the prominent bone. Once pinned
through the holes with a central line, the Cutting
Block can be repositioned by using the Distal Pin
Holes in the Block to translate it proximally 2 mm. Angel Wing

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Distal Resection

Cut Through Trial Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

Divergent Pin Holes

Secure the Cutting Block to the femur with two

Universal or Non-Headed Pins through the holes
marked with a center line. If necessary for additional
stability, insert a Universal or Non-Headed Pin through
one of the Divergent Pin Holes on the Cutting Block.

Disengage the Distal Femoral Cutting Block from the

Outrigger Slide by pressing the lever on the Outrigger.
Pull the entire Instrument distally.

1
Optionally, the distal femoral resection may be made 1
with the Distal Femoral Jig Assembly in place by using
a narrow, 1/2 inch, Saw Blade.

To further adjust the distal resection depth once

the Distal Femoral Jig is removed, use the Distal
2
or Proximal Pin Holes, that move the Block 2 mm
in either direction.

If desired, the Canal Reamer can be removed from

the femoral canal in order to complete the distal
femoral resection.

Resect the distal femur.

Remove the Distal Femoral Cutting Block and Pins.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Sizing the Femur

Cut Through Trial Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

When sizing the femur, select the component that maximizes

the femoral size while avoiding M/L overhang.

There are three suggested methods to assess the femoral size

based on M/L dimension in addition to pre-operative templating:

• Place the Cut Through Trial Body over the distal femur

• Hold the Conventional Cut Guide against the distal

femoral bone as the M/L width of the Conventional
Cut Guide represents that of the Femoral Implant

• Place the Solid Femoral Trial backwards against the distal

femur as the M/L width of the Femoral Trial represents that
of the Femoral Implant

For Conventional Cut Guide proceed to page 80.

For Cut Through Trial proceed to page 121.

i INFORMATION

The Cut Through Trials are available in Sizes 3 - 10. The Conventional Cut
Guide must be utilized to prepare femurs of sizes 1 or 2.

i INFORMATION

If there is substantial bone loss, once the femoral size has been determined
and the canal has been prepared, the Cut Through Trial may be assembled
to the corresponding IM Connector, Boss Trial or Offset Adaptor Trial, Stem
Trial Bolt and appropriate Stem Trial and inserted into the femoral bone.

Proceed to Femoral Preparation through the Cut Through Trial on page 121.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Setting Femoral Position

Conventional Cut Guide

Straight Stem
Proceed to page 81

Femoral Sleeve and Stem

Proceed to page 83

Offset Stem
Proceed to page 91

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Setting Femoral Position

Conventional Cut Guide

Straight Stem
IM Adaptor

This is the Intramedullary Preparation of the

Revision Femoral Component with a Press-Fit
or long Cemented Stem.

Once the definitive Reamer diameter has been “click”

determined, assemble the:
Torque Limiting
Screwdriver Assembly
1. Conventional Cut Guide to IM Adaptor with
the Hex Attachment

Lock Barrel

2. Stem Stabilizer to the IM Adaptor by aligning

the triangular feature on the Adaptor to the
corresponding features on the Stem Stabilizer
and turning the lock barrel of the IM Adaptor
to tighten to the Stem Stabilizer. Triangular Stem
Feature Stabilizer

3. Stem Trial to the Stem Stabilizer

Ensure that the correct “Right or Left” marking is

facing upward on the IM Adaptor when assembled
to the Conventional Cut Guide.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Setting Femoral Position

Conventional Cut Guide

Straight Stem

Introduce the Conventional Cut Guide Assembly

into the femoral bone. If impaction is necessary,
the Revision System Handle must be attached
to the IM Adaptor and used to gently seat the
assembly. The Conventional Cut Guide should
not be impacted directly.

Ensure that the construct is stable in the canal.

Revision System
Handle
Please note that the Stem attached to the Conventional
Cut Guide Construct is designed to provide support
and therefore the Stem length will not be identical
to all of the variable Final Trial Constructs. The IM
Adaptor length is designed to align with the middle
of the femoral box groupings (sizes 4 - 7) to reduce i INFORMATION
complexity within the system, and is 4 mm shorter
The Stem Stabilizers are tapered and measure 1 mm
than the largest grouping (sizes 8 - 10).
larger in diameter at the distal end and taper to
be equivalent to the comparable Stem Trial at
The markings on the Reamer Reference Tools are the proximal end. If necessary, to avoid potential
positioned for the femoral canal to be prepared to femoral fracture, the distal femoral canal may be
the longest of the femoral box groupings (sizes 8 - 10) opened with the next larger Canal Reamer to
to ensure the canal is prepared for the final Implant allow for introduction of the Stem Stabilizer, but

of all size groupings. care should be taken not to sink in the Reamer
too far in the canal.

For Gap Balancing and Setting Rotation with a Stem Stabilizers are available in 14, 16, 18, 20, 22, and
Straight Stem, proceed to page 95. 24 mm sizes and should be chosen to correspond with
the Stem diameter used but may be adjusted in order
to provide stability in the canal.

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Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Sleeve and Stem

Conventional Cut Guide

Femoral Sleeve and Stem

This is the Intramedullary Preparation of the Revision

Femoral Component with a Sleeve and Stem.

Attention should be paid to the entry point of the

Canal Reamers and Broach as there is no ability to
use an Offset Stem with a Femoral Sleeve.

Assemble the appropriately sized Stem Trial to the

Femoral Broach Starter Reamer.

Seat the Femoral Broach Starter Reamer until the

line of the appropriate femoral size grouping is level
with the distal surface of the femur (or desired distal
surface of the femur).

! CAUTION

Do not reverse ream.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Sleeve and Stem

Conventional Cut Guide

Femoral Sleeve and Stem

Stem Trial

Assemble the corresponding Stem Trial to the

smallest Femoral Broach.

Femoral Broach

Connect the correct side, “Left or Right”, Broach Stop

of the appropriate size grouping, 1 - 3, 4 - 7, 8 - 10, to
the Revision Broach Handle.

Broach Stop
!

! CAUTION

A Broach Stop must be utilized when broaching

the femur.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Sleeve and Stem

Conventional Cut Guide

Femoral Sleeve and Stem

Connect the Broach Assembly to the Broach

Handle Assembly and introduce to the reamed
femoral canal.

Care should be taken to maintain a posterior

positioning of the Broach to aid in posteriorizing
the Femoral Component as a means for filling the
flexion gap. Additionally the anterior flat surface of
the Broach and Broach Stop should be rotated to the
anticipated rotation of the Femoral Component
to maximize Femoral to Sleeve compatibility. See
chart on Page 87 for rotational allowance between
Broaches/Sleeves and the Femoral Component.

Two additional tools to aid in placement of the

Femoral Broach include:

• Broach Stop Shims available in 4, 8, 12, 16 mm,

representative of the Distal Augment thicknesses
in the system. If it is intended to have differing
Augment thicknesses medial to lateral, then
the Broach Stop Shim utilized will represent the
thinner of the two intended Distal Augments.
Additionally, Broach Stop Shims may be added
to aid in leaving the Broach proud to allow for i INFORMATION

future adjustment when assessing extension gap

If within a size 1, 2, or 3 femoral size, use the 30 mm
Femoral Broach for canal fixation when preparing the
• Distalizing Gauge to aid in assessing the distal femur. If a larger Femoral Sleeve is required,
proximal - distal position relative to the level these femoral sizes (1, 2, or 3) are only compatible
of the epicondyles with up to a 35 mm Femoral Sleeve per the chart on
page 87, however, no rotation is allowed.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Sleeve and Stem

Conventional Cut Guide

Femoral Sleeve and Stem

Advance the Broach until the Broach Stop, or Broach

Stop Shim, is contacting the most prominent aspect of
the distal femur. If there is significant bone loss on the
distal femur, consider putting Broach Stop Shims on
the Broach Stop to aid in replicating the expected
joint line while broaching.

Check that the Broach is rotationally stable. If not,

progressively increase the Broach size until rotational
stability is achieved.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

ATTUNE Revision Femoral Component to ATTUNE Revision
Femoral Sleeve Compatibility Chart

Conventional Cut Guide

Femoral Sleeve and Stem

ATTUNE Revision Femoral Sleeve and ATTUNE Revision Femoral Component Compatibility*1

ATTUNE Revision Femoral Sleeve Size (mm)

30 35 40 45 50 55
1 X X
2 X X
3 X X
4 X X X X
ATTUNE 5 X X X X X X !
Revision Femoral
Component Size 6 X X X X X X
7 X X X X X X
8 X X X X X X
9 X X X X X X
10 X X X X X X

* Clearance between the ATTUNE Revision Femoral Component and ATTUNE Revision Femoral Sleeve was
assessed at nominal conditions.

The distance between the distal most anterior aspect of the Sleeve and
the inside of the anterior flange limits the amount of rotation possible
before impingement of the Sleeve on the implant. The "X"s in the table
above indicate recommended compatibility.

! CAUTION

For the seven highlighted scenarios in the Chart,

there is less than 10 degrees of rotational freedom.
Caution is recommended when broaching the femur
with these component combinations.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

For Femoral Sizes 1 - 3

Conventional Cut Guide

Femoral Sleeve and Stem

If after reviewing the chart, the patient anatomy requires a 35 mm

Femoral Sleeve, use the 30 mm Femoral Broach for canal fixation
when preparing the distal femur. After completing the bone
preparation and assembling the Femoral Trial, transcribe the
lines on the medial and lateral sides of the Femoral Trial on
to the distal femur and utilize the corresponding marks on the
sides of the Broach Handle and Broach Stop to position the final,
35 mm Femoral Broach, thus ensuring that the rotation of the
Broach closely matches the rotation of the trial.

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Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Distal Clean-up Resection

Conventional Cut Guide

Femoral Sleeve and Stem

If desired, once rotational stability and the

corresponding Broach size are achieved, a distal
clean-up resection may be performed using the
proximal surface of the Broach Stop or Broach Stop
Shim, if used. If a resection is performed, reseat
the Broach.

Disconnect the Broach Handle from the Femoral

Broach, leaving the Femoral Broach in the bone.

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broach Adaptor Assembly

Conventional Cut Guide

Femoral Sleeve and Stem

Conventional Cut Guide

Assemble the appropriate size (1 - 3, 4 - 7, or

8 - 10) Broach Adaptor to the appropriately sized Broach Adaptor
Conventional Cut Guide ensuring that the correct
orientation, Right or Left, are legible.

Tighten using the Torque Limiting Screwdriver

Assembly.
“click”

Torque Limiting
Screwdriver Assembly
Using the Torque Driver and the 6 mm Hex Driver,
assemble the Conventional Cut Guide Assembly to
the Broach in the prepared femur.

For Gap Balancing and Setting Rotation with

Sleeve, proceed to page 95.

Torque Driver Assembly

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Offset Preparation

Conventional Cut Guide

Offset Stem

This is the Intramedullary Preparation of the Revision

Femoral Component with an Offset Adaptor and
Press-Fit Stem.

Once the definitive Reamer diameter has been determined,

and either the femoral canal is determined to be offset
from the distal femur or offset is desired to address the
flexion gap, proceed with utilizing the Femoral Offset
Instrumentation.

Please note, the Offset Adaptor adds an additional 25 mm

to the overall implant construct length. However, the
Conventional Cut Guide with the Offset Assembly has a
construct length appropriate for a Straight Stem. This
allows the evaluation of offset without having to increase
the ream depth.
Stem Trial
If the original ream depth was determined based on a
Straight Stem assumption, once it is determined that an Stem Stabilizer
offset is required, then ensure that the ream depth is
increased to be appropriate for an offset construct.

Approximate the magnitude of offset required (2 mm,

4 mm or 6 mm) based on M/L canal offset or desired
flexion gap A/P compensation.

Femoral Offset
Guide

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Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Offset Preparation

Conventional Cut Guide

Offset Stem

Assemble the corresponding:

1. C
onventional Cut Guide to Femoral Offset Guide
with the Hex Attachment. Ensure the Femoral
Offset Guide matches the operative side of the
knee and corresponding size. The guide shows
either "R" or "L" to indicate side and "2 mm",
"4 mm", or "6 mm" to indicate the “click”
corresponding offset.

Torque Limiting
Screwdriver Assembly

2. S tem Stabilizer to the Femoral Offset Guide by Offset Guide

aligning the triangular feature on the Femoral
Offset Guide to the corresponding features on
Lock Barrel
the Stem Stabilizer and turning the Lock Barrel
of the Femoral Offset Guide to tighten to the
Stem Stabilizer.

Triangular Stem
Feature Stabilizer

3. Stem Trial to the Stem Stabilizer.

Stem Trial

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Offset Preparation

Conventional Cut Guide

Offset Stem

Introduce the Conventional Cut Guide Assembly

into the femoral bone. If impaction is necessary, the
Revision System Handle must be attached to the Femoral
Offset Guide and used to gently seat the assembly. The
Conventional Cut Guide should not be impacted directly.
Please note the Stem attached to the Conventional Cut
Guide Construct is designed based on the Straight Stem
Construct length to allow for evaluation of offset vs straight
stem prior to changing the reaming depth. The Stem is
designed to provide support and therefore the Stem length
will not be identical to all of the variable Final Trial Constructs.

The markings on the Reamer Reference Tools are positioned

for the femoral canal to be prepared to the longest of the
femoral box groupings (Sizes 8 - 10) to ensure the canal is
prepared for the final Implant of all size groupings. If the Example of Femoral Templates
for Size 1 or 2
reamer has engaged a femoral bow during the last 25 mm
of reaming, the resultant axis may have changed. This
should be considered when positioning the Conventional
i INFORMATION

Cut Guide assembly to ensure the cuts are positioned The Stem Stabilizers are tapered and measure 1 mm
appropriately for the implant. For Gap Balancing and larger in diameter at the distal end and taper to
be equivalent to the comparable Stem Trial at
Setting Rotation with an Offset Stem, proceed to
the proximal end. If necessary, to avoid potential
page 95. For Femoral Offset with Size 1 or 2 see below.
femoral fracture, the distal femoral canal may be
opened with the next larger Canal Reamer to
Femoral Offset Preparation Sizes 1 and 2 allow for introduction of the Stem Stabilizer, but
The Femoral Offset Guides cannot assemble to the Sizes care should be taken not to sink in the Reamer
1 or 2 Conventional Cut Guides due to space constraints as too far in the canal.
there are numerous cutting slots on a small Block. Therefore,
Stem Stabilizers are available in 14, 16, 18, 20, 22, and
for femoral Sizes 1 and 2, assemble the desired Femoral Offset 24 mm sizes and should be chosen to correspond with
Guide to the Femoral Template Size 1 or 2 as appropriate. the Stem diameter used but may be adjusted in order
Assess the appropriate offset to address the patient’s need. to provide stability in the canal.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Femoral Offset Preparation Sizes 1 and 2 (cont'd)

Conventional Cut Guide

Offset Stem

Determine the offset position following a similar

approach as illustrated in pages 95 - 103. Note that there
is no anterior capture on the Template, however the
Angel Wing can be used against the open surface of the
Template to indicate the anterior cut position. Insert Pins
through the Parallel Pin holes in the Template.

Disconnect the Femoral Offset Guide from the

Conventional Cut Guide by unlocking the Hexes.

Connect the Revision System Handle to the Femoral Torque Limiting

Offset Guide Assembly and translate the Femoral Offset Screwdriver Assembly
Guide distal to the Femoral Template.

While translating the Femoral Offset Guide out of the

prepared femur, also translate the Femoral Template
along the Parallel Pins.

Once the Femoral Offset Guide, Stem Stabilizer, and

Stem Trial have cleared the prepared femur, position
the corresponding size Conventional Cut Guide over
the Parallel Pins.

Proceed with preparing the Anterior and Posterior

cuts utilizing the Anterior Cutting Guide and Posterior
Capture. Additional fixation may be achieved by utilizing
the Angled Pin Holes in the Conventional Cut Guide.

For Chamfer and Distal Augment Resections, proceed to

page 112.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Initial Flexion Gap Assessment

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

The general approach in this surgical technique is to do an initial

assessment of Flexion and Extension Gaps, adjust Extension Gap
if required, and then establish the final Flexion Gap and Set
Femoral Rotation.

The ATTUNE Revision Knee System provides two instrument

options to balance the flexion gap with the Conventional Cut
Guide: Spacer Block and Femoral Positioner, both of which
are to be used with the Spacer Block Shims.

Introduce the preferred balancing tool and set rotation and Revision Spacer Block
balance the flexion gap.

To gap balance with a Femoral Broach in place, slightly loosen

the Central Bolt in the Broach Adaptor to allow rotation.

Femoral Positioner
! CAUTION

The ATTUNE Revision Spacer Block and Spacer Block

Shims cannot be used interchangeably with the
ATTUNE Primary INTUITION Spacer Block and Shims.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Initial Flexion Gap Assessment

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

• Spacer Block • Femoral Positioner

Use thick end for flexion

The thick end of the Revision Spacer Block is only The Femoral Positioner connects to the Conventional
utilized in flexion, resting on the Tibial Trial and Cut Guide for a secure rotational balance with respect
against the posterior aspect of the Conventional to the tibial plateau, and may be especially helpful
Cut Guide as this accounts for the thickness of the when preparing the femur for an Offset Stem. If the
posterior condyles of the Femoral Implant. The thin posterior femoral bone contacts the Femoral Positioner,
end will be utilized to assess extension. it may limit rotation.

Revision Tibial Inserts are available in 2 mm increments (6 - 26 mm). The Revision Femoral Component is also
designed to articulate with the PS Tibial Inserts available in 1 mm increments (5 - 8 mm) and 2 mm increments
(10 - 20 mm). For establishing Extension Gap using a Straight Stem or Sleeve proceed to Page 98, for Offset
Stems proceed to Page 97.

i INFORMATION

To assess for the 5 or 7 mm PS Tibial Inserts, the ATTUNE Primary INTUITION Spacer Block Handle and Shims must be utilized
and the Revision Tibial Base Trial must be removed from the joint space.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Initial Flexion Gap Assessment

Conventional Cut Guide

Offset Stem

Attach the Anterior Cutting Guide to the Conventional Cut Guide

and introduce the Angel Wing to assess the anterior resection. !

Use the Torque Limiting Screwdriver Assembly to adjust the femoral

offset while assessing ligament tension, anterior resection, and M/L fit.

The surgeon should use their preferred method to assess the balance
and flexion gap. Options available within the Revision Instrument
System include using the Revision Spacer Block, the Femoral Positioner
or visual landmarks.

Revision Spacer Block Femoral Positioner Visual Landmarks

! CAUTION

The surgeon may want to support the thigh as

the offset is being adjusted in order to allow for
tensioning of the joint space not to be impacted
by the weight of the leg.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Initial Extension Gap Assessment

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

Thick End

Remove the flexion gap assessment tools and place

the knee into extension. Move the final Spacer Block Thin End

Shim utilized to assess flexion to the thin end of

the Revision Spacer Block and introduce into the
extension space.

Place the Spacer Block in the extension joint space

between the distal surface of the Conventional Cut
Guide and the top of the Tibial Base Trial.

Optionally, if exposure permits, the Distalizing Gauge

may be utilized to provide an additional reference to
the epicondyles.

i INFORMATION

The Conventional Cut Guide is 9 mm thick to replicate

the distal thickness of the definitive Femoral Implant.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Balance Flexion and Extension Gaps

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

As the knee comes out to full extension, if the tension in the medial and lateral collateral ligaments is unequal,
appropriate soft tissue releases should be performed in a manner to allow the tension to be equal on both the
medial and lateral sides of the knee.

Should the selected joint line differ widely from the joint line anatomical markers, the surgeon has the ability
to change the distal/proximal position of the Femoral Component but will have to mirror these changes with
appropriate selection of the Tibial Insert and changes to the femoral sizing.

Loose Extension Stable Extension Tight Extension

Cause Cause Cause
1. Flexion and extension gaps are too large. 1. Flexion gap is too large. 1. E xtension gap is too small and flexion gap is too
large.

Possible Solution(s) Possible Solution(s) Possible Solution(s)

Loose Flexion

• Increase Tibial Insert thickness • Upsize Femoral Component • Proximalize and upsize the Femoral
• Distalize and upsize the Femoral Component • Assess if offset is appropriate to move the Component by recutting the Distal Femur and
and add any necessary Distal Augments Femoral Component posteriorly to fill adding any necessary Posterior Augments.
• Assess if offset is appropriate to move the the flexion gap and add any necessary Care should be taken to not raise the
Femoral Component posteriorly to fill the flexion Distal Augments femoral position such that it results in
gap and add Distal Augments • Increase Tibial Insert thickness and resect patella baja
• If Sleeve preparation: increase femoral Broach more distal femur (re-evaluate A/P resections). • Assess if offset is appropriate to move the
size, add Distal Augments, and upsize the Care should be taken to not raise the Femoral Component posteriorly to fill the
Femoral Component femoral position such that it results in flexion gap, and decrease Tibial
patella baja Insert thickness

Cause Desired ligament balance. Cause

Stable Flexion

1. Extension gap is too large. 1. Extension gap is too small.

Possible Solution(s) Possible Solution(s)

• Distalize the Femoral Component and add • Proximalize the Femoral Component by
any necessary Distal Augments recutting the distal femur (re-evaluate A/P
resections). Care should be taken to not
raise the femoral position such that it
results in patella baja

Cause Cause Cause

1. F lexion gap is too small and extension gap is too 1. Flexion gap is too small. 1. Flexion and extension gaps are too small.
large. 2. Posterior osteophytes.
2. Posterior osteophytes.

Possible Solution(s) Possible Solution(s) Possible Solution(s)

Tight Flexion

• Remove osteophytes if present • Remove osteophytes if present • Decrease Tibial Insert thickness
• Downsize Femoral Component and distalize • Ensure that there is no soft tissue • If the smallest Insert is still too tight,
the Femoral Component adding any impingement resect more tibia
necessary Distal Augments • Possibly downsize Femoral Component
• Assess if offset is appropriate to move the • Distalize the Femoral Component using Distal
Femoral Component anteriorly to loosen the Augments and decrease the
flexion gap. And reassess Insert thickness and Insert thickness
Distal Femoral Augments • Assess if offset is appropriate to move the
Femoral Component anteriorly to loosen the
flexion gap

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Balance Flexion and Extension Gaps

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

For adjusting the Extension Gap with

a Straight Stem, proceed to page 101.

For adjusting the Extension Gap with a

Femoral Sleeve and Stem, proceed to page 104.

For adjusting the Extension Gap with

an Offset Stem, proceed to page 101.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Adjusting Extension Gap

Conventional Cut Guide

Straight Stem Offset Stem

Take the knee into extension and utilize the thin end of
the Revision Spacer Block Handle and Shims to assess the
extension space.

Place the Spacer Block in the extension joint space between

the distal surface of the Conventional Cut Guide and the
top of the Tibial Base Trial.

Allow the Cut Guide Assembly to translate proximally or

be manipulated distally in the femoral canal through the
addition of Distal Spacers and establish the extension space
that will then match the flexion space.

Remove the Spacer Block and return the knee to flexion.

For Establishing the Flexion Gap and Setting Rotation with

a Straight Stem, proceed to page 102.

For Establishing the Flexion Gap and Setting Rotation with

an Offset Stem, proceed to page 103.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Establishing the Flexion Gap and Setting Rotation

Conventional Cut Guide

Straight Stem

Balance the knee using the surgeon’s preferred

technique (per pages 96 - 98). Set rotation and
balance the flexion gap to match the extension gap.

Once the desired femoral position is achieved, pin

the Conventional Cut Guide and proceed with
Femoral Preparation.

For completing femoral resections with a Straight

Stem, proceed to page 108.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Establishing the Flexion Gap and Setting Rotation

Conventional Cut Guide

Offset Stem

Femoral Offset Guide

Balance the knee using the surgeon’s preferred
technique (per pages 96 - 98).

When the desired offset position has been achieved,

pin the Conventional Cut Guide through the Parallel Pin
Holes on the anterior face of the Guide.

Femoral
Note the preliminary offset position from alignment of Offset Dial
the etch line/number on the Femoral Offset Dial with the
engraved line on the Femoral Offset Guide. This will be
used to set the initial offset position on the Trial.

Torque Limiting
Screwdriver Assembly

Once pinned in place and offset position noted, proceed

to next step.

For completing femoral resections with an Offset Stem,

proceed to page 108.

i INFORMATION

Consider using Threaded Non-Headed Pins for the

Dial shows an offset position
Parallel Pins. The Parallel Pins allow for the Conventional between 4 and 5
Cut Guide to be translated distally to remove the Femoral
Offset Guide Assembly from the construct and then the
Guide to be repositioned back over the Parallel Pins to
allow for further femoral preparation.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Adjusting Extension Gap

Conventional Cut Guide

Femoral Sleeve and Stem

If the extension gap is tight, you may advance

!
the Broach construct by assembling the System
Handle to the Broach Adaptor and impacting
the System Handle.

! CAUTION

Do not advance the Broach by hitting the Cutting Block

directly.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Adjusting Extension Gap

Conventional Cut Guide

Femoral Sleeve and Stem

4 mm
Distalizing the Femoral Position when utilizing
a Broach (Optional)

Femoral Sleeves are specifically designed to not

only fill bone voids, but also to aid in distalizing
the Femoral Component in the case of a loose
extension gap. This can be achieved through
upsizing the Broach used, as each size has an
identical proximal geometry to the previous size,
but grows distally by 4 mm.

For example, if after broaching for a 30 mm Sleeve,

it is determined that the extension gap is loose, the
4 mm Broach Stop Shim can be added to the
Broach Handle and then re-broach using the next
size larger Broach (35 mm).

Adding the 4 mm Broach Stop Shim will distalize

the Femoral Component by 4 mm, and upsizing a
Broach/Sleeve size will ensure that the Broach sits
4 mm
in the original depth location in the femur but has
extended distally by 4 mm.

If it is desired to distalize the extension gap by less

than 4 mm, simply decrease the Broach Stop Shim
by 4 mm and impact the Broach further, but not
far enough to seat the Broach Stop as this will
return to the original loose extension gap. 4 mm Broach
Stop Shim
Disconnect the Broach Handle Assembly leaving
the new Broach in position.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Adjusting Extension Gap

Conventional Cut Guide

Femoral Sleeve and Stem

Reassemble the Conventional Cut Guide Assembly

to the new Broach retained in the bone leaving the
central bolt slightly loose.

Torque Driver Assembly

Add the Distal Spacers that correspond to the

Broach Stop Shim that was utilized.

Slide Distal Spacer into

place from the side

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Establishing the Flexion Gap and Setting Rotation

Conventional Cut Guide

Femoral Sleeve and Stem

Return the knee to flexion, re-introduce the Revision

Spacer Block Assembly (or Femoral Positioner
Assembly), set the rotation of the Conventional
Cut Guide and lock the Central Bolt.

“click”

Torque Driver Assembly

Pin the Conventional Cut Guide and proceed with

femoral preparation.

For completing femoral resections with a Sleeve,

proceed to page 108.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Anterior and Posterior Resections

Conventional Cut Guide

Straight Stem Offset Stem Femoral Sleeve and Stem

Remove the Spacer Block or Femoral Positioner prior to

performing femoral resections.

Attach the Anterior Cut Block and perform the

anterior resection.

Assemble the corresponding sized Posterior Capture to

the Cut Guide and perform the posterior resection. If
Anterior Cut Block
Posterior Augments are required, the Posterior Augment
resection may be made through the Augment slots in the
Cut Guide.

Posterior
Capture

For completing femoral resections with a Straight Stem

or Sleeve, proceed to page 109.

For completing femoral resections with an Offset Stem, Straight Stem Assembly
proceed to page 110. Depicted

i INFORMATION

When using an Offset Stem in smaller sizes of femur, certain orientations of the Femoral Offset Guide may inhibit the
ability to complete the anterior resection. Therefore, prior to completing the anterior resection, check for Saw Blade
impingement on the Femoral Offset Guide. If necessary, prior to initiating the anterior cut, the Conventional Cut
Guide or FE Guide can be pinned and the Femoral Offset Guide removed using the System Handle.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Chamfer and Distal Augment Resections

Conventional Cut Guide

Straight Stem Femoral Sleeve and Stem

Perform the posterior chamfer resection.

Attach the Notch Cutting Guide and perform the anterior Notch Cutting
chamfer and any necessary Distal Augment resections. Guide

If Distal Augment resections were made, Distal Spacers !

may be inserted in the Conventional Cut Guide to
stabilize the Guide.

For Box preparation with a Straight Stem,

proceed to page 114.

For completing the Box resection with a Sleeve,

proceed to page 116.

Anterior
! CAUTION Chamfer Slot

If Pins were added to the distal surface of the

Conventional Cut Block, they will need to be removed
from the deficient side prior to performing any
Augment resections.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Anterior and Posterior Resections

Conventional Cut Guide

Offset Stem

To perform the anterior and posterior chamfer, box

resection and any necessary Distal Augment resections,
disconnect the Femoral Offset Guide from the
Conventional Cut Guide.

Torque Limiting
Screwdriver Assembly

Connect the Revision System Handle to the Femoral

Offset Guide Assembly and translate the Femoral Offset
Guide distal to the Conventional Cut Guide.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Anterior and Posterior Resections

Conventional Cut Guide

Offset Stem

While translating the Femoral Offset Guide out of

the prepared femur, also translate the Conventional
Cut Guide along the Parallel Pins.

Once the Femoral Offset Guide, Stem Stabilizer,

and Stem Trial have cleared the prepared femur,
re-introduce the Conventional Cut Guide onto
the distal femur via the Parallel Pins.

i INFORMATION

i
For smaller magnitude offsets and/or smaller diameter
INFORMATION Stem Stabilizers and Stem Trials, the Femoral Offset
In cases of significant distal bone loss, one could Guide may be extracted from the femur without
proceed to the Cut Through Trial workflow at this time simultaneously having to remove the Conventional
with the Femoral Offset position noted. The box Cut Guide. In these situations, the Angled Pin Holes can
resection and Boss Ream may alternatively be made be used in preference to the Parallel Pin Holes for initial
through the Cut Through Trial. fixation.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Chamfer and Distal Augment Resections

Conventional Cut Guide

Offset Stem

Pin through the Angled Pin Holes, and remove all

Parallel Pins. Complete the posterior chamfer resection.

Attach the Notch Cutting Guide and perform the

anterior chamfer and any necessary Distal Augment
resections.

If Distal Augment resections were made, Distal

Spacers may be inserted in the Conventional Cut
Guide to stabilize the Guide.

For Boss and Offset Adaptor preparation with an

Offset Stem, proceed to page 113.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Boss and Offset Adaptor Reaming

Conventional Cut Guide

Offset Stem

Assemble the appropriately sized Conventional

Cut Guide Reamer Guide with the correct
orientation facing upwards, “Left or Right”,
to the Conventional Cut Guide.

Assemble the Modular Stop to the "FEM" line on

the Offset Drill and prepare the femoral canal.

Seat the Drill to the Stop.

With the femoral Offset Adaptor prepared for,

remove the Offset Drill and Conventional Cut
Guide Reamer Guide from the Cut Guide Assembly.

For Box Resection, proceed to page 114.

i INFORMATION

The Notch Cutting Guide size must match the Conventional Cut Guide size.

Additional fixation may be achieved utilizing the Omni-Ball Pin Holes in the Notch Cutting Guide which allows for
an adjustable Pin direction and position Pins superiorly in the Anterior Femur.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Box Resection

Conventional Cut Guide

Straight Stem Offset Stem

With the Notch Cutting Guide attached, complete resection of the

two sides and top of the box with a Reciprocating Saw Blade.

Optionally, the Notch Guide may be pinned through the Parallel

Pin Holes to allow for removal of the Conventional Cut Guide to
complete the Box resection, if desired.

With the femoral preparation complete, remove the Conventional

Cut Guide Assembly.

Reciprocating Saw

Omni-Ball Pin Hole

For Boss preparation with a Straight Stem, proceed to page 115.

For Femoral Trial Assembly with Offset Stem, proceed to page 117 for Cut Through Trials
and page 118 for Solid Femoral Trials.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Boss Reaming

Conventional Cut Guide

Straight Stem

Press-Fit
Remove all Pins and the Conventional Cut Guide Stem Trial
Assembly from the bone.

Assemble the appropriate Stem Trial to the

Femoral Boss Reamer.

Utilize the Stem Trial in the reamed femoral canal

to pilot the Boss Reamer until the appropriate
Boss Reamer
femoral size marking in the grouping of markings
on the Boss Reamer is aligned with the distal
surface of the femur. If Distal Augments were
prepared, the size grouping line should be proud
of the respective distal femur surface by the
thickness of the Distal Augment(s).

The size groupings on the Boss Reamer represent !

the distal bone surface and not the anticipated
joint line.

For Femoral Trial Assembly with Straight Stem,

proceed to page 117 for Cut Through Trials and
page 118 for Solid Femoral Trials.

! CAUTION

Do not reverse ream.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Box Resection

Conventional Cut Guide

Femoral Sleeve and Stem

To allow for complete resection of the box, disengage

and remove the Broach Adaptor from the Conventional
Cut Guide and Broach by releasing the two Hexes in the
Cutting Block and the one Hex in the Broach Adaptor.

An additional Pin may be added to the Notch !

Cutting Guide to aid in fixation.
Reciprocating Saw
With the Notch Cutting Guide attached, complete
resection of the two sides and top of the box with
a Reciprocating Saw Blade.

Optionally, the Notch Guide may be pinned through

Omni-Ball
the Parallel Pin Holes to allow for removal of the Pin Hole
Conventional Cut Guide to complete the Box
resection, if desired.

With the femoral preparation complete, remove

the Conventional Cut Guide Assembly leaving the
Broach in place. For Femoral Trial Assembly with a
Broach, proceed to page 119 for Cut Through Trials
and page 120 for Solid Femoral Trials.

i INFORMATION

The Notch Cutting Guide size must match the ! CAUTION

Conventional Cut Guide size.
Care should be taken when placing a Pin through the
Additional fixation may be achieved utilizing the
Omni-Ball Hole in the Notch Cutting Guide which allows
Omni-Ball Pin Holes in the Notch Cutting Guide
for an adjustable Pin direction to angle the Pin towards
which allows for an adjustable Pin direction and
the periphery of the bone to avoid pinning into the
position Pins superiorly in the Anterior Femur.
Femoral Broach.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Cut Through Trial

Straight Stem Offset Stem

Assemble the Femoral Trial with the Box Trial, Boss

Trial or appropriate Offset Adaptor Trial, Stem Trial
Bolt, Stem Trial, as described on pages 55 and 57,
and any appropriate Augment Trials as described
on page 60. !

If offset is being used, position the Femoral Offset

Adaptor Trial to the offset orientation previously
noted from the Femoral Offset Guide, and tighten
the Stem Trial Bolt. Utilize the marking on the
posterior aspect of the Box Trial and corresponding
number on the Offset Boss Adaptor Trial as described
on page 57.

Introduce the Femoral Trial Assembly to the prepared

femur. Utilize the ATTUNE System Impactor to seat
the Femoral Trial.

Introduce the Revision Tibial Insert Trial and proceed to

Setting Tibial Base Rotation on page 147.

! CAUTION
! CAUTION
If the box resection is not complete, the connecting
components may not seat. The ATTUNE Revision Femoral Augment Trials contain
magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
i INFORMATION device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
If the Cut Through Trial is unstable, pinning should be kept at an appropriate location when not in
anteriorly is an option. use in the surgical site.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Solid Femoral Trial

Straight Stem Offset Stem

Assemble the Femoral Trial, Boss Trial or appropriate

Offset Adaptor Trial, Stem Trial Bolt, Stem Trial as
described on pages 56 and 57 any appropriate
Augment Trials as described in page 60. !

If offset is being used, position the Femoral Offset

Adaptor Trial to the offset orientation previously noted
from the Femoral Offset Guide, and tighten the Stem
Trial Bolt. Utilize the marking on the posterior aspect of
the Femoral Box and corresponding number of the
Offset Boss Adaptor Trial as described on page 57.

Introduce the Femoral Trial Assembly to the prepared

femur. Utilize the ATTUNE System Impactor to seat
the Femoral Trial.

Introduce the Revision Tibial Insert Trial and proceed to

Setting Tibial Base Rotation on page 147.

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
! CAUTION device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
If the box resection is not complete, the connecting should be kept at an appropriate location when not
components may not seat. in use in the surgical site.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Cut Through Trial

Femoral Sleeve and Stem

Assemble the Cut Through Femoral Trial with the Box

Trial and any appropriate Augment Trials as described
on page 60. !
Broach Trial Bolt

Introduce the Femoral Trial Assembly to the prepared “click”

!
femur and introduce the Femoral Broach Trial Bolt
through the hole in the Box Trial and into the
Femoral Broach. Tighten with the Torque Driver with
6 mm Hex Driver.

Torque Driver
Assembly
Introduce the Revision Tibial Insert Trial and proceed
to Setting Tibial Base Rotation on page 147.

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials i INFORMATION
should be kept at an appropriate location when not If the Femoral Trial Assembly and Broach Trial Bolt do
in use in the surgical site. not engage in the Broach, slightly extract the Broach
with the Broach Handle, attach the Femoral Trial
! Assembly to the Broach via the Broach Bolt leaving it
CAUTION
slightly loose to allow the instruments to locate within
If impaction of the Femoral Trial is necessary, the the prepared cavity, and advance the trial construct
ATTUNE System Impactor is recommended. until seated to the prepared depth.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Solid Femoral Trial

Femoral Sleeve and Stem

Assemble the Femoral Trial with any appropriate

Augment Trials as described on page 60. !

Broach Trial Bolt

Introduce the Femoral Trial Assembly to the prepared
femur and introduce the Femoral Broach Trial Bolt “click”
through the hole in the Femoral Box and into the
Femoral Broach. Tighten with the Torque Driver with
6 mm Hex Driver. !

Torque Driver
Assembly

Introduce the Revision Tibial Insert Trial and proceed

to Setting Tibial Base Rotation on page 147.

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
i INFORMATION

should be kept at an appropriate location when not in If the Femoral Trial Assembly and Broach Trial Bolt do
use in the surgical site. not engage in the Broach, slightly extract the Broach
with the Broach Handle, attach the Femoral Trial
Assembly to the Broach via the Broach Bolt leaving it
! CAUTION
slightly loose to allow the instruments to locate within
If impaction of the Femoral Trial is necessary, the the prepared cavity, and advance the trial construct
ATTUNE System Impactor is recommended. until seated to the prepared depth.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Setting Femoral Position

Cut Through Trial

Straight Stem
Proceed to page 122

Offset Stem
Proceed to page 125

Femoral Sleeve and Stem

Proceed to page 136

i INFORMATION

Prior to proceeding to the Femoral Sleeve and

Stem workflow the Straight Stem workflow must
be completed.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial

Cut Through Trial

Straight Stem

If there is substantial bone loss, once the femoral Press-Fit

canal has been prepared and if the femoral size has Stem Trial
been determined to be a size 3 or larger following
the methods described from pages 75 to 79 then it is
possible to use the Cut Through Trial workflow. Ream
for the Femoral Boss by assembling the appropriate
Stem Trial to the Femoral Boss Reamer.

Utilize the Stem Trial in the reamed femoral canal to

pilot the Boss Reamer until the appropriate femoral Boss Reamer
size marking in the grouping of markings on the Boss
Reamer is aligned with the distal surface of the femur.
If Distal Augments were prepared, the size grouping
line should be proud of the respective distal femur
surface by the thickness of the Distal Augment(s).

The size groupings on the Boss Reamer represent the !

distal bone surface and not the anticipated joint line.

i INFORMATION

The Cut Through Trials are available in Sizes 3 - 10.

The Conventional Cut Guide must be utilized to prepare
femurs of sizes 1 or 2.

i INFORMATION

If the prior Femoral Component was malrotated, the

revised femur bone may influence the rotation of the !
! CAUTION
Cut Through Trial if not mindful of this when assessing
femoral position. Do not reverse ream.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial Assembly

Cut Through Trial

Straight Stem

“click”
Assemble the Cut Through Trial to the
corresponding IM Connector, Stem Trial Bolt,
IM Connector
Boss Trial, and appropriate Stem Trial.

Torque Limiting
Screwdriver Assembly

“click” Boss Trial

Torque Driver Assembly Stem Trial Bolt

i INFORMATION i INFORMATION

To aid in stabilizing the femoral rotation, Posterior The Cut Through Trial IM Connector is size and
Augment Trials may be added to the Cut Through Trials. side specific.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial Placement

Cut Through Trial

Straight Stem

Introduce the Femoral Trial Assembly to the

prepared femur. Allow the Femoral Trial Assembly
to sit slightly proud of the femoral bone to allow
for joint line assessment.

Trial proud to allow for

joint line assessment

Optionally, the Distalizing Gauge may be utilized to

provide an additional reference to the epicondyles.

For Gap Balancing, Setting Rotation, and completing

femoral resections with a Straight Stem, proceed to
Distalizing
page 128. Gauge

! CAUTION
i INFORMATION
To prevent the potential for femoral bone fracture the
It is optional to allow the Femoral Trial to sit proud. This IM Connector and Cut Through Trial should only be
option allows for final assessment of the superior/inferior used in the cases with substantial bone loss. Otherwise
position to be determined with the aid of an Insert Trial go to Revision Femoral with a Straight Stem utilizing
or Spacer Block. the Conventional Cut Guide on page 81.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial Assembly

Cut Through Trial

Offset Stem

Once the femoral canal has been prepared using Cut Through Trial
the Canal Reamers and the femoral size has been
determined following the methods described from
pages 75 to 79, proceed with this workflow only if
there is substantial bone loss, enough to allow for
the Cut Through Trial assembled with the IM Connector,
Offset Boss Adaptor Trial, and appropriate Stem Trial “click”
to be introduced to the femoral bone.

Assemble the Cut Through Trial to the corresponding

IM Connector by tightening the Hexes. Torque Limiting IM Connector
Screwdriver Assembly

i INFORMATION

The Cut Through Trials are available in Sizes 3 - 10.

The Conventional Cut Guide must be utilized to
prepare femurs of sizes 1 or 2.

! CAUTION

To prevent the potential for femoral bone fracture

the IM Connector and Cut Through Trial should only
be used in the cases with substantial bone loss.
Otherwise go to Revision Femoral with Offset Stem
utilizing the Conventional Cut Guide on page 91.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial Assembly

Cut Through Trial

Offset Stem

Loosely assemble the Stem Trial Bolt to the

Femoral Offset Adaptor Trial through the IM
Stem Trial
Connector using the Torque Driver Assembly. Bolt

Torque Driver Assembly

Orient the Femoral Offset Adaptor Trial to the

estimated offset orientation to achieve desired
femoral position and tighten the Stem Trial Bolt.
“click”

Thread the Stem Trial on to the Femoral Offset

Adaptor Trial.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Cut Through Trial Placement

Cut Through Trial

Offset Stem

Introduce the Femoral Trial Assembly into the femur.

Allow the Femoral Trial Assembly to sit slightly proud of

the femoral bone to allow for joint line assessment.

Trial proud to allow for

joint line assessment

Optionally, the Distalizing Gauge may be utilized to

provide and additional reference to the epicondyles.

Distalizing
Gauge

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Gap Balancing and Setting Rotation

Cut Through Trial

Straight Stem Offset Stem

i INFORMATION

If preparing for an Offset Stem, fine tune the Cut Through gap balancing, as necessary. If an acceptable offset
Trial rotation, then tighten the Femoral Offset Adaptor position cannot be achieved, replace the Femoral Offset
Trial to the IM Connector (or Box Trial) with the Stem Trial Adaptor Trial with one of another magnitude (2 mm,
Bolt and assemble to the bone. This can be loosened, 4 mm or 6 mm) and reposition the Cut Through Trial.
removed, rotationally adjusted, and re-tightened during

The ATTUNE Revision Knee System provides two It is recommended to use the ATTUNE Primary INTUITION
instrument options to balance the flexion gap with PS Insert Trials as the ATTUNE Revision Tibial Insert Trial is
the Cut Through Trial: ATTUNE Primary INTUITION PS not compatible with the IM Connector.
Tibial Insert Trials, and ATTUNE Revision Spacer Block
and Shim.

• Primary PS Insert Trial • Revision Spacer Block

i INFORMATION

When choosing Tibial Insert Trials with which to balance the ATTUNE Primary Tibial Inserts are available in 1 mm
the flexion gap, it should be noted that the Revision Tibial increments (5 - 8 mm) and 2 mm increments (10 - 20 mm).
Inserts are available in 2 mm increments (6 - 26 mm), while

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Balance Soft Tissue

Cut Through Trial

Straight Stem Offset Stem

As the knee comes out to full extension, if the tension

in the medial and lateral collateral ligaments is unequal,
appropriate soft tissue releases should be performed in
a manner to allow the tension to be equal on both the
medial and lateral sides of the knee.

Should the selected joint line by the positioning of the

Trials differ widely from the joint line anatomical markers,
the surgeon has the ability to change the distal/proximal
position of the Femoral Component but will have to
mirror these changes with appropriate selection of the
Tibial Insert and changes to the femoral sizing.

For solutions to address discrepancies between Flexion

and Extension, refer to the chart on page 99.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Flexion/Extension Balancing

Cut Through Trial

Straight Stem Offset Stem

Set rotation and balance the flexion space and, when

possible, re-establish the joint line.

• Revision Spacer Block and Shim • PS Insert Trial

Once desired flexion/extension balance is achieved, note the final

Insert thickness used.

If the thinnest Revision Tibial Insert Trial/Spacer Block Assembly may not be utilized,
the surgeon has two options:

• The Femoral Cut Through Trial can be downsized which allows increase of the
flexion space

• Alternatively, the tibial resection may be increased with a further resection of two
or more additional millimeters. This maneuver will also increase the extension gap.
Further tibial resection may require that tibial preparation be repeated

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Flexion/Extension Balancing

Cut Through Trial

Straight Stem Offset Stem

Once the desired flexion space is achieved, with the Tibial, Femoral,
and ATTUNE PS Tibial Insert Trials or Revision Spacer Block and Shim
retained in the joint, gently take the knee into extension.

Allow the Femoral Trial to translate proximally in the femoral

canal such that when the knee reaches full extension, the
extension space will then match the flexion space.

As the leg goes into extension, the Femoral

Trial is able to slide up the canal (along
the Stem Trial) until it gets to full extension
and the extension space then matches the
flexion space.

Check that the Femoral Trial is appropriately distalized to

maintain tension in the medial and lateral collateral ligaments,
and pin the Femoral Trial in position. To allow for trial
reduction, the Antero-Medial Pin Hole should be utilized on
the Femoral Trial.

The process of assessing flexion and extension gaps may be

repeated until desired balance is achieved. Refer to the table on
page 99 to aid in balancing the flexion and extension gaps.

i INFORMATION

As an additional reference, if preferred, the interface of

the Femoral Trial and Tibial Insert Trial represents the joint
line of the implant and should be aligned to the meniscal
scar as a re-establishment of the native joint line.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Augment Resections

Cut Through Trial

Straight Stem Offset Stem

Pin the distal surface of the Cut Through Trial.

With the Femoral Trial pinned in place, if Femoral
Augments are required, remove the Tibial Insert Trial
or Revision Spacer Block Assembly and make the
appropriate resections through the Distal and/or
Posterior Augment slots ensuring that Pins are not
in the way of the resections.

If Distal Augments are required on both the Medial

and Lateral sides, pin one side first and resect the
opposite side. Assemble the appropriate Augment
Trial to the resected side and pin through the
augmented distal surface. Remove the opposite
distal pin and complete the opposite side resection
and insert the corresponding Augment Trial.

Insert the appropriate Femoral Augment Trials by

loading from the side of the Femoral Trial. !

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
should be kept at an appropriate location when not in
use in the surgical site.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Box Resection

Cut Through Trial

Straight Stem Offset Stem

With the Femoral Trial pinned in place, remove the Tibial

Insert Trial or Revision Spacer Block and Shim. Disconnect
the two distal Hexes and remove the IM Assembly
utilizing the Angel Wing.

Torque Limiting
Screwdriver Assembly

Angel Wing

Slide the wide end of the Angel Wing in to the slot on

the anterior flange between the Cut Through Trial and
IM Connector and lever the IM Connector distally.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Box Resection

Cut Through Trial

Straight Stem Offset Stem

A Reciprocating Saw is recommended for resecting the sides

of the Femoral Box. Use the side walls of the box opening on
the Cut Through Trial as a Guide.

Attach the Box Cut Platform to the anterior flange of the

Cut Through Trial and proceed to resect the top of the box
with the Reciprocating Saw or Narrow Saw Blade.

A groove is machined into the bridge between the posterior

condyles, once the top of the box resection has been
completed this groove is fully visible.

Check completeness of the box resection using the Angel

Wing against the Box Cut Platform and along the sides of
the box opening in the Cut Through Trial. !

Remove the Box Cut Platform and the Cut Through Trial
from the prepared femur.

For Femoral Trial Assembly with a Straight or Offset Stem,

proceed to page 135.

! CAUTION
Machined Groove
If the box resection is not complete, the connecting
on Bridge
components may not seat.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Cut Through Trial

Straight Stem Offset Stem

Assemble the Femoral Trial, Box Trial, Stem Trial Bolt,

Boss Trial or Offset Adaptor Trial, and Stem Trial as
described in pages 55, 57 and any appropriate Augment
Trials as described on page 60. !

If offset is being used, position the Femoral Offset

Adaptor Trial to the offset orientation previously noted
in the Cut Through Trial with Offset Stem workflow
from pages 125 to 127, and tighten the Stem Trial Bolt.

Introduce the Femoral Trial Assembly to the prepared

femur. Utilize the ATTUNE System Impactor to seat the
Femoral Trial Assembly.

Introduce the Revision Tibial Insert Trial and proceed

to Setting Tibial Base Rotation on page 147 or if it is
now desired to add a Sleeve to the construct, proceed
to page 136.

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
should be kept at an appropriate location when not in
use in the surgical site.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

The following workflow is for an intraoperative

transition from a well balanced Cut Through
Trial with a Long Straight Stem to a Sleeve and
Stem Preparation using the Cut Through Trial.

i INFORMATION

Prior to continuing with this workflow the

Straight Stem workflow must be completed.

Once the flexion and extension gaps have been

established through the Cut Through Trial and the
box resection has been performed proceed with the
following steps for Broach Preparation.

Translate the lines on the medial, lateral sides and

anterior flange of the Cut Through Trial onto the
distal femoral bone.

These lines represent the A/P and M/L positions of

the Femoral Boss and shall correspond with the
desired Broach axis as the subsequent Broaching steps
are performed. See image on page 140.

Connect the lines on the medial and lateral femur

across the distal surface of the femur.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

Revisit the Femur Reference Tool to ensure that the Ream to Groove 6. The resultant implant construct
femoral canal has been reamed to the appropriate (Femoral Component, 60 mm Stem, 55 mm Femoral
depth for a Femoral Broach and Stem. Sleeve) will align with the Femoral Sleeve Trial
construct but will be slightly longer than the 110 mm
Example of Reamer Reference Tool use for Press-Fit
Stem Trial without sleeve as can be seen by comparing
Stem and Femoral Sleeve:
the position of the 55 mm Sleeve and 60 mm Stem
The Cut Through Trial assessment was performed
versus the 110 mm Stem without Sleeve on the Reamer
with a 110 mm Stem Trial and Pre-operative Planning
Reference Tool.
suggested use of a 55 mm Sleeve. To accommodate
the Sleeve within the overall construct length, a 60 mm
Stem should now be used instead of the 110 mm Stem.

Revision Femoral Revision Femoral Trial with

Trial with 110 mm 55 mm Femoral Broach
Stem Trial and 60 mm Stem Trial

Ream to
Next Groove

Reference Tool
on Press-Fit Side

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem Stem Trial

Assemble the corresponding Stem Trial to the

smallest Femoral Broach.

Femoral Broach

Connect the correct side, “Left or Right”, Broach

Stop of the appropriate size grouping, 1 - 3, !
4 - 7, 8 - 10, to the Revision Broach Handle.

Broach Stop

! CAUTION

A Broach Stop must be utilized when broaching

the femur.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Broach Stop Shim

(thickness of shim is same
Femoral Sleeve and Stem
as Augments)

If Distal Augment Trials were utilized in the Cut

Through Trial to achieve desired placement of the
Femoral Component, apply the Broach Stop Shim
that corresponds to the thinnest of the Distal
Augment Trials utilized.

Example
8 mm Distal Medial and 4 mm Distal Lateral
- Utilize the 4 mm Broach Stop Shim

8 mm Distal Medial and NO Distal Lateral

- No Broach Stop Shim is to be applied Broach Stop

4 mm Gap

8 mm Distal Medial and 4 mm Distal Lateral

8 mm Gap

8 mm Distal Medial and NO Distal Lateral

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

Connect the Broach Assembly to the Broach

Handle Assembly.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

Utilize the A/P reference line indicated on the distal femur along
with the marking lines along the side of the Broach, Broach
Handle and Broach Stop to aid in guiding the placement of the
Femoral Broach during Broaching.

Frequently check that the A/P position indicated by the lines

along the sides of the Broach, Broach Handle, Broach Stop, and/
or Broach Stop Shims has not migrated anteriorly or posteriorly
with respect to the A/P reference line on the distal femur.

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

If rotation is required for Femoral Broach fixation then the markings on the
medial and lateral aspects of the Broach will not align to the markings on the
femoral bone and the distance between the marked line on the femur and the
line on the Broach should be equivalent on both the medial and lateral sides.

Uniform Rotation Non-Uniform Rotation

3 7

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4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

Every effort in broaching should be made to align

the markings on the Femoral Broach with those on
the distal femur so that the position of the Femoral
Component is not shifted.

Options to Address Broach Positional Variation

The Conventional Cut Guide and Notch Guide should be utilized to
If the M/L position of the re-prepare the box resection in the correct M/L placement
Broach Positional Variation from Original Cut Through Trial

Broach shifts Assess bone coverage and potential overhang/underhang introduced

by new M/L position
Assess the impact to the flexion space and potentially upsize the
Femoral Component. Assess potential overhang of the new
If the Broach shifts anteriorly femoral size
If upsizing is not possible, assess the need to resect more posterior
with Stem Assessment

bone and/or increase the Insert thickness and proximalize the Broach
Assess the impact to the anterior cortex as well as the flexion space
and potentially downsize the Femoral Component. Assess potential
overhang/underhang/notching of the new femoral size
If the Broach shifts posteriorly
If downsizing is not possible, assess the need to resect more anterior
bone, decrease the Insert thickness, and distalize the Broach by
increasing the Broach size and utilizing the Broach Stop Shims
If the Broach non-uniformly
rotates with respect to the A/P This will result in either anterior or posterior shift of the Broach. See
reference line. For example see the above options to address either shift
previous page
If the Broach uniformly rotates
with respect to the A/P
No adjustment is necessary
reference line. For example see
previous page

For Sleeve/Femoral Component compatibility, refer

to page 87. i INFORMATION

With the construct change from a femur with a long

Stem to a femur with a Sleeve and shorter Stem, one
can anticipate there may be some subtle changes in
the position of the femur.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

Advance the Broach until the Broach Stop, or Broach

Stop Shim is seated on the most prominent surface
of the distal femur.

Check that the Broach is rotationally stable. If not,

progressively increase the Broach size until
rotational stability is achieved.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Femoral Preparation

4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Broaching

Cut Through Trial

Femoral Sleeve and Stem

After progressively broaching the femoral canal to

stability, detach the Broach Handle.

For Femoral Trial Assembly with a Broach, proceed to

page 146.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Femoral Preparation
4. REVISION FEMORAL COMPONENT WITH INTRAMEDULLARY PREPARATION

Seating the Femoral Trial

Cut Through Trial

Femoral Sleeve and Stem Femoral Trial Assembly

Assemble the Femoral Trial with the Box Trial and any
!
appropriate Augment Trials as described on page 60.

Introduce the Femoral Trial Assembly to the prepared

femur and introduce the Femoral Broach Trial Bolt
through the hole in the Box Trial and into the Femoral
Broach. Tighten with the Torque Driver with 6 mm
Hex Driver.
Femoral Broach
Trial Bolt

Introduce the Revision Tibial Insert Trial and

proceed to Setting Tibial Base Rotation on page 147.

i INFORMATION “click”

If the Cut Through Trial Assembly and Broach Trial

Bolt do not engage in the Broach, slightly extract
the Broach with the Broach Handle, attach the Cut
Through Trial Assembly to the Broach via the Broach Torque Driver Assembly
Bolt leaving it slightly loose to allow the instruments
to locate within the prepared cavity, and advance the
trial construct until seated to the prepared depth using
the ATTUNE System Impactor.

! CAUTION

The ATTUNE Revision Femoral Augment Trials contain

magnets. These devices should be kept at a safe
distance from a patient’s active implantable medical
device(s) (i.e. pacemaker) in order to avoid adversely
affecting the device. The Femoral Augment Trials
should be kept at an appropriate location when not in
use in the surgical site.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Setting Tibial Base Rotation

5. TRIALING AND FINAL PREPARATION

Now set the Tibial Base rotation with the surgeon’s
preferred technique. Options include:

• Alignment with the medial third of the Tibial

Tubercle

• Optimizing Tibial Base rotation based on

trial reduction with the Tibial Insert Trial and
Femoral Component

Cut Through Trial

Solid Femoral Trial

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Setting Tibial Base Rotation
5. TRIALING AND FINAL PREPARATION

Optimizing the Tibial Base Rotation Based on a Trial Reduction

With the knee in flexion, introduce the Tibial Insert Trial between the Femoral Trial and Revision
FB Tibial Base Trial.

Cut Through Trial Solid Femoral Trial

Extend the knee carefully, noting the A/P and M/L stability, and the overall alignment in the A/P and M/L planes.

While taking the knee from flexion to extension, observe the orientation of the FB Tibial Base Trial.

Cut Through Trial Solid Femoral Trial

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Setting Tibial Base Rotation

5. TRIALING AND FINAL PREPARATION

When the definitive orientation of the FB Base
Trial has been determined, with the knee in
flexion, either pin the trial in place through the
medial anterior fixation hole or utilize the
marks on the anterior aspect of the FB Tibial
Base Trial to mark the rotation with respect to
the anterior tibia.

If a medial Tibial Augment is required, and the

Anterior Fixation Pin is desired then pin through
the lateral anterior hole.

Cut Through Trial

Solid Femoral Trial

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Setting Tibial Base Rotation
5. TRIALING AND FINAL PREPARATION

To remove the Tibial Insert Trial, fully flex the

knee and connect the ATTUNE Primary
INTUITION Insert Trial Handle to the anterior
features on the Tibial Insert Trial and pull
assembly out of the joint space to remove the
Tibial Insert Trial. ATTUNE Primary
INTUITION Insert
Trial Handle
If Tibial Augment preparation is required,
proceed to page 151.

If Tibial Augments are not required or have

been prepared previously in the procedure,
proceed to Keel Preparation on page 153.

Cut Through Trial

ATTUNE Primary
INTUITION Insert
Trial Handle

Solid Femoral Trial

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Tibial Augment Preparation

5. TRIALING AND FINAL PREPARATION

Tibial Base Mount
With the FB Base orientation determined, Tibial
Augment resection may be performed at this time
if it has not previously been prepared.

Ensure no Pins are in the way of the Augment

resection. Assemble the Revision Base Mount with
the Tibial Base Trial.

Assemble the Cutting Block Mount to the Revision

Tibial Cutting Block and connect to the Base Mount. Revision Tibial
Base Trial
Make the appropriate Augment resection taking
care to maintain proper tibial rotation.

The "0" (zero) slot is aligned with the bottom

surface of the tray. It does not allow for a clean-up Cutting Block Mount
resection at this stage; to perform a clean-up
resection return to either page 33 for EM Tibial Tibial Cutting Block
Resection or page 42 for IM Tibial Resection.

Once any necessary Tibial Augment resections are

complete, remove all Tibial Augment resection
instruments.

Should Lateral Augments be required, if exposure

permits, utilize the opposite leg Tibial Cutting Block.

Ensure all bone debris is cleared from the joint space.

i INFORMATION

To complete the Augment resection, the Tibial Base

Trial and additional tibial instrumentation may need
to be removed from the bone after pinning the
Cutting Block in place. The vertical slot in the central
aspect of the Tibial Cutting Block may aid in initiating
the center line of the Tibial Augment resection.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Tibial Augment Preparation
5. TRIALING AND FINAL PREPARATION

If Tibial Augments have been prepared, assemble

the appropriate Tibial Augment Trial to the correct
side of the Revision FB Base Trial with the Torque
Limiting Screwdriver Assembly.

System Hex
Attachment Torque Limiting
Screwdriver

Tibial Augment

Revision Base Trial “click”

Place the Revision FB Base Trial assembly back onto

the tibia to check the fit.

For Keel Preparation, proceed to page 153.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Keel Preparation

5. TRIALING AND FINAL PREPARATION

Attach the Revision Keel Punch corresponding to the
correct tibial size grouping (1 - 2, 3 - 5, 6 - 8, and
9 - 10) to the Revision System Handle.

Revision Keel Punch

Impact the Keel Punch into the cancellous bone in the

correct alignment until the Keel Punch is fully seated
with the Tibial Base Trial. Remove the Keel Punch and
Handle.

Revision Tibial
Base Trial

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Patella Resection and Preparation
6. PATELLA RESECTION AND PREPARATION

– Instrument Assembly
Patella Resection Guide

Clamp Teeth
Height Gauge sets Resection Depth
to 9.5 mm and can be rotated to find
the highest point on the Patella or to
Saw Slot be moved out of the way

Release button unclamps the

Resection Guide from the bone

Clamp Trigger

Patella Drill Trials

Medialized Dome
Patella Drill Trial

Trial Handle

Assemble by inserting the Trial Handle into the

slot on the Drill Trial until it clicks into place.

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Patella Resection and Preparation

6. PATELLA RESECTION AND PREPARATION

– Instrument Assembly
Patella Drill Clamp

Medialized Dome Patella

Button and Button
Medialized Anatomic
Holder Assembly
Patella Button and
Button Holder Assembly

Drill Trial Patella Clamp

Button Holder

A Medialized Dome or Medialized Anatomic Silicone Button

is assembled to the Patella Clamp Button Holder to protect
the implant surface during cement pressurization

Clamp Connection Post attaches to either the

Drill Trials or Patella Clamp Button Holder with
a snap-on mechanism

Release button locks and

unlocks clamping force

i INFORMATION

The patella instrumentation is designed for a medial

approach only.

The clamp and trial handle are designed for a medial

approach only. The Resection Guide and Drill Trials
(used as stand alone without the clamp) can be used
for a medial or lateral approach.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Patella Resection
6. PATELLA RESECTION AND PREPARATION

Use the Caliper to estimate the thickness of the patella and evaluate the
level of bone resection. The Height Gauge on the Patella Resection Guide
accounts for a resection of 9.5 mm of bone, which is the average thickness
of the ATTUNE Knee Systems Patellae.
!

Patella Guide Shim

Place the leg in extension and evert

the patella.

Position the Patella Resection Guide so the

Height Gauge is against the articular surface
of the patella. Align the serrated jaws at the
medial and lateral margins of the articular
surface. Engage the largest tooth on the
lateral side then engage the largest tooth on
the opposite side to temporarily secure the
clamp while allowing for rotation of the
patella until the inferior and superior
orientation is achieved and clamp fully.

! CAUTION i INFORMATION

If the patellar thickness is less than 21.5 mm, the The resection extends from the medial chondro-osseous
thickness of the bone remaining after resection junction to the lateral chondro-osseous junction.
would be less than 12 mm and resecting less bone
should be considered.
If less resection is required, the Patella Guide Shim
is available which reduces the depth of the resection
to 7.5 mm.

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Patella Resection

6. PATELLA RESECTION AND PREPARATION

Perform the resection using an Oscillating
Saw through the Saw Capture.

Patella Wafer

i INFORMATION
If desired, place a Patella Wafer on the
resected surface by hand to protect the
When resecting the patella, care should be taken patellar bone bed.
to avoid Saw Blade excursion into the Femoral
Trials or Implants.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Patella Implant Options
6. PATELLA RESECTION AND PREPARATION

Medialized Anatomic Patella

Medialized Dome Patella

Patella Size Chart

Size Thickness
29 8.5 mm
32 9 mm
35 9.5 mm
38 10 mm
41 10.5 mm

Two patella options are available, the Medialized Dome Patella or

the Medialized Anatomic Patella.

The Medialized Anatomic Patella is designed to be conforming with

the Femoral Component and has a built in range of +/- 15 degrees
freedom of rotation from its optimal position. Therefore, accurate
alignment of the Patella Drill Trial is important for proper patella
placement and tracking.

The following steps will aid in accurate alignment of both patella

designs, but is particularly critical for the Medialized Anatomic Patella.

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Patella Drill Trialing

6. PATELLA RESECTION AND PREPARATION

If used, remove the Patella Wafer from the
patella. Place the Patella Drill Trial on the
resected patella to assess bone coverage.
Select the correct size of Patella Drill Trial for
maximum patella bone coverage. Verify the
medial lateral location of the patella implant
apex relative to the native anatomy ridge.

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Patella Drill Trialing
6. PATELLA RESECTION AND PREPARATION

Press the trial onto the bone manually or with the Patella Medialized Anatomic
Modular Clamp and Clamp Ring to engage spikes. Patella Drill Trial

The Drill Trials have one larger central spike to allow

engagement of only the central spike so that the Drill Trial Medialized Dome
may be rotated about the central axis to aid in assessment Patella Drill Trial
of its optimal position prior to being fully seated on bone.
Large Central Spike

3 7

Correct trial handle alignment Incorrect trial handle alignment

i INFORMATION

In a case where a short patella tendon raises concern

about the Medialized Anatomic Patella contacting
the top of the spine of the PS or Revision Insert, it is
recommended to downsize the patella, superiorize
and medialize its position. If that recommended
positioning does not resolve the concern, the surgeon
should consider using the medialized dome patella.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Lug Hole Preparation

6. PATELLA RESECTION AND PREPARATION

Patella/Femoral Lug Drill

Medialized Dome Patella Drill Trial

Medialized Anatomic
Patella Drill Trial

! Use the Patella Modular Clamp to secure the

Drill Trial if desired. Drill the holes using the
Patella/Femoral Lug Drill.

! CAUTION

If the surgeon is not satisfied with alignment or

tracking of the Medialized Anatomic Patella Trial
after drilling the peg holes, it is recommended to
use a Medialized Dome Patella. The patella peg hole
preparation is identical for the Medialized Dome
Patella and the Medialized Anatomic Patella.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Final Trial Assessment
7. FINAL TRIAL ASSESSMENT

Complete final Trial evaluation and proceed to Trial

removal on the following page.

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Femoral Trial Removal

8. TRIAL REMOVAL
Remove any Pins prior to extracting the Trial Assemblies.

Remove the Tibial Insert Trial using the ATTUNE Primary

INTUITION Insert Trial Handle.

Femoral Trial Extractor

When using an Offset Adaptor or a Femoral Sleeve ensure that
the Central Bolt is tightened prior to extraction.

To remove the Femoral Trial Assembly, assemble the Femoral

Extractor to the Central Bolt feature of the Femoral Box Trial and
extract from the prepared femur. If necessary, the Slap Hammer
may be assembled to the Femoral Extractor to aid in Trial removal.

Retain the Trial Assembly to aid in setting rotation for final

Implant Assembly.

i INFORMATION

If the Broach or Offset Adaptor Trial loosens during

extraction from the femur, then partially assemble the
Trial back to the bone and tighten the Central Bolt to
regain the correct Trial orientation. This will then be
used to aid in setting the rotation of the final implant
assembly.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Tibial Trial Removal
8. TRIAL REMOVAL

Remove any Pins prior to extracting the Trial Assemblies.

For Offset FB Base constructs ensure that the Central Bolt

is tightened prior to extraction.

To remove the Revision FB Tibial Base Trial, assemble the

Revision System Handle to the central feature of the FB
Tibial Base Trial and extract from the prepared tibia.

Retain the Trial Assembly to aid in setting rotation for

final Implant Assembly.

i INFORMATION

If the Offset Adaptor Trial loosens during extraction

from the tibia, then partially assemble the Trial
back to the bone and tighten the Central Bolt to
regain the correct trial orientation. This will then
be used to aid in setting the rotation of the final
implant assembly.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Implant Assembly

9. IMPLANT ASSEMBLY
There are 14 Assembly Instruments in the system to After extracting the ATTUNE Revision Trial from the
aid in the building of the final Implant construct: prepared bone, retain the assembled trial construct
to reference in the definitive Implant Assembly.
1. Revision Sleeve Impactor
2. Torque Driver
3. Augment 2.5 mm Wobble Bit
4. Implant Assembly Wrench
5. Assembly Wrench Adaptor
6. Assembly Base
7. Offset Stabilizer
8. Tibial Vice
9. Femoral Implant Post
10. Femoral Trial Post
11. Femoral Shim (1 per Femoral Component size)
12. Sleeve Counter Torque Wrench
13. Tibial Straight Stem Wrench
7
14. Femoral Straight Stem Wrench

2
5
8

9
1
3
11
6

10
12

13

14

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Augment Assembly
9. IMPLANT ASSEMBLY

Straight Stem

For all Revision FB Tibial Bases or Femoral constructs

with Straight Stems, assemble appropriate Augments
after assembling any Stems.

Offset Stem

For all Revision FB Tibial Bases or Femoral constructs

with Offset Stems, assemble appropriate Augments
prior to adding the Offset Adaptor and Stem.

Femoral Sleeve and Stem

For Femoral constructs with a Sleeve, assemble

Torque Driver
appropriate Augments prior to assembling the Sleeve.

2.5 mm Augment
Wobble Bit

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Tibial Augment Assembly

9. IMPLANT ASSEMBLY
Tibial Augment Implants are shared across two Tibial
Base sizes (1 - 2, 3 - 4, 5 - 6, 7 - 8, 9 - 10).

- The 5 mm Tibial Augments may be utilized on either

the Medial or Lateral side of the Tibial Base.

- The 10 and 15 mm Tibial Augments are side specific

and come in LM/RL or LL/RM offerings.

Using the 2.5 mm Wobble Bit and Augment Screws,

affix the previously prepared for Tibial Augment(s)
to the backside of the previously prepared for (size-
specific) Revision Tibial Base Implant.

Torque Driver

Ensure both Augment Screws are engaged with the

Revision Tibial Base Implant prior to completing fixation.
Attach the Torque Driver to the 2.5 mm Wobble Bit
and continue to turn until a “click” is heard, to ensure
adequate screw fixation.

“click”

i INFORMATION

Using the 2.5 mm Wobble Bit by hand (to start each

Augment Screw) prior to attaching the Torque Driver
may assist by providing tactile feedback.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Femoral Augment Assembly
9. IMPLANT ASSEMBLY

Using the Torque Driver with the 2.5 mm Wobble Bit,

assemble the appropriate Posterior Augment(s) to the
correct location(s) of the Revision Femoral Implant. Posterior Augment
!

Tighten the Femoral Augment Collet using the

Torque Driver until a “click” is heard.

“click”

If a Posterior Augment is in place, the Distal Augment

Implant will assemble into the distal location by
rocking into location around the Posterior Augment.
Otherwise, the Distal Augment will assemble into the
distal location by loading from the proximal location.

“click”

! CAUTION
Distal Augment
Always assemble Posterior Augments to the Revision
Femoral Component prior to any Distal Augments.

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Revision FB Tibial Base and Straight Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Straight Stem

Poly Plug
i INFORMATION Remover

Note: The Base Protector should be retained on

the Tibial Base during Assembly and Seating of the Tibial Straight
Tibial Base. Stem Wrench

FB End Cap Remover

Remove the End Cap from the Revision Tibial Base

Implant by utilizing the FB End Cap Remover in the
End Cap
Tibial Straight Stem Wrench and rotating the Tibial
Straight Stem Wrench counter clockwise to unscrew
the End Cap.

Thread the appropriate Stem Implant into the Revision Stem Implant
FB Tibial Base until hand tight.

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Revision FB Tibial Base and Straight Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Straight Stem
Implant Assembly Wrench

Assemble the Assembly Wrench Adaptor to the

Implant Assembly Wrench with the Stem Wrench
facing outwards.

Stem Wrench

Assembly Wrench Adaptor

Place the Tibial Straight Stem Wrench over the Keels

of the Revision Tibial Base Implant. For Stem diameters
of 20 mm or greater, to avoid contact with the Stem,
the Tibial Straight Stem Wrench should be assembled
from the anterior of the Base and then dropped down
onto the Keels.

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Revision FB Tibial Base and Straight Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Straight Stem

Hold the Tibial Straight Stem Wrench in the left

hand, ensuring that the surface of the Tibial Straight
Stem Wrench is flush on the Revision Tibial Base.

Hold the Implant Assembly Wrench in the right hand

and position on the Hex of the Stem that has been
threaded onto the Tibial Base, trying to achieve Implant Assembly
Wrench
an angle of approximately 90 degrees between
the Implant Assembly Wrench and Tibial Straight
Stem Wrench. This will make it easier to apply the
desired torque.

90 degrees

Tibial Straight
Stem Wrench

Gradually bring hands together to rotate the Implant

Assembly Wrench until the marker is within the
!
torque range marking.

Always assemble Tibial Augments after Straight

Stems as described on page 167.

! CAUTION
!
Torque
Do not apply so much torque that the marker fully Range Marking
passes the torque range marking.

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Revision Femoral Component and Straight Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Straight Stem

Assemble Femoral Augments after Stems as

described on page 168.

Offset Stabilizer
Arm
Femoral Implant
Post
Assemble the Femoral Implant Post and Offset
Stabilizer Arm to the Assembly Base.

Assembly Base

Femoral Shim

Slide the appropriate sized Femoral Shim onto

the correct wing, Left or Right, of the Femoral
Implant Post. For example, for a size 4 Femoral
select the size 4 Femoral Shim.

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Revision Femoral Component and Straight Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Straight Stem
FB End
Cap Remover

Remove the Poly Plug from the Revision Femoral

Implant by utilizing the Poly Plug Remover in Poly Plug Remover
the Sleeve Counter Torque Wrench or Tibial
Straight Stem Wrench and rotating the Poly Plug
counter clockwise.

Tibial Straight
Stem Wrench

Place the Revision Femoral Implant on the Femoral

Implant Post by engaging the post in the boss area.

Rotate the Femoral Implant on the Assembly Base

until the "Left" or "Right" arrow for the respective
Femoral Component is pointing to the "9 o'clock"
position. This orientation helps with access to the
Stem for tightening, without being obstructed by
the Femoral Anterior Flange.

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Revision Femoral Component and Straight Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Straight Stem

Lock the orientation by rotating the Front Base Knob

to the locked position.
Front Base Knob

Thread the appropriate Stem on the Revision Femoral

Implant until hand tight.

Implant Assembly Wrench

Assemble the Assembly Wrench Adaptor to the

Implant Assembly Wrench with the Stem Wrench
outward.

Assembly Wrench
Stem Wrench Adaptor

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Revision Femoral Component and Straight Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Straight Stem

Hold the Offset Stabilizer Arm in the left hand.

Hold the Implant Assembly Wrench in the right

hand and position on the Hex of the Stem that
has been threaded to the Femoral Implant, trying
to achieve an angle of approximately 90 degrees
between the Implant Assembly Wrench and Offset 90 degrees
Stabilizer Arm. This will make it easier to apply the
desired torque.

Gradually rotate the Implant Assembly Wrench

towards the Offset Stabilizer Arm until the marker
is within the torque range marking. !

Torque
Range Marking

! CAUTION !

Do not apply so much torque that the marker fully

passes the torque range marking.

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Alternative Revision Femoral Component and
9. IMPLANT ASSEMBLY

Straight Stem Implant Assembly

Straight Stem
Implant Assembly Wrench

Assemble Femoral Augments after Stems as described

on page 168.

Assemble the Assembly Wrench Adaptor to the Implant

Assembly Wrench with the Stem Wrench facing outwards.

Stem Wrench

Assembly Wrench Adaptor

Femoral Straight
Stem Wrench

Place the ATTUNE Revision Femoral Straight Stem Wrench

around the box of the Femoral Implant between the
anterior flange and posterior condyles. The handle of
the Femoral Straight Stem Wrench should run above
the posterior condyles of the femoral implant.

Tighten the thumb screw on the Stem Wrench until it is

secured against the side of the box. Thread the desired
Stem Implant on the Femoral Boss until hand tight.

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Alternative Revision Femoral Component and

9. IMPLANT ASSEMBLY
Straight Stem Implant Assembly

Straight Stem
Implant Assembly Wrench

Hold the Femoral Straight Stem Wrench in the left hand.

Hold the Implant Assembly Wrench in the right hand

and position on the Hex of the Stem that has been
threaded to the Femoral Implant, trying to achieve an
angle of approximately 90 degrees between the Implant
Assembly Wrench and Femoral Straight Stem Wrench.
This will make it easier to apply the desired torque.
90 degrees
Femoral Straight
Stem Wrench

Gradually rotate the Implant Assembly Wrench towards

the Femoral Straight Stem Wrench until the marker
is within the torque range marking. !

Torque
Range Marking

! CAUTION

Do not apply so much torque that the marker fully

passes the torque range marking.

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Revision FB Tibial Base and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

i INFORMATION

Note: The Base Protector should be retained on

the Tibial Base during assembly and seating of
the Tibial Base.

The intent of the Offset Assembly Instruments is to have the offset

orientation on the implant replicate the orientation of the offset in the
Trial construct. It does this in two steps:

1. Use the Trial to set the orientation of the Assembly Jig.

2. Use the Assembly Jig to set the orientation of the Offset Adaptor on
the Implant.

Assemble the Tibial Vice and Offset Stabilizer Arm to the Assembly Base.

Offset Stabilizer

Tibial Vice

Assembly Base

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Revision FB Tibial Base and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Offset Stem

Place the Trial Construct in the Tibial Vice and

rotate the Tibial Vice Knob to tighten the Tibial
Vice to the Tibial Trial Construct.

Tibial Vice
Knob

Offset Stabilizer Arm

Orient the Tibial Offset Adaptor Trial to the
Offset Stabilizer Arm and slide the Arm to
contact the Trial. !

! CAUTION

In order to ensure that the Offset Adaptor is not

Aligned with the Alignment Window
inserted 180 degrees out of position, ensure that
the black mark on the Tibial Offset Adaptor Trial is
visibly positioned within the window of the Offset
Stabilizer and that the Trial Construct offset number
matches the number on the Base.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision FB Tibial Base and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem
Offset Locking Knob

Lock the Offset Stabilizer Arm using the Offset

Front Base Knob
Locking Knob. Lock the orientation of the
Tibial Vice by rotating the Front Base Knob to
the locked position. ! !

The Assembly Jig is now locked and replicates

the Trial orientation.

1 2

4
1. Loosen the Offset Locking Knob from the
Tibial Offset Adaptor Trial.

3
2. Slide the Offset Stabilizer backwards.

3. Rotate the Tibial Vice Knob in the counter

clockwise direction.

4. Remove the Tibial Trial.

! CAUTION

Do not unlock Assembly Base Knob, as this has set

your orientation.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision FB Tibial Base and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly
Poly Plug
Remover

Tibial Straight
Offset Stem Stem Wrench

Remove the End Cap from the Revision Fixed Bearing FB End Cap Remover
Tibial Base Implant by utilizing the FB End Cap Remover
in the Tibial Straight Stem Wrench and rotating the
Wrench counter clockwise to unscrew the End Cap.

End Cap

If necessary, assemble Tibial Augments as described

on page 167 before assembling the Offset Stem
Adaptor or Stem.

Tibial Vice Knob

Place the Revision FB Tibial Base Implant on the

Tibial Vice and rotate the Tibial Vice Knob clockwise
to tighten the Tibial Vice on to the Revision FB Tibial
Base Implant.

Offset Adaptor Implant

Ensure the Offset Locking Nut is in the correct starting

position. If loose, tighten by rotating in the opposite
direction of the arrow on the Offset Locking Nut until
hand tight.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision FB Tibial Base and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

Ensure the line on the Locking Nut is closest to the

Revision FB Tibial Base.

Thread the Offset Adaptor clockwise on to the

Revision FB Tibial Base Implant until fully seated.

Once fully seated, rotate the Offset Adaptor counter

clockwise until it aligns with the Offset Stabilizer Arm.

!
Do not rotate the Offset Adaptor more than
360 degrees.

! 2
1

Slide the Offset Stabilizer Arm forward and tighten

on to the Offset Adaptor by rotating the Offset
Stabilizer Arm Locking Knob clockwise. Ensure that
the black mark is aligned in the alignment window.

! CAUTION

In order to ensure that the Offset Adaptor is not

inserted 180 degrees out of position, ensure that
the angled face of the Offset Adaptor is away from
the Offset Stabilizer Arm.

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Revision FB Tibial Base and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Offset Stem

The implant has now been aligned to the

orientation of the Assembly Jig, which was set off
Offset Locking Nut
of the Trial.

The next step is to tighten the Offset Locking Nut

and Stem.

Rotate the Offset Locking Nut in the direction of

the arrow on the Offset Adaptor Implant until
hand tight.

Implant Assembly Wrench

Assemble the Assembly Wrench Adaptor to the

Implant Assembly Wrench, with the Offset Locking
Nut Wrench facing outward.

Offset Locking
Nut Wrench

Assembly Wrench
Adaptor

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision FB Tibial Base and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

Holding the Implant Assembly Wrench with left

hand, assemble it to the Offset Locking Nut so that
the angle between the Implant Wrench Assembly
and the Offset Stabilizer Arm is approximately 90
degrees. This will make it easier to apply the desired
90 degrees
torque.

Hold the Offset Stabilizer in the right hand and

rotate the Implant Assembly Wrench counter
clockwise, gradually bringing hands together to
tighten the Locking Nut until the marker is within
Torque
the torque range marking. !
Range Marking

Thread the appropriate Stem on to the Offset

Adaptor by rotating the Stem clockwise on to the
Offset Adaptor until hand tight.

! CAUTION

Do not apply so much torque that the marker fully

passes the torque range marking.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision FB Tibial Base and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly
Implant Assembly Wrench

Offset Stem

Assemble the Assembly Wrench Adaptor to the Implant

Assembly Wrench with the Stem Wrench facing outward.

Stem Wrench

Hold the Implant Assembly Wrench in the right hand and

position on the Hex of the Stem that has been threaded
on to the Revision FB Tibial Base Implant to create an
angle of approximately 90 degrees with the Offset
Stabilizer Arm. 90 degrees

Grasp the Offset Stabilizer with left hand and gradually

bring hands together to rotate the Implant Assembly
Wrench clockwise to tighten the Stem until the marker is
within the torque range marking. !
Torque
Range Marking

Loosen the Front Knob first to release any tension in

the system. Then loosen the Locking Knob of the Offset
Stabilizer Arm and slide back. Finally, loosen the Tibial
Vice Knob to remove the final Implant Construct.

Confirm visually that the implant offset is in the correct

orientation relative to the Trial.

! CAUTION

Do not apply so much torque that the marker fully

passes the torque range marking.

Trial Implant

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

Assemble Femoral Augments before Stems as described on

page 168.
Femoral Trial Post
The intent of the Offset Assembly Instruments is to have
the offset orientation on the Implant replicate the
orientation of the offset in the Trial Construct. It does this
in two steps:

1. Use the Trial to set the orientation of the

Assembly Jig.
Offset Arm

2. Use the Assembly Jig to set the orientation of the

Offset Adaptor on the Implant.

Assemble the Femoral Trial Post and Offset Stabilizer Arm Assembly Base
to the Assembly Base.

Femoral Shim

Slide the appropriate sized Femoral Shim onto the correct

wing, Left or Right, of the Femoral Trial Post.

For example, for a size 4 Femoral select the 4 Femoral Shim.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Component and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly
Femoral Offset
Offset Stem Trial Construct

Place the final Femoral Offset Trial Construct on the

Femoral Trial Post by engaging the Femoral Post in the
Trial Boss.

Orient the Femoral Offset Adaptor Trial to the Offset

Stabilizer Arm and slide the Arm to contact the Trial.
! 2

! CAUTION

In order to ensure that the Offset Adaptor is not

inserted 180 degrees out of position, ensure that the
black mark on the Femoral Offset Adaptor Trial is
visibly positioned within the window of the Offset
Stabilizer and that the Trial Construct offset number
Aligned with the
matches the number on the Base corresponding to
Alignment Window
the “left or right” mark as appropriate.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem
Offset Locking Knob

Lock the Offset Stabilizer Arm using the Offset

Locking Knob. Lock the orientation of the
Femoral Offset Adaptor by rotating the Front
Base Knob to the locked position. !

!
Front Base Knob

The Assembly Jig is now locked and replicates the

Trial orientation. 1 2
3

1. Loosen the Offset Stabilizer Arm from the Femoral

Offset Adaptor Trial.
4
2. Slide the Offset Stabilizer Arm backwards.

3. Lift the Femoral Trial Assembly out of the

Assembly Base.

4. Lift the Femoral Trial Post out of the Assembly Base.

! CAUTION

Do not unlock Assembly Base Knob, as this has set

your orientation.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Component and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly
Femoral Implant Post
Offset Stem

Assemble the Femoral Implant Post to the Assembly

Base and transfer the Shim from the Femoral Trial Post
to the Femoral Implant Post.
Assembly Base

Femoral Shim

Poly Plug
Remover
Tibial Straight
Remove the Poly Plug from the Revision Femoral Stem Wrench
Implant by utilizing the Poly Plug Remover in the
FB End
Sleeve Counter Torque Wrench or Tibial Straight Stem Cap Remover
Wrench and rotating the Poly Plug counter clockwise.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

Place the Revision Femoral Implant on the Femoral

Implant Post by engaging the post in the boss area
of the Implant.

Ensure the Offset Locking Nut is in the correct starting

position by rotating in the opposite direction of the Offset Adaptor
arrow on the Offset Adaptor until hand tight.

Ensure the line on the Locking Nut is closest to

the Femoral Component.

Thread the Offset Adaptor clockwise on to the Revision

Femoral Implant until the Offset Adaptor is fully seated.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Component and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Offset Stem

Once fully seated, rotate the Offset Adaptor counter

!
clockwise until it aligns with the Offset Stabilizer Arm.

Slide the Offset Stabilizer Arm forward and tighten on

to the Offset Adaptor by rotating the Offset Stabilizer
Arm Lock Knob clockwise. Ensure the black mark is
aligned in the alignment window.

The implant has now been aligned to the orientation

!
3
of the Assembly Jig, which was set off of the Trial.

The next step is to tighten the Offset Locking Nut

and Stem.

Rotate the Offset Locking Nut in the direction

of the arrow on the Offset Adaptor Implant Offset Locking Nut
until hand tight.

! CAUTION

In order to ensure that the Offset Adaptor is not

inserted 180 degrees out of position, ensure that
angled face of the Offset Adaptor is away from
the Offset Stabilizer Arm.

! CAUTION

Do not rotate the Offset Adaptor more than

360 degrees.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem
Implant Assembly Wrench

Assemble the Assembly Wrench Adaptor to the Implant

Assembly Wrench, with the Offset Locking Nut Wrench
facing outward.

Holding the Implant Assembly Wrench with left hand,

assemble it to the Offset Locking Nut so that the angle
Offset Locking
between the Implant Assembly Wrench and the Offset Nut Wrench
Stabilizer Arm is approximately 90 degrees. This will
make it easier to apply the desired torque.

Assembly Wrench
Adaptor

Hold the Offset Stabilizer in the right hand and

rotate the Implant Assembly Wrench counter
clockwise, gradually bringing hands together to
tighten the Locking Nut until the marker is within
the torque range marking. !

90 degrees

Torque
Range Marking

!
! CAUTION

Do not apply so much torque that the marker fully

passes the torque range marking.

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Revision Femoral Component and Offset Stem

9. IMPLANT ASSEMBLY
Implant Assembly

Offset Stem

Thread the appropriate Stem on to the Offset Adaptor

by rotating the Stem clockwise on to the Offset
Adaptor until hand tight.

Assemble the Assembly Wrench Adaptor to the Implant Assembly Wrench

Implant Assembly Wrench, with the Stem Wrench
facing outward.

Stem Wrench

Assembly Wrench
Adaptor

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Offset Stem
9. IMPLANT ASSEMBLY

Implant Assembly

Offset Stem

Hold the Implant Assembly Wrench in the right hand

and position on the Hex of the Stem that has been
threaded on to the Revision Femoral Implant to
create an angle of approximately 90 degrees with the
Offset Stabilizer Arm.

Grasp the Offset Stabilizer Arm with left hand and 90 degrees

gradually bring hands together to rotate the Implant

Assembly Wrench clockwise to tighten the Stem until
the marker is within the torque range marking. !

Torque
Range Marking

Loosen the front knob first to release any tension in the

system. Then loosen the Locking Knob of the Offset
Stabilizer Arm and slide back to remove the final
Implant Construct.

Confirm visually that the implant offset is in the correct

orientation relative to the Trial.

! CAUTION

Do not apply so much torque that the marker fully

Trial Implant
passes the torque range marking.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Component and Femoral

9. IMPLANT ASSEMBLY
Sleeve Assembly

Femoral Sleeve and Stem

Femoral
Femoral Shim
Implant Post
Assemble Augments to the Femoral Implant before Stems
or Sleeves as described on page 168.

Slide the appropriate sized Femoral Shim onto the correct

wing, Left or Right, of the Femoral Implant Post.

For example, for a size 4 Femoral select the 4 Femoral Shim.

The Poly Plug should be retained in the Revision Femoral

Component when being assembled with a Femoral Sleeve.

Place the Revision Femoral Implant on the Femoral

Implant Post.

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Revision Femoral Component and Femoral
9. IMPLANT ASSEMBLY

Sleeve Assembly
Trial Orientation Features

Femoral Sleeve and Stem

Using the retained Femoral Trial Assembly and Sleeve

orientation features as a reference, position the Femoral
Sleeve Implant in the correct orientation on the Revision
Femoral Implant.

Remove the Poly Plug from the Femoral Sleeve by

utilizing the Poly Plug Remover in the Sleeve Counter
Torque Wrench and rotating the Poly Plug counter
clockwise.

Once the desired rotation has been set, gently press

on the Femoral Sleeve to establish an initial taper
engagement.
Implant Orientation Features

Fully seat and lock the Sleeve Taper on the Revision

Femoral Implant, using the Femoral End of the ATTUNE
Revision Sleeve Impactor and a mallet.

Femoral End

i INFORMATION

To aid in visualization, the Femoral Trial and Femoral End

Broach Assembly may be placed on the Femoral
Trial Post.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Component and Femoral

9. IMPLANT ASSEMBLY
Sleeve Assembly

Femoral Sleeve and Stem

Thread the appropriate Stem on to the Femoral Sleeve

until hand tight.

Assemble the Assembly Wrench Adaptor to the

Implant Assembly Wrench with the Stem Wrench
facing outward.

Implant Assembly Wrench

Stem Wrench

Assembly Wrench Adaptor

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision Femoral Component and Femoral
9. IMPLANT ASSEMBLY

Sleeve Assembly

Femoral Sleeve and Stem

Hold the Implant Assembly Wrench in the right hand

and position on the Hex of the Stem that has been
threaded on to the Revision Femoral Implant.

Hold the Sleeve Counter Torque Wrench in the left

hand and position on the Femoral Sleeve to create an 90 degrees
angle of approximately 90 degrees with the Implant
Assembly Wrench. This will make it easier to apply
the desired torque.

Torque
Range Marking

Gradually rotate the Implant Assembly Wrench towards

the Sleeve Counter Torque Wrench until the marker is
within the torque range marking. !
!

Using the alignment features of the Femoral Trial and

Implant confirm visually that the Implant Sleeve is in
the correct orientation relative to the Trial.

! CAUTION

Do not apply so much torque that the marker fully

passes the torque range marking.

111    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Cementing Technique

10. CEMENTING TECHNIQUE

!

Bone should be cleansed and dried prior to applying

cement and implantation of all components.

During cementing of implants, movement of the

components should be minimized while the cement
is curing.

Things to consider:

• Avoid leaving dead space in the prepared bone

• When a Press-Fit Stem is to be implanted, no cement

should be applied to the Stem or the medullary canal

• When implanting a Porous Coated Sleeve, do not put

cement on the sleeve or in the medullary canal

For additional information on cementing, please refer to

the “Guidance for Cementing Primary Total Knee
Replacements” document.

! CAUTION

Blood lamination can reduce the mechanical properties

of the cement; therefore, it is vital to choose cement
that reaches its working phase quickly. If applying
cement to both the implant and bone, implantation
should be completed early in its dough state to ensure
good cement-cement adhesion and reduce the risk of
dry laminations; which can weaken the cement.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    111
Revision FB Tibial Construct alone or with
10. CEMENTING TECHNIQUE

Cemented Stems or Augments

Consider the use of a cement restrictor.

Apply a thick layer of cement to the bone, the

implant surface or to both.

It is critical to ensure that cement fully surrounds

the cone of the Revision FB Tibial Base Implant
and any Cemented Stems or Augments.

Cemented Stem

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision FB Tibial Construct with

10. CEMENTING TECHNIQUE

Press-Fit Stems or Augments
Apply a thick layer of cement to the proximal tibial
bone, the underside and cone of the Revision FB Tibial
Base Implant and the bone contacting surface of any
Tibial Augments. !

Care should be taken to avoid cement from contacting

the Press-Fit Stem and being driven down the canal.

Press-Fit Stem

! CAUTION

If cementing the Offset Adaptor, difficulties in extraction

may be encountered.

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Revision Femoral Construct with Cemented Stems,
10. CEMENTING TECHNIQUE

Augments, and/or Cemented Sleeves

Consider the use of a cement restrictor.

Apply a thick layer of cement to the Revision Femoral

Component and any Cemented Stems, Augments or
Sleeves and the femur.

Cemented Stem

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Revision Femoral Construct with Press-Fit Stems

10. CEMENTING TECHNIQUE

and Augments
Apply a thick layer of cement to the distal femoral
bone, the Revision Femoral Component, and the
bone contacting surface of any Augments.

Care should be taken to avoid cement from

contacting the Press-Fit Stem and being driven
down the canal.
!

! CAUTION
If cementing the Offset Adaptor, difficulties in extraction
may be encountered.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Revision Femoral Construct with Press-Fit Stems
10. CEMENTING TECHNIQUE

and Porous Coated Sleeves and Augments

Apply a thick layer of cement to the distal femoral
bone, the Revision Femoral Component, and the
bone contacting surface of any Augments.

Care should be taken to avoid cement from

contacting the Press-Fit Stem and the Porous Coated
Sleeve and being driven down the canal.

Press-Fit Stem

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Seating the Tibial Construct

11. FINAL IMPLANTATION

Carefully insert the Revision Tibial Base Implant using
the ATTUNE System Impactor, avoiding malrotation.

System
Impactor

Impact to seat the Revision Tibial Base Implant and

!
to pressurize the cement. Then use a Curette to
remove all extruded cement.

i INFORMATION

The Fixed Bearing Tibial Base Implant should be

directly impacted to the bone prior to mating with ! CAUTION
the polyethylene Tibial Insert as shown in the Tibial To prevent damage to the bearing surface, do not
Insert Implantation section on Page 208. remove the Base Protector before impacting the Base.
The polyethylene Tibial Insert should not be Care must be taken not to pull cement from under
attached to the Tibial Base prior to Tibial Base the edge of the implant in order to ensure the edges
implantation. remain sealed.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Seating the Femoral Construct
11. FINAL IMPLANTATION

Place the Revision Femoral Component Assembly onto

the bone by hand.

Condylar
Seat the Revision Femoral Component Assembly using Impaction
the ATTUNE System Impactor.

Use only condylar impaction to seat the Revision

Femoral Component Assembly. Notch impaction will
attempt to extend the implant relative to the Stem or
Sleeve and be in conflict with the bone preparation.

Then use a Curette to remove all extruded cement.

Notch
Impaction

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Solid Tibial Trial Extraction

11. FINAL IMPLANTATION

A Trial reduction may be performed using a Tibial
Insert Trial. The ATTUNE Primary INTUITION Insert
Trial Handle can then be used to aid in removal of
Tibial Insert Trials.

ATTUNE Primary
INTUITION Insert
Trial Handle

Connect the Insert Trial Handle to the anterior

features on the Tibial Insert Trial and pull assembly
up and out of the joint space to remove the Tibial
Insert Trial.

This upward movement works with the geometry of

the condyles to aid in removal of the Revision Tibial
2. Out
Insert Trial.

Lift the handle of the

ATTUNE Primary INTUITION
Insert Trial Handle

1. Up

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Tibial Insert Implantation
11. FINAL IMPLANTATION

Remove any loose fragments or particulates from the

final Tibial Base.

For Fixed Bearing Tibial Base components, the Revision

Tibial Insert must be inserted vertically into the Fixed
Bearing Tibial Base.

First, engage the Reinforcement Pin into the central hole

in the Fixed Bearing Tibial Base.

Second, ensure that the anterior recess on the Insert is

aligned with the anterior locking features of the
Tibial Base.

Third, using the Revision FB Insert Impactor, impact the

Fixed Bearing Insert to engage the locking mechanism
of the Insert into the Base.

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
PS or CR Tibial Insert Implantation

11. FINAL IMPLANTATION

If an ATTUNE PS or CR Insert is being utilized with Insert slides back
the Revision Fixed Bearing Tibial Base, angle the and then down

Tibial Insert posteriorly and slide the posterior tabs

into the posterior undercuts of the Tibial Base.

The Fixed Bearing Tibial Insert is impacted into place

on the Tibial Base, using the Fixed Bearing Insert
Impactor.

Position the Impactor at approximately 60 degrees

60˚
on the Insert so that the notch rests on the anterior
edge of the center of the insert. Use a mallet to
strike the Fixed Bearing Insert Impactor.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Final Patella Preparation
11. FINAL IMPLANTATION

Medialized Anatomic Patella Button

Medialized Dome Silicone Button

and Patella Clamp Button Holder

Connect the Patella Clamp Button Holder to the Patella Drill Clamp.

Apply cement to the patella implant. Thoroughly clean the

cut surface of the patella with pulsatile lavage. Apply cement
to the surface of the patella and insert the component.

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Patella Component Implantation

11. FINAL IMPLANTATION

The Medialized Dome or Medialized Anatomic
Patella Buttons are designed to fully seat and
stabilize the implant as the cement polymerizes.

Center the Medialized Dome or Medialized

Anatomic Patella Button and Button Holder
Assembly over the articular surface of the implant
and the metal backing plate against the anterior
cortex of the patella, avoiding skin entrapment.

Engage the Patella Drill Clamp to firmly hold the

Patella Implant until polymerization is complete.
Remove all extruded cement with a Curette.

Release the Patella Drill Clamp by unlocking

the Locking-Switch on the handle and slightly
squeezing the Patella Drill Clamp Handles to
disengage the locking mechanism.

Reduce the patella.

Final Medialized
Anatomic Patella
Final Medialized
Dome Patella

i INFORMATION

In the case of a lateral approach, please consider that

the clamp ring matches the medialized geometry of
the implant specific for a medial approach.

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Final Cement Curing
11. FINAL IMPLANTATION

Confirm seating by circumferential inspection.

Move the leg into extension, and then lift the leg
back into flexion for final removal of excess cement.

Once all components are implanted, extending

the leg will further pressurize the cement. The leg
should then remain in extension until the cement
hardens for the appropriate time depending on
the cement type used. !

! CAUTION

Care should be taken when flexing the knee past

45 degrees to avoid putting force on the posterior
aspect of the Tibial Base while the cement is curing.

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Femoral Sleeve Disassembly

12. EXTRACTION AND DISASSEMBLY

Should a Femoral Sleeve Implant need to be
removed from a Revision Femoral Component
Implant, use the Femoral Sleeve Taper Separator:

Fully thread the Femoral Sleeve Taper Separator

Base into the Revision Femoral Implant.

Femoral Sleeve
Taper Separator Base

Fully insert the Femoral Sleeve Separator Push Rod

into the Femoral Sleeve Taper Separator Base.

Femoral Sleeve
Separator Push Rod

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Femoral Sleeve Disassembly
12. EXTRACTION AND DISASSEMBLY

Thread the Femoral Sleeve Taper Separator Driver

into the Femoral Sleeve Taper Separator Base.

Femoral Sleeve Taper

Separator Driver

Place the Hex of the Taper Separator Hex Wrench

onto the Femoral Sleeve Taper Separator Base. Place
the hex of the Taper Separator Rod/Handle onto the
Femoral Sleeve Taper Separator Driver.

Taper Separator
Hex Wrench

Hold the Taper Separator Hex Wrench while turning

the Taper Separator Rod/Handle clockwise until the
Revision Femoral Implant separates from the
Femoral Sleeve.

Taper Separator
Rod/Handle

i INFORMATION

If unable to disassemble the Sleeve after applying an

initial torque, it may be necessary to tap the end of
the Separator Driver with a Mallet, re-adjust wrench
placement, and reapply torque with the wrenches.

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Compatibility Information

ATTUNE Revision FB Tibial Insert to ATTUNE Revision CRS Femoral Component /

ATTUNE Revision FB Tibial Base Compatibility1

ATTUNE Revision
ATTUNE Revision
CRS Femoral
FB Tibial Base
Component
ATTUNE CR FB
No Yes
Tibial Insert

Tibial Insert
ATTUNE PS FB
Yes Yes
Tibial Insert
ATTUNE Revision
Yes Yes
CRS FB Insert

Patella to ATTUNE Revision CRS Femoral Component Compatibility1

ATTUNE Revision
CRS Femoral
Component

ATTUNE Medialized Dome Yes

Patella

ATTUNE Medialized Anatomic Yes

ATTUNE Revision Femoral Sleeve to ATTUNE Revision Offset Adaptor Compatibility1

ATTUNE Revision
Offset Adaptor

ATTUNE Revision Femoral Sleeves No

ATTUNE Revision Cemented Stems No

ATTUNE Revision CRS Femoral Component Yes

ATTUNE Revision FB Tibial Base Yes

ATTUNE Revision Press-Fit Stems Yes

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies    222
Compatibility Data

Table 7: ATTUNE Revision Compatibility Chart1

SIZE
SZ

Pink 1 1 1 2 3 29 32 35 38 41
Dark Blue 2 2 1 2 3 4 29 32 35 38 41
Grey 3 3 1 2 3 4 5 29 32 35 38 41
Black 4 4 2 3 4 5 6 32 35 38 41
Green 5 5 3 4 5 6 7 32 35 38 41
Yellow 6 6 4 5 6 7 8 32 35 38 41
Light Blue 7 7 5 6 7 8 9 35 38 41
Red 8 8 6 7 8 9 10 35 38 41
Purple 9 9 7 8 9 10 38 41
Brown 10 10 8 9 10 38 41

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Symbols on Surgical Instruments

Some of the instruments have markings on them for guidance.

The interpretation of these markings is as detailed in the table below.

Symbol oror
Symbol Text
Text Definition
Definition Symbol
Symbol or Text
or Text Definition
Definition

R Cleaning
Right position here L
FLEXION Lateral (for Patella Trials)
Flexion

LEFT Dismantle
Left for cleaning M
EXTENSION Medial (for Patella Trials)
Extension

RIGHT Unlock
Right SZ LL Left Lateral
Size

CR Lock Implant
ATTUNE Cruciate Retaining TIB RL Right Lateral
Tibia

PS L Left
ATTUNE Posterior Stabilized Implant ! Caution

RPR Right
Rotating Platform FLEXION
DEG Flexion
Degrees

CR ATTUNE Cruciate Retaining Implant CEMTIB Tibia

Cemented

PS ATTUNE Posterior Stabilized Implant LM Refer to Accompanying

Left Medial Documents

FB Fixed Bearing RMDEG Degrees

Right Medial

FB L Lateral (for Patella Trials)

Fixed Bearing ! Cemented/Press-Fit Stem Assembly Icon

M Medial (for Patella Trials) Offset Adaptor Assembly Icon

LL Left Lateral Femoral Implant Icon

RL Right Lateral Femoral Trial Icon

FB Fixed Bearing Indication Arrow

Femoral Implant Icon Tibial Implant Icon

Base Protector Offset Adaptor Gap Assessment Icon

FEM Femur ANT Anterior

ATTUNE® Revision Knee System Fixed Bearing Surgical Technique  DePuy Synthes Companies  222
Notes

222    DePuy Synthes Companies  ATTUNE® Revision Knee System Fixed Bearing Surgical Technique
Reference

1. Data on file at DePuy Orthopaedics, Inc. SEA 103236081.

DePuy Orthopaedics, Inc. DePuy (Ireland) DePuy International Ltd

700 Orthopaedic Drive Loughbeg, Ringaskiddy St Anthony's Road
Warsaw, IN 46582 Co. Cork, Ireland Leeds LS11 8DT
Tel: +1 (800) 366 8143 Tel: +35 (321) 491 4000 England
Fax: +1 (574) 267 7196 Fax: +35 (321) 491 4199 Tel +44 (0) 113 270 0461

www.depuysynthes.com

© DePuy Synthes 2017. All rights reserved.

DSUS/JRC/0217/2020 Rev. 1