1578.2-GLBL-En Persona Kinematically Aligned TKA SurgTech-digital1

Persona® Personalized Alignment™
Total Knee Arthroplasty

Surgical Technique
Table of Contents
Introduction............................................................................................................... 2
Preoperative Planning............................................................................................... 6
Expose and Assess the Knee..................................................................................... 6
Resect Distal Femur................................................................................................... 7
Size Femur and Establish External Rotation........................................................... 14
Complete Femoral Resections and Measure Thicknesses...................................... 17
Locate the A/P Axis of the Tibia............................................................................... 23
Resect Proximal Tibia.............................................................................................. 24
Check Extension Gap............................................................................................... 32
Check Flexion Gap................................................................................................... 33
Establish Size of the Tibia........................................................................................ 33
Initial Trial Reduction............................................................................................... 35
Restore V/V and I/E Laxity...................................................................................... 42
Drill and Broach Tibia.............................................................................................. 45
Prepare the Patella.................................................................................................. 50
CR Femoral Finishing and Final Trial Reduction...................................................... 54
Implant Components............................................................................................... 55
Optional Techniques................................................................................................ 60
2 Degrees Valgus Recut Guide............................................................................ 60
2 Degrees Varus Recut Guide............................................................................. 60
Compatibility Charts............................................................................................... 61
2 | Persona Personalized Alignment Total Knee Arthroplasty Surgical Technique
Introduction Native Laxity Defined

A Personalized Alignment (PA) Total Knee Arthroplasty The native laxities in extension are restored when
(TKA), is a kinematically aligned (KA) approach which the varus/valgus (V/V) and internal/external (I/E)
strives to restore the native alignment of the knee and rotations of the knee are negligible and the native knee
limb by performing measured bone resections and and limb alignments are restored.
minimizing release of the posterior cruciate, collateral,
and retinacular ligaments. Taking caliper measurements of the distal and
posterior bone resections is a critical step used
Personalized Alignment is based on three principles: to confirm the proper Personalized positioning of
1. Restoration of a patient’s native HKA alignment the femoral component. Personalized Alignment
(prior to osteoarthritis).1 is achieved when these resections are equal to the
9 mm thickness of the femoral component after
2. Restoration of a patient’s native distal femoral and compensating for 2 mm of cartilage wear and 1 mm
proximal tibial joint line.2,3 for the saw blade thickness. Recording and verifying
3. Restoration of a patient’s natural soft-tissue laxity.4 these measurements facilitates the proper positioning
of the femoral component and its articular surface.
Intraoperatively, these three principles are achieved
through: Femoral Resection Formula
• Ensuring resected femoral bone thickness equals Personalized Alignment restores the native pre-arthritic
the implant thickness (after accounting for distal femoral joint line by replacing the bone and cartilage
cartilage wear and blade thickness), resections with the implant thickness (Figure 1):
• Cutting proximal tibia in a sufficient amount
Target Resection =
of varus (thereby achieving balanced medial
Implant Thickness – Cartilage Wear – Saw Blade Thickness
and lateral gaps through proximal tibial bone
resection), and Target Resection of Worn Distal Femoral Condyle =
• The removal of any osteophytes that “tent” soft 9 mm – 2 mm – 1 mm = 6 mm
tissue (including the posterior capsule, IC notch,
Target Resection of Unworn Femoral Condyles =
medial/lateral femur, and the medial/lateral tibia).
9 mm – 0 mm – 1 mm = 8 mm
Constraint Options
The degree of constraint of the articular surface can
be planned based on surgeon preference and patient
requirements. The use of the cruciate-retaining (CR)
femoral provisionals and components can be used
with a CR articular surface when the posterior cruciate
ligament (PCL) is intact. The CR femoral provisionals
and components can be used when the PCL is sacrificed
or deficient and removed, if used with ultracongruent
(UC) articular surface provisionals and components.
The CR femoral provisionals and components can
be used with the MC articular surface either when a
functional posterior cruciate ligament exists or when
both cruciate ligaments are excised.
Figure 1
Introduction (cont.)
Indications Contraindications
When a Personalized alignment approach is utilized, This device is contraindicated for the following:
this device is indicated for patients with severe knee • Previous history of infection in the affected joint
pain and disability due to: and/or other local/systemic infection that may
• Rheumatoid arthritis, osteoarthritis, traumatic affect the prosthetic joint.
arthritis, polyarthritis. • Insufficient bone stock on femoral or tibial
• Collagen disorders, and/or avascular necrosis surfaces.
of the femoral condyle. • Skeletal immaturity.
• Moderate valgus, varus, or flexion deformities. • Neuropathic arthropathy.
The Personalized Alignment (PA) Surgical Technique • Osteoporosis or any loss of musculature or
may only be used with Persona CR Femoral neuromuscular disease that compromises the
Components, Persona CR, UC Articular Surface affected limb.
Components, Medial Congruent (MC) Articular
• A stable, painless arthrodesis in a satisfactory
Surface Components and cemented nonporous
functional position.
Persona Tibial Components without a stem extension.
• Severe instability secondary to the absence of
Porous coated components may be used cemented collateral ligament integrity.
or uncemented (biological fixation). All other femoral,
Total Knee Arthroplasty is contraindicated in patients
tibial baseplate, stem extension, and all-polyethylene
who have rheumatoid arthritis (RA) accompanied by
(UHMWPE and VEHXPE) patella components are
an ulcer of the skin or a history of recurrent breakdown
indicated for cemented use only.
of the skin because their risk of postoperative infection
Please refer to the package inserts for complete is greater. RA patients using steroids may also have
product information, including warnings, precautions, increased risk of infection. Late infections in RA patients
and adverse effects. have been reported 24+ months postoperative.
Cautionary Statement The Personalized Alignment Surgical Technique

Clinical data by Howell et al. has suggested that
5 is contraindicated for patients with greater than
KA TKA on preoperative deformities, including varus 5 degrees valgus deformity with MCL insufficiency.
deformities, does not adversely affect implant survival
Warning
and function. However, the long-term outcomes of
KA TKA with severe deviations in restored alignment For patients with a history of non-traumatic patella
remain unknown6–8. Please proceed with caution and instability, consider alternatives to the Personalized
consider alternatives to Personalized Alignment for Alignment Surgical Technique.
patients with severe preoperative deformities.
Magnet Usage
Warning: Some instruments in the Persona System
contain magnets. All magnetic instruments should
be kept at a safe distance from a patient’s active
implantable medical device(s) (i.e. pacemaker).
These types of devices may be adversely affected by
magnets. Instruments containing magnets should be
kept on an appropriate table or stand when not in use
at the surgical site.
Symbols
Symbols have been established for the following:
• Left
Left Right Varus/Valgus
• Right
• Varus/Valgus
• Medial/Lateral
• Standard
M/L Std
Medial/Lateral Standard Do not implant –
• Do not Implant – Not for Implant Not for implant
• Do Not Impact
• Inset Only
• Posterior Referencing
• Lock Do not impact Inset Only Posterior Referencing
• Unlock
• Cemented
• Stemmed
Lock Unlock
Cemented Stemmed
Screw/Pin Information
The chart below contains relevant information on
various 3.2 mm screws/pins that are compatible with
the Persona Knee System. If these screws/pins are
used during the procedure for instrument fixation,
they should be removed prior to closure as they are
NOT implantable.
Shipped Sterile/ Quantity

Screw/Pin Screw/Pin Item # Compatible Driver Non-sterile per Package Single use?
25 mm x 2.5 mm Sterile 2 Yes

Female Hex Screw 2.5 mm Male Hex Driver
42-5099-025-25* 42-5099-025-00
75 mm x 3.2 mm Sterile 4 Yes

Trocar Tipped Drill Pin/Screw Inserter
Pin (2.5 mm hex) 00-5983-049-00
00-5901-020-00
Hex Headed Screw Sterile 2 Yes

33 mm long Pin/Screw Inserter
00-5901-035-33 00-5901-021-00
MIS Quad-SparingTM Sterile 1 Yes

Total Knee Headed Screw Inserter/Extractor
Screw 48 mm long 00-5983-049-00
00-5983-040-48
25 mm Shorthead Non-Sterile 1 No
Holding Pin
00-5977-056-03 Multi Pin Puller
00-5901-022-00
* The 2.5 mm female hex screws and 2.5 mm male hex driver should not be used
in cortical bone, as this may increase the incidence of stripping of the driver.
Figure 2
Preoperative Planning Expose and Assess the Knee

Examine Radiographs Surgical Approach
Review the full length hip-knee-ankle, A/P and lateral The surgeon can choose a midvastus approach, a
radiographs and/or the MRI of the patient’s knee. subvastus approach, or a parapatellar medial
Identify the location of cartilage loss on each femoral arthrotomy. Also, depending on surgeon preference,
condyle and the location of osteophytes on the the patella can be either everted or subluxed. The
femur and tibia. Removal of osteophytes can restore femur, tibia, and patella are prepared independently,
the native resting lengths of the posterior cruciate, using the principle of measured resection (removing
collateral, and retinacular ligaments and the posterior enough bone to allow replacement by the prosthesis).
capsule.
Locate the Cartilage Wear
Patient Preparation on the Distal Femoral Condyles
To prepare the limb for total knee arthroplasty, Position the knee in 90 degrees of flexion and view
adequate muscle relaxation is required. The the distal medial and lateral femoral condyles to
anesthesiologist should adjust the medication based determine whether the medial and/or lateral distal
on the patient’s habitus and weight, and administer femoral condyle has cartilage wear.
to induce adequate muscle paralysis for a minimum
of 30-40 minutes. It is imperative that the muscle Note: Depending on the severity of the deformity,
it is possible to have unequally distributed condylar
relaxant be injected prior to inflation of the tourniquet.
wear. In situations where one condyle is worn and
Alternatively, spinal or epidural anesthesia should
the other is not worn, the unworn cartilage must
produce adequate muscle relaxation. If desired, apply
be removed in order to achieve a normal joint line.
a proximal thigh tourniquet and inflate it with the
(Figure 2).
knee in hyperflexion to maximize that portion of the
quadriceps that is below the level of the tourniquet.
Once the patient is draped and prepped on the
operating table, determine the landmarks for the
surgical incision.
Figure 3a
Figure 4
Figure 3b Figure 5a Figure 5b
Resect Distal Femur

Establish Femoral Alignment
Select the entry of the drill at the midpoint between Suction the canal to remove medullary contents.
the anterior cortex of the distal femoral shaft and the
anterior boundary of the intercondylar notch. Insert the IM rod 100 mm into the distal femoral
metaphysis (Figure 4).
Orient the drill perpendicular to the distal femoral joint
line and parallel to the anterior cortex of the femoral Insert the fixed resection tower (Figure 5a) into the
shaft. adjustable valgus guide (Figure 5b).
Note: Positioning the drill entry point and Note: The adjustable resection tower is compatible
orientation parallel to the anterior cortex of the with the adjustable valgus guide. The fixed and
distal femoral shaft minimizes the risk of flexing the adjustable resection towers can be interchanged
femoral component, which could lead to patellar to accommodate surgical preference.
instability.
Drill the IM canal using the 8 mm IM step drill (Figures

3a-3b), advancing it 10-15 cm into the distal femur
without engaging the step of the drill.
Figure 6 Figure 7
Resect Distal Femur (cont.)

Establish Femoral Alignment (cont.)
There are two instrument options to make a 9 mm Avoid turning the locking knob of the valgus alignment
distal resection that matches the implant (assuming 2 guide excessively in the counterclockwise, or
mm of cartilage was removed from the distal condyles): “unlocking”, direction to prevent it from binding.
1. Place the 7 mm resection plate onto the valgus Slide the resection plate and valgus alignment guide
alignment guide (Figure 6). down the IM rod and place flush against the distal
femur (Figure 7).
2. Place the 9 mm resection plate onto the valgus
alignment guide and use the -2 mm holes in the Note: To ensure the correct distal resection
distal cut block in the next surgical step. thickness, it is crucial that the guide rests against
both distal femoral condyles with bony anatomy.
Figure 8 Figure 9

To restore the native proximal/distal (P/D) position
and varus/valgus (V/V) angle of the distal femoral
joint line, set the valgus angle on the adjustable valgus
alignment guide by pressing the button and rotating
the dial to the appropriate left or right valgus angle
from 0 to 9 (Figure 8), until both of the feet are
touching the femoral condyles (Figure 9).
Figure 10 Figure 12a
Figure 11 Figure 12b

Rotate the lock lever on the fixed resection tower to Set the orientation of the adjustable valgus alignment
the unlocked, or “in-line”, position and fully insert into guide by placing it against the distal condyles and
the cut guide (Figure 10). rotating it about the IM rod so that the posterior
feet of the guide are equidistant from both posterior
Flip the lock lever to the locked, or “vertical”, position condyles (Figure 12a).
to secure it to the cut guide (Figure 11).
Turn the lock knob on the adjustable valgus alignment
guide clockwise, to the locked position, to secure
orientation of the assembly (Figure 12b).
Note: Setting rotation of the adjustable valgus

alignment guide is important for creating a distal
resection that matches the desired valgus angle
selected. It does not set the rotation of the femoral
component.
Note: For additional fixation, or in lieu of using the

lock knob, impact the captured pin on the medial
or lateral side of the adjustable valgus alignment
guide until the head of the captured pin is flush with
the plate.
Figure 13 Figure 14

Resect Distal Femur
Verify that the adjustable valgus alignment guide is Flip the lock lever on the fixed resection tower to the
set to the proper side (left or right) and angle. unlocked, or “in-line”, position and remove the IM
rod and assembled distal resection instrumentation
Note: If using the adjustable resection tower, make leaving only the cut guide attached to the femur
sure the setting is at ‘0’. If unsure of the depth (Figure 14).
setting, rotate the dial clockwise until a “click” is
felt. This occurs when the dial moves from the ‘4’ Note: Additional 2 mm adjustments may be made
setting to the ‘0’ setting. The bold ‘0’ will be visible by using the sets of holes marked -2, +2, and +4.
on the dial and the line will be aligned with the ‘0’ These sets of holes indicate, in millimeters, the
mark along the shaft amount of additional bone resection each will yield
relative to the resection setting on the resection
Insert a trocar tipped drill pin through each of the tower (where ‘0’ represents 7 mm when the 7 mm
standard pin holes marked ‘0’ on the anterior surface resection plate is used).
of the cut guide (Figure 13).
Insert the resection guide (angel wing) into the cut
Note: If the 7 mm resection plate was used, leave slot of the cut guide to verify the depth of resection.
the cut guide in the holes marked ‘0’. If the 9 mm
resection plate was used, move the cut guide to the
holes marked ‘-2’.
Figure 15b
Figure 15a Figure 15c

Insert a trocar tipped drill pin through at least one of The top surface of the cut guide is 4 mm from the cut
the locking, or oblique, pin holes in the cut guide to slot. Therefore, if cutting from the top surface, the
further secure the cut guide to the femur (Figure 15a). position of the cut guide must be adjusted by moving
the cut guide from the trocar tipped drill pins through
Using a 1.27 mm (0.050 inch) oscillating saw blade
the ‘0’ holes and reinserting the cut guide onto the
through the cut slot in the cut guide, resect the distal
trocar tipped drill pins through the holes marked ‘+4’
femur.
(Figure 15c). Insert a trocar tipped drill pin through at
If desired, the bone resection can be made from the least one of the locking, or oblique, pin holes in the cut
top (most distal) surface of the cut guide (Figure 15b). guide to further secure the cut guide to the femur prior
to resecting the femur.
Figure 16

Measure and Record the Thickness
of the Distal Femoral Resections
Use the femur caliper to measure the thickness of Note: The flatness of the distal femoral resection
the distal medial and lateral femoral resections at the is critical to ensuring adequate contact between
location where the distal cut paddles were touching the porous femoral implant and the bone. If using
and record these measurements (Figure 16). a porous femoral implant, evaluate the flatness of
the resection prior to sizing and modify the cut as
Note: In order to restore the native distal femoral necessary so that it is completely flat.
joint line and match the 9 mm thickness of the
CR femoral component, the resection thickness of Remove all pins and the cut guide.
the condyles should measure approximately 6 mm
thick (compensating for the approximate 1 mm
thickness of the saw blade). If the initial resection is
1 mm or less than the desired thickness, place the
oscillating blade back through the distal cut guide
and resect additional distal femur. If the resection
is 2 mm less than the desired thickness, move the
distal cut block back 2 mm (move to the +2 holes in
the cut guide) and resect additional bone.
Figure 17b
Figure 17a Figure 18
Size Femur and

Establish External Rotation
Assemble the posterior referencing sizer boom with Set the femoral rotation to 0 degrees by holding
the posterior referencing sizer (Figures 17a-17b). the body (silver portion) of the sizer in one hand,
positioning the opposite index finger behind the “L”
or “R” with the thumb over the “L” or “R” and, squeeze
to adjust (Figure 18).
Note: Remove any osteophytes that interfere with

instrument positioning.
Figure 19 Figure 20
Size Femur and

Establish External Rotation (cont.)
Apply the sizer so that the flat surface of the sizer is This will decrease the tension of the patellar tendon to
flush against the resected surface of the distal femur facilitate placement of the sizing boom. The position
and the feet of the sizer are flush against the posterior of the boom tip approximates the proximal position
condyles. Center the sizer mediolaterally. of the anterior flange of the femoral component. The
sizing boom can be rotated to facilitate insertion
While holding the sizer in place and if necessary,
under the soft tissue envelope. A palpable indication,
secure the sizer to the femur using 25 mm X 2.5 mm
as well as size markings on the top portion of the
female hex screws (Figure 19) in one or both of the
sizing boom, ensures that the sizing boom is rotated to
holes on the lower portion of the sizer to help draw the
the correct position.
sizer adjacent to the distal femur, particularly in MIS
situations. Note: Positioning the sizing boom tip on the “high”
part of the femur by lateralizing the location of the
Note: Use of 48 mm screws in the region is not sizing boom tip can often lessen the likelihood of
recommended due to potential perforation through
notching the femur.
the posterior femoral condyles.
After the posterior referencing sizing boom is
Note: Do not impact the sizer onto the femur. appropriately positioned, read the femoral size directly
Slightly extend the knee and retract soft tissues to from the sizer, between the arrowed engraved lines on
expose the anterior femoral cortex. Clear any soft the sizing tower (Figure 20). There are 10 sizes labeled
tissue from the anterior cortex. Ensure that the leg is 3 through 12.
in less than 90 degrees of flexion (70–80 degrees).
Figure 21 Figure 22
Size Femur and

Establish External Rotation (cont.)
The same size markings are present on the anterior The holes in the midline of the A/P portion of the
surface of the sizing boom and approximate the sizer are used to drill 3.2 mm holes for pegs on the
proximal position of the anterior flange of the femoral posterior referencing 4-in-1 femoral cut guides. Drill
component when telescoped to the same size that through the posterior referencing sizer’s holes while
has been determined by the vertical A/P sizing tower being careful not to disturb the position of the sizer
(Figure 21). during drilling (Figure 22).
Select the posterior referencing 4-in-1 femoral cut

guide that matches the femoral component size
indicated on the posterior referencing femoral sizer.
Note: These instruments make a 9 mm resection of

the posterior femoral condyles including the blade
thickness, regardless of the size of the femoral
component.
Figure 23 Figure 24
Complete Femoral Resections

and Measure Thicknesses
Note: In the rare case a distal femoral condyle is By hand, place the posterior referencing 4-in-1 femoral
inadvertently over resected by 1-2 mm, place a cut guide on the femur by aligning the two pegs
resection guide (angel wing) between the bone and on the back of the guide with the previously drilled
the posterior referencing 4-in-1 femoral cut guide positioning holes (Figure 23).
on the over resected condyle.
Impact the face of the guide until the guide is flush
Warning: If the posterior referencing 4-in-1 femoral with the distal resection or against the resection guide
cut guide has been offset distally to correct for over (angel wing) if one side is intended to be offset. Place
resection of the distal femur do not use a porous a resection guide (angel wing) through the anterior
coated femoral component. Use a cemented slot of the cut guide to ensure the desired anterior
femoral component and fill the gap between the resection (Figure 24).
implant and the distal femur with cement.
Figure 25 Figure 26

and Measure Thicknesses (cont.)
If there is a risk of unacceptable notching of the Note: Utilizing the posterior referencing
anterior cortex, use the slaphammer to axially remove instruments will not alter the depth of the
the cut guide (Figures 25–26). Place the next larger- posterior femoral resection.
sized femoral cut guide on the femur and recheck
the anterior resection level with the resection guide
(angel wing).
Figure 27 Figure 28

After final placement of the desired posterior Prior to posterior condylar resection, place a 3/4 inch
referencing 4-in-1 femoral cut guide, insert 3.2 mm (~19 mm) osteotome at the bottom of the posterior
trocar-tipped pins or 3.2 mm headed screws (see referencing 4-in-1 femoral cut guide and and draw a
List and Description of Screws and Pins) through line on the tibia (Figure 28).
the oblique holes in the posterior referencing 4-in-1
femoral cut guide (Figure 27). Note: This line is not intended to be a depth guide,
it provides a visual aid for the V/V angle of the
Note: It is not recommended that the following proximal tibial resection.
headed screws are used through the oblique holes
of the posterior referencing 4-in-1 femoral cut Use a 1.27 mm (.050 inch) thick oscillating saw blade
guides, as the head of the screw may interfere with to resect the posterior femoral condyles.
the saw blade: 00-5791-041-00, 00-5791-043-00,
00-5791-044-00, 00-5061-063-00.
Figure 31
Figure 29
Figure 30

Measure the thickest portion of the posterior medial If the posterior resection is insufficient, the cut guide
and lateral femoral resections with the femur caliper can be shifted 2 mm anteriorly by drilling through
before making the anterior and chamfer cuts (Figure the two holes marked “2 mm”. Remove the original
29), and record these measurements. posterior referencing 4-in-1 femoral cut guide, and
place the next smaller-sized posterior referencing
In order to match the thickness of the 9 mm Persona 4-in-1 femoral cut guide into the “anteriorized” holes in
CR Femoral Implant, each resection should measure the femur (Figures 30–31). Downsizing in combination
approximately 8 mm thick (compensating for the with the anterior shift will leave the anterior resection
approximate 1 mm thickness of the saw blade). level unaltered. Verify the final resection levels using
the resection guide (angel wing).
Note: If the 2 mm shift holes are to be used, assure

that the desired holes on the distal femur are used.
The resection guide (angel wing) can be used as
final verification of the anticipated anterior and
posterior resections.
The shift block can be used to shift the posterior

referencing 4-in-1 femoral cut guide 1 mm in the
anterior or posterior directions.
Figure 32a Figure 32b Figure 32c

Optional Instruments: Shift Block
Prior to performing the remaining facet cuts with After making sure the appropriate face is locked in
the posterior referencing 4-in-1 femoral cut guide, place, drill through the holes that have been selected
determine whether the A/P position of the block using a 3.2 mm drill (Figure 32c).
and external rotation are sufficient. If adjustment
is needed, remove the posterior referencing 4-in-1 Note: Ensure the shift block is locked in place for
femoral cut guide from the femur and insert the shift an accurate shift.
block using the same holes in the distal face of the If additional adjustment with the shift block is desired,
femur (Figure 32a). remove it from the bone, using an osteotome if
To select the method of adjustment, depress button necessary, and replace it in the newly drilled holes
and rotate the drill guide until the desired face is and repeat the drilling process. Otherwise, place the
shown. posterior referencing 4-in-1 femoral cut guide in the
newly drilled holes and perform bone resections.
If an A/P shift is desired, rotate the guide to the
appropriate 1 mm shift face (Figure 32b). Note: The shift block can be rotated 180 degrees
to create new drill holes in the opposite M/L
Note: Do not impact or torque the shift block while direction while providing the same A/P shift. If a
inserting or drilling. 180 degree rotation is performed, be careful to
avoid overlapping previously drilled holes.
Figure 33 Figure 34

Complete the anterior, posterior chamfer and anterior Upon completion of the cuts, use the multi pin puller
chamfer resections through the cut slots (Figure 33). or pin/screw inserter to remove the oblique pins. Use
the slaphammer to remove the cut guide from the
femur. Insert slaphammer and rotate 1/4 turn clockwise
to engage the locking feature to extract (Figure 34).
Figure 35 Figure 36
Locate the A/P Axis of the Tibia

To improve the exposure of the tibial surface, retract Drill two 3.2 mm holes (one posterior, one anterior),
the tibia anteriorly. Carefully position the retractor approximately 15-20 mm deep on the centerline of the
against the posterior cortex of the tibia subperiosteally ellipse (Figure 36).
to prevent neurovascular injury. Retract the patella
laterally. Note: The holes created by the pins will be used to
visualize the A/P axis of the Personalized Alignment
Remove the medial and lateral menisci. Protect and Tibial Component after resecting the proximal tibia.
retain the insertion of the posterior cruciate ligament
(PCL).
Outline the nearly elliptical boundary of the lateral

tibial plateau with a marking pen. Define the A/P axis
of the tibia by marking the major axis of the ellipse with
an electrocautery or marking pen (Figure 35).
Figure 37 Figure 38
Resect Proximal Tibia

Assemble Extramedullary (EM) Alignment Guide
Depress and hold the button on the EM distal rod and Attach the 7 degree tibial cut guide to the EM alignment
insert the threaded rod on the EM ankle clamp into the guide (Figure 38).
distal rod and release the button. Depress and hold
the button on the distal end of the EM proximal tube 1. Lift the lever on the EM proximal tube up.
and insert the EM distal rod into the EM proximal tube 2. Translate the cut guide onto the top of the EM
and release the button (Figure 37). proximal tube, under the locking cone.
3. Push down the lever on the EM proximal tube

to lock the cut guide in place.
Figure 39 Figure 40
Resect Proximal Tibia (cont.)

Assemble Extramedullary (EM) Alignment Guide
(cont.)
The buttons shown in Figure 39 are used to adjust One full rotation of the dial equals 4 mm of height
the following: varus/valgus angle of the cut guide, adjustment and ¼ turn equals 1 mm of height
slope of the cut guide, the height of the cut guide. adjustment (Figure 40). Rotating the height adjustment
The height adjustment button can be depressed for dial clockwise shortens the alignment guide and
macro-adjustment or the dial can be rotated for micro- rotating the dial counterclockwise lengthens the
adjustment. alignment guide.
Figure 41 Figure 42 Figure 43

Position Alignment Guide
Remove anterior osteophytes to ensure tibia cut head Note: To visualize the V/V tibial resection angle,
rests on the bone. adjust the slider on the EM distal rod (Figure 42)
until the varus/valgus angle of the saw slot of the
Adjust the EM alignment guide to the approximate tibial cut guide is parallel to previously drawn line
length of the tibia. Place the spring arms of the EM on the tibia from the osteotome (Figure 43). The
ankle clamp around the ankle proximal to the malleoli. short vertical engraved lines on the varus/valgus
Align the vertical slot in the cut guide parallel to the adjustment rail are incremented by 5 mm to aid
previously drilled holes in the proximal tibia to set tibial in setting the desired varus/valgus position of the
component rotation (Figure 41). EM alignment guide. Excessive soft tissue or poor
A 3.2 mm pin or screw may be inserted through the exposure or visualization can make it difficult to
12 mm vertical slot in the cut guide to secure the palpate bony landmarks so care should be taken to
desired M/L and rotational position of the proximal ensure accurate cuts.
portion of the guide.
Note: This pin will need to be removed to allow the

“+2” or “+4” mm shifts with the cut guide.
Note: Care should be taken when pinning into the

tibia to avoid perforating the posterior cortex.
Figure 44

Position Alignment Guide (cont.)
Adjust the EM alignment guide in the sagittal plane to As necessary, adjust the tibial slope of the EM
be parallel to the anterior tibial crest. A 3.2 mm drill or alignment guide. If there is bulky bandage around
the 3.2 mm pin can be placed through the hole in the the ankle or if there is excessive adipose tissue, the
slot of the cut guide to help assess the expected slope guide can be adjusted to create the desired slope.
of the tibial resection to match the patient’s specific This will help ensure that the tibia will be cut with the
anatomic slope (Figure 44). proper slope. Care should be taken to avoid excessive
posterior slope.
Figure 45 Figure 46

Set Resection Level
To assemble, push and hold the lever on the stylus Rest the 10 mm tip of the stylus on the cartilage of
and insert the stylus into the top of the cut guide the least involved tibial condyle 2/3 of the way back
and release the lever (Figure 45). The stylus rotates posteriorly (Figure 46). This will allow the removal
and telescopes to facilitate desired positioning of the of the same amount of bone that the thinnest tibial
stylus tip. The 10 mm tip is used to establish the component will replace. The surgeon must determine
resection level from the least involved tibial plateau. the appropriate level of resection based on patient’s
needs, such as age and bone quality. Rotate the micro-
Note: Boom tip must be in the vertical position to adjustment dial of the EM proximal tube to position
accurately assess resection level. Correct position the stylus and the cut guide to the desired level.
is verified with an audible click as the boom twists.
Note: When adjusting the height of the EM
WARNING: An excessive bone resection will result if alignment guide steady the distal portion of the
the boom is not in the vertical position. guide with one hand and use the other hand to
adjust the height of the proximal portion of the
guide.
Note: A conservative posterior slope and

conservative P/D resection minimizes the likelihood
of injury to the PCL.
Figure 48
Figure 47 Figure 49

Set Resection Level (cont.)
A resection guide (angel wing) can be placed through The entire EM alignment guide can be left in place for
the cut slot on the cut guide, to verify the desired level additional stability during resection. Optionally, the
and slope of the resection (Figure 47). Insert a 3.2 mm EM alignment guide can be removed by lifting the
trocar tipped pin through one of the “0” holes in the lever on the EM proximal tube up to the open position,
cut guide with the pin/screw inserter. Ensure the cut translating the EM alignment guide anteriorly while
guide is flush to the bone and not impeded by soft leaving the cut guide in place (Figure 49). If the EM
tissues before making the cut. alignment guide has been removed, additional 2 mm
adjustments may be made by shifting the cut guide to
Insert a second trocar tipped pin through the other the sets of holes marked “+2”, and “+4”. The markings
“0” hole in the cut guide with the pin/screw inserter on the cut guide indicate, in millimeters, the amount of
(Figure 48). Remove the stylus by pushing the lever on additional bone resection relative to the standard tibial
the side of the stylus and remove. resection set by the cut guide and stylus. If a pin or
screw was inserted into the 12 mm vertical slot, it will
need to be removed to make the 2 mm adjustments.
Figure 50 Figure 51

Once the resection level has been determined, insert a Note: The patellar tendon may be located behind
3.2 mm trocar tipped pin in the oblique hole indicated the lateral side of the cut guide due to the patellar
by a lock pin symbol, to further secure the cut guide tendon relief cutout on the cut guide. Be careful to
(Figures 50–51). If a pin or screw was inserted into the avoid cutting the patellar tendon when resecting
12 mm vertical slot, then a pin through the oblique the tibia.
hole may not be needed for secure fixation.
Figure 52 Figure 53

Use a 1.27 mm (.050 inch) oscillating saw blade through If the resection thickness and slope of the medial and
the slot on the cut guide to resect the proximal surface lateral tibial resections differ from the native tibial
of the tibia (Figure 52). articular surface, a small 2 degree correction in the
slopes may be required (see Optional Techniques
Prior to removing the cut guide, a contralateral or section).
universal cut guide (of any angle) can be inverted and
placed on the resected tibia to assure that a planar cut Remove the oblique pins and the tibial cut guide.
has been achieved (Figure 53). If necessary, perform a
clean-up cut. Note: If unable to complete the resection on the
lateral side of the tibia, remove the cut guide,
extend the knee and retract the soft tissue on
the lateral side. If necessary, use an osteotome to
complete the resection.
Figure 54
Check Extension Gap

After the proximal tibia and distal femur have been If the knee is in excessive recurvatum, trial with a
resected, the extension gap can be evaluated using thicker spacer block.
spacer blocks. Position the knee in extension. The
distal thickness of the femoral component is 9 mm If the knee does not go into extension, confirm the
and the minimum tibial articular surface/baseplate posterior osteophytes have been removed. If the
construct is 10 mm. If a 10 spacer block (19 mm removal of posterior osteophytes is adequate, then
thickness) does not fit into the resected joint space in resect additional tibia to regain extension.
extension, it will be necessary to remove additional If the knee is tight in extension and well balanced
bone from either the tibia or the femur. in flexion, consider removing posterior osteophytes.
Insert the thinnest appropriate spacer block between When the knee remains tight in extension, consider
the resected surfaces of the femur and tibia (Figure stripping the posterior capsule.
54). If necessary, insert progressively thicker spacer
blocks until the desired soft tissue tension is obtained.
Apply varus and valgus stress for optimal ligament
balancing. The leg should fully extend, and the limb
should be stable with negligible V/V or I/E laxity.
2. Insert
1. Depress
3. Release
Check Flexion Gap Establish Size of the Tibia

After the tibia and femur have been resected, and Attach the tibial sizing plate handle to the cemented
with the knee in 90 degrees of flexion, use the spacer tibial sizing plate (Figure 57). The engraved lines on
block to check ligament balance and joint alignment the cemented tibial sizing plate can be used to aid
in flexion. If necessary, insert progressively thicker in establishing the desired tibial rotation. Rotate the
spacer blocks until the desired soft tissue tension is cemented tibial sizing plate to attain the desired tibial
obtained. The spacer block should fit snugly on the rotational alignment. The notch in the lateral periphery
medial side and slightly looser on the lateral side to of the sizing plate is used to establish proper position
recreate the native asymmetric or trapezoid shaped with respect to the lateral border of the tibia without
gap at 90 degrees of flexion (Figure 55). medialization of the sizing plate.
Once tibial osteophytes have been thoroughly

Locate A/P Axis of the Tibia removed, select the appropriate right or left sizing
Using the edge of an osteotome, draw a line in the plate that provides the desired tibial coverage, without
center of the tibia parallel to the holes in the proximal overhang at any location. Appropriate tibial sizing is
tibia (Figure 56). This establishes a tibial A/P axis important as an oversized tibia component can result
reference to be used later to set tibial rotation with the in overhang, soft tissue impingement and pain.
tibial sizing plate.
Figure 58 Figure 59
Establish Size of the Tibia (cont.)

When the desired tibial rotation and position have Note: Do not use 48 mm screws for cemented
been attained, secure the cemented tibial sizing plate tibial sizing plate fixation. 48 mm screws are not
by placing 25 mm x 3.2 mm (2.5 mm female hex) recommended due to potential bone perforation.
screws or 25 mm x 3.2 mm short head holding pins in
the medial and lateral holes near the PCL cutout of the Note: Do not impact, lever, or pry the tibial sizing
cemented tibial sizing plate (Figure 58). The remaining plate handle; this instrument is designed for
adjunct fixation holes shown on the surface of the alignment purposes only.
cemented tibial sizing plate can be used if necessary.
Note: If using a screw through the anterior medial
If the cemented tibial sizing plate is to be used as
hole on the periphery of the cemented tibial sizing
a provisional in later steps, male-headed screws/
plate, ensure that the cemented tibial sizing plate
pins used in these holes must be removed prior to
remains in the desired position and does not lift off
using the tibial articular surface provisionals (TASPs)
posteriorly.
(Figure 59). Ensure that the cemented tibial sizing
plate remains in the proper position when securing it
to the bone. Remove the tibial sizing plate handle from
the cemented tibial sizing plate.
Figure 60 Figure 61
Initial Trial Reduction

In this step, an initial trial reduction is performed to Femoral sizes 3 through 11 are provided in two profiles,
check component position, patellar tracking, range- standard and narrow. The size 3 through 11 standard
of-motion (ROM), and joint stability. femoral provisionals have intermittent cutouts around
the periphery, with the inner dimension representing
Note: Reference the orientation and size etched the outer profile of the narrow femoral implant and
and/or engraved markings to identify the correct the outer dimension representing the outer profile
provisional. of the standard femoral implant (Figure 61). Femoral
Assemble the femoral CR impactor pad to the size 12 is provided in one profile, standard and does
femoral inserter/extractor. Hold the femoral inserter/ not have intermittent cutouts. Care should be taken
extractor with the handle in the open position and to use the appropriate standard or narrow implant as
insert the femoral CR impactor pad, aligning the “CR” is related to side (left or right) and size based on the
on the femoral CR impactor pad with the arrow on provisional fit and ROM provided during the trialing
the femoral inserter/extractor (Figure 60). The phase.
femoral CR impactor pad is keyed, so the femoral CR
Note: Do not impact the anterior flange of the
impactor pad may have to be rotated while placing CR femoral provisional, as this may damage the
and aligning the femoral CR impactor pad onto the provisional. Do not impact the medial or lateral
femoral inserter/extractor. aspects or the release lever of the femoral inserter/
extractor.
Figure 63
Figure 62
Figure 64
Initial Trial Reduction (cont.)

Remove any posterior osteophytes or overhanging To remove the femoral inserter/extractor from the
bone on the femur to facilitate maximum knee flexion. CR femoral provisional, pinch the release lever while
Attach the femoral inserter/extractor to the correct pulling out/down (Figure 63). Alternatively, if the CR
CR femoral provisional by inserting the hook on the femoral provisional is placed on the femur by hand,
femoral inserter/extractor arm into the anterior notch the femoral inserter/extractor handle must be in the
in the CR femoral provisional and close the handle closed and locked position prior to engaging the
on the femoral inserter/extractor to secure the CR CR femoral provisional. Then the femoral inserter/
femoral provisional (Figure 62). extractor can be used to impact the provisional onto
the femur. For additional fixation of the fully seated
Place the correct CR femoral provisional onto the provisional, insert the 25 mm x 3.2 mm screw (2.5 mm
femur in the desired medial/lateral position. Impact female hex) with the 2.5 mm male hex driver through
the end of the femoral inserter/extractor handle to the hole in the lateral anterior flange of the CR femoral
fully seat the CR femoral provisional onto the femur provisional (Figure 64).
(Figure 63).
Note: If trialing with TASP leave femoral provisional
Note: Be sure that soft tissue is not trapped in place until trialing is complete.
beneath the provisionals. Impact until fully seated.

With the knee in extension, ensure that the femoral Note: If the distal cut was inadvertently over
provisional is flush against the resected distal surface resected and a resection guide (angel wing) was
of the femur on the medial condyle. Retract the lateral used behind the posterior referencing 4-in-1
side and check to make sure it is flush distally and on femoral cut guide, the femoral provisional may not
the lateral side. sit flush on both sides.
If patella resurfacing has been performed, insert the

appropriate patella provisional during the trialing
phase.
Figure 65 Figure 66

Tibial Articular Surface Provisional (TASP)
Assembly
The TASP consists of three parts: a TASP bottom, a Note: TASP bottom pins are offset to prevent
TASP shim, and a TASP top. Select the TASP bottom assembly of left TASP tops on right TASP bottoms
that matches the cemented tibial sizing plate or tibial and vice versa.
base plate implant. Select the TASP top that mates with
both the TASP bottom and the femoral provisional or Note: As shown on the anterior face of the TASP
component as marked on the anterior face of the TASP top, confirm the correct constraint, femoral
top (Figure 65). In addition to the markings on the compatibility, tibial size, and side.
parts, the same colors are used for the mating TASP Note: Apply gentle manual pressure without
tops and bottoms. Axially align the pin slots on the impacting the TASP construct with either a mallet
TASP top with the pins on the TASP bottom during or hand. The TASP construct includes the TASP top,
assembly as these parts must be assembled before bottom, shim, and tibial sizing plate handle.
the TASP shim can be used (Figure 66). Select the set
of TASP shims that match the selected tibial implant Note: If using the cemented tibial sizing plate
size. during the trialing phase, please ensure that the
necessary male-headed screws/pins are removed
Note: There are two TASP bottom thicknesses +0 from the anterior surface of the cemented tibial
mm and +6 mm. Use +0 mm bottom for 10-14 mm sizing plate to avoid interference and potential
constructs and the +6 mm bottom for 16-20 mm damage to the TASP.
constructs.
Figure 70
2. Insert
1. Depress
3. Release

Assembly (cont.)
The shims (10, 11, 12, 13, and 14 mm) are not side- Note: During assembly of the TASP construct,
specific. Attach the tibial sizing plate handle to the slide the shim in using a direct anterior approach
appropriate 10 mm shim (Figure 67). While holding between the TASP top and bottom. To avoid
the TASP top and bottom together with one hand, inadvertent separation, maintain slight pressure
lock the TASP top and bottom together by inserting between the TASP top and bottom while inserting
the appropriate 10 mm shim with the tibial sizing plate the shim.
handle (Figure 68). The 10 mm shim will create a TASP
construct which matches the thickness of the thinnest
tibial articular surface implant, 10 mm (Figures 69–70).
Figure 71 Figure 72

Assembly (cont.)
The shims are incremented by 1 mm to create TASP It is recommended that the thinnest TASP construct
constructs of 10 mm, 11 mm, 12 mm, 13 mm or (10 mm) be inserted into the joint space, with the knee
14 mm to match the implant offering. The +6 mm at greater than 30 degrees of flexion, to perform an
bottoms are included for instances where the TASP initial ROM assessment (Figure 71).
construct needs to be 16 mm, 18 mm or 20 mm. In
If a thicker construct is needed to appropriately
these circumstances, the 10 mm, 12 mm, and 14 mm
fill and balance the joint space, place the knee in
shims are to be used to create the respective TASP
approximately 5–15 degrees of flexion to facilitate in
constructs.
vivo removal and insertion of the shims with the tibial
Note: The maximum thickness of available CR sizing plate handle (Figure 72).
implants is 18 mm. UC implants are available in
thicknesses up to 20 mm. Also, 15 mm, 17 mm and
19 mm thicknesses are not available in CR or UC.
10 mm
11 mm
12 mm
13 mm
14 mm
TASP Shim/Construct Thickness

Anterior divots in the shim correspond to the overall
construct thickness as shown in the image above.
Color Coded Side Specific Shared Sizing*

Figure 74 Tibial Sizing Plate No Yes No
Articular Surface Tops Yes Yes Yes
+0 Bottoms Yes Yes Yes
+6 Bottoms Yes Yes Yes
Shims No No Yes
* Shared Sizing – A and B, C and D, E and F, G and H Cemented Tibial

Figure 73 Sizing Plates have common TASP Tops, Bottoms and Shims respectively.
Figure 75

Assembly (cont.)
The entire TASP construct can be removed to exchange Size A and B tibias, size C and D tibias, size E and F
the shims of the TASP construct. This is accomplished tibias, and size G and H tibias, share side specific tibial
by flexing the knee greater than 30 degrees, then bottoms, tibial tops and color, respectively (Figure 75).
lifting the tibial sizing plate handle while attached to
the TASP construct. Once the anterior lip of the TASP
bottom is above the anterior rail of the tibial sizing
plate (Figure 73), rotate the TASP out of the joint
space medially or laterally (Figure 74). This will aid in
preventing unwanted shim disassembly during TASP
removal.
Note: Varus/valgus forces may make it difficult to

remove the TASP construct. To aid in the removal
of the TASP and prevent breakage, ensure that the
joint is in a neutral position when removing the
TASP construct.
Figure 77
Figure 76 Figure 78
Restore the V/V and I/E Laxity

A Personalized Alignment Knee should fully extend If the PCL is recessed or becomes deficient
with negligible V/V and I/E laxity (Figure 76). In intraoperatively, the PCL should be fully resected and
flexion, there should be slightly more V/V laxity and the ultracongruent (UC) TASP should be trialed to
the tibia should passively I/E rotate approximately ±15 assure desired ROM and joint stability prior to articular
degrees on the femur (Figure 77). Proper Personalized surface implant selection.
Alignment restores native limb alignment through
measured V/V tibial resection and utilizing a tibial When trialing with a CR articular surface and the
articular surface with the appropriate thickness. PCL is retained, posterior soft tissue tightness may
occur, resulting in the femur booking open (Figure 78).
Check ligament stability in extension and in 30, 60, Should this occur, consider resecting the PCL. If the
and 90 degrees flexion. In flexion, attempt to distract PCL is resected, a UC insert should be used.
the joint in the A/P direction.
Extension
Tight OK Loose
Tight 1 2 3
Flexion
OK 4 5 6
Loose 7 8 9
Flexion/Extension
Mismatch Solutions
Note: Ensure that the trials are fully seated 3. If the joint is tight in flexion but loose in extension:
appropriately. Soft tissue can get trapped under the a. Ensure tibial baseplate rotation is correct.
femur, causing inadvertent placement of femoral
b. Increase the posterior slope of the tibial
trial in flexion.
component (ensuring not to exceed the
natural slope of the native tibia) and increase
1. If the joint is tight in flexion and extension,
the thickness of the articular surface.
resecting additional proximal tibial bone or
decreasing the thickness of the articular surface c. Downsize the femoral component and shift
may be sufficient to balance the construct. the cuts 1 mm anteriorly with the shift block,
or 2 mm with the posterior referencing 4-in-1
2. If the joint is tight in flexion but acceptable in femoral cut guide 2 mm holes and increase
extension: the thickness of the articular surface.
a. Ensure tibial baseplate rotation is correct. 4. If the joint is acceptable in flexion but tight in
b. Increase the posterior slope of the tibial extension:
component (ensuring not to exceed the a. Remove posterior osteophytes and release
natural slope of the native tibia). the posterior capsule from the femur.
c. Downsize the femoral component and shift b. Resect additional proximal tibial bone with
the cuts anterior 1mm with the shift block or decreased posterior slope and increase the
2 mm with the posterior referencing 4-in-1 thickness of the articular surface.
femoral cut guide 2 mm holes.
c. Recut the distal femoral resection 1 or 2
d. Release the PCL either by island osteotomy mm as needed and then recut the anterior
or ligament release (pie crusting technique), and posterior resections with the posterior
both of which lengthen the ligament. referencing 4-in-1 femoral cut guide.
e. Resect the PCL and change to a UC
constraint. 5. If the joint is acceptable in flexion and extension,
no further modification is necessary.
Extension
Tight OK Loose
Tight 1 2 3
Flexion
OK 4 5 6
Loose 7 8 9
Flexion/Extension
Mismatch Solutions (cont.)
6. If the joint is acceptable in flexion but loose in 8. If the joint is loose in flexion and acceptable in
extension: extension:
a. Increase the posterior slope of the tibial a. Release the posterior capsule from the femur
component (ensuring not to exceed the and increase the thickness of the articular
natural slope of the native tibia) and increase surface.
the thickness of the articular surface. b. Resect additional proximal tibial bone with
b. Downsize the femoral component and shift decreased tibial slope and increase the
the cuts anterior 1 mm with the shift block or thickness of the articular surface.
2 mm with the posterior referencing 4-in-1
femoral cut guide 2 mm holes and increase 9. If the joint is loose in flexion and extension,
the thickness of the articular surface. increase the thickness of the articular surface.
c. Release the PCL either by island osteotomy
or ligament release (pie crusting technique),
both of which lengthen the ligament, and
increase the thickness of the articular surface.
d. Resect the PCL and change to a UC constraint
and increase the thickness of the articular
surface.
7. If the joint is loose in flexion but tight in extension:

a. Remove posterior osteophytes, release
the posterior capsule from the femur and
increase the thickness of the articular surface.
b. Resect additional proximal tibial bone with
decreased posterior slope and increase the
thickness of the articular surface.
c. Recheck the distal femoral cut and ensure
there is not hyperextension of the femoral
component. If needed, recut the femur to
correct the hyperextension.
Restore the V/V and I/E Laxity Drill and Broach Tibia
If the knee does not fully extend, insert a 1 mm thinner Warning: The Personalized Alignment (PA) Surgical
tibial articular surface provisional or recut the tibia to Technique may only be used with cemented,
remove more bone. nonporous Persona Tibial Components without a
stem extension. Do not use a stem extension with
Potential solutions to medial/lateral mismatches: a Persona Tibial Component when the PA Surgical
• If the knee is loose medial and tight lateral and Technique is used.
all osteophytes have been removed, use the 2
degree valgus recut guide to recut the tibia in The keel of the tibial implant has a unique location for
valgus and add a 2 mm thicker tibial articular every size; therefore it is critical to select the proper
surface provisional. size at this step, before drilling and broaching. Once
these subsequent steps have been performed, the size
• If the knee is tight medial and loose lateral and should not be changed. If desired, femoral finishing
all osteophytes have been removed, use the 2 can be performed in conjunction with provisional
degree varus recut guide to recut the tibia in varus trialing at this stage to assure that the desired range
and add a 2 mm thicker tibial articular surface of motion and soft tissue balance can be attained
provisional. with the cemented tibial sizing plate in place prior to
In situations where two options exist to help solve the drilling and broaching the tibia.
soft tissue mismatch, the position of the patella or the
joint line helps to determine which option to select.
Note: After applying one of these solutions, perform

another trial reduction. This will identify any new
problem or a variation of the initial problem that
may exist.
Flex the knee through a full range of motion and

confirm the patellar tracking is optimal.
Warning: To mitigate the occurrence of patella

instability postoperatively, assess patellar tracking
intraoperatively. If patellar maltracking exists, perform
a lateral retinaculum release. If this does not correct
the problem, externally rotate the tibial component.
Note: If the TASP construct is used with the femoral

and/or tibial implants, contact with bone cement
should be avoided to prevent potential damage to
the TASP components.
Note: The articular surface inserter should not be

used with the TASP.
Note: Use only the tibial sizing plate handle to

remove the TASP construct. The use of other
instruments may damage or break the TASP.
Figure 79a
Figure 80b
Figure 79b Figure 80a Figure 80c
Drill and Broach Tibia (cont.)

By hand, place and hold the cemented tibial drill Use the cemented tibial drill to drill until the center of
guide on the tibia cemented tibial sizing plate, by first the size-specific engraved line on the cemented tibial
engaging the posterior tabs in the undercuts in the drill is in line with the top of the cemented tibial drill
cemented tibial sizing plate and then making sure that guide (Figures 80a–80c). After drilling is complete,
the distal anterior portion of the cemented tibial drill remove the cemented tibial drill and cemented tibial
guide is flush against the cemented tibial sizing plate drill guide.
(Figures 79a–79b).
Note: Insert cemented tibial drill into cemented
tibial drill guide prior to starting cemented tibial
drill. By hand, hold the cemented tibial drill guide
flush against the cemented tibial sizing plate while
drilling.
Figure 82a
Figure 81 Figure 82b Figure 82c

Optional Technique
If desired, the cemented tibial drill stop collar, may be Confirm that the correct size is displayed in the
used to aid in drilling to the correct depth. Depress cemented tibial drill stop collar window (Figures 82a–
the button on the cemented tibial drill stop collar 82c) and that the cemented tibial drill stop collar is
and slide the cemented tibial drill stop collar to the locked on the cemented tibial drill.
desired size-specific position on the cemented tibial
drill (Figure 81). Note: Verify that the cemented tibial drill stop
collar is locked on the cemented tibial drill by
attempting to slide the cemented tibial drill stop
collar on the cemented tibial drill by hand. The
cemented tibial drill stop collar will make an audible
“click” when it locks on the cemented tibial drill.
Note: Insert cemented tibial drill into cemented

tibial drill guide prior to drilling.
Figure 83b
Figure 83a Figure 83c Figure 84

Optional Technique (cont.)
After positioning the cemented tibial drill stop collar in Insert the correct-sized cemented tibial broach into
the proper position, drill through the cemented tibial the cemented tibial broach inserter/extractor handle
drill guide until the cemented tibial drill stop collar (Figure 84). Retract the impaction head until it locks
contacts the cemented tibial drill guide (Figure 83a– in the fully retracted position, which will facilitate
83c). After drilling is complete, remove the cemented placement on the cemented tibial sizing plate. After
tibial drill and cemented tibial drill guide from the seating the cemented tibial broach inserter/extractor
cemented tibial sizing plate. handle on the cemented tibial sizing plate, tap the
impaction head once to seat the cemented tibial
broach.
Figure 87
Figure 85 Figure 86

Impact the cemented tibial broach inserter/extractor Note: Make sure that the cemented tibial broach
handle assembly with care to prevent fracture inserter/extractor handle remains flush against the
of the tibia (Figure 85). Impact until the impaction cemented tibial sizing plate and in full contact
head bottoms out on the cemented tibial broach with the cemented tibial sizing plate and that the
inserter/extractor handle stop (Figure 86). While cemented tibial broach inserter/extractor handle
holding the cemented tibial broach inserter/extractor does not tip during impaction. The orientation
handle, impact the extraction button to remove the of the cemented tibial broach inserter/extractor
cemented tibial broach from the bone (Figure 87). handle is important to ensure proper and complete
Avoid dislodging the cemented tibial sizing plate broaching resulting in full seating of the tibial
when removing the cemented tibial broach inserter/ implant on the bone.
extractor handle.
Note: Do not extract with mallet blows on either
Note: Assure that no metallic debris is present on the medial or lateral side of the under surface of
the magnetic feet of the cemented tibial broach the impaction head of the cemented tibial broach
inserter/extractor handle as this may inhibit the inserter/extractor handle. Do not attempt to
mating with the cemented tibial sizing plate and extract the cemented tibial broach with a horizontal
may introduce unwanted debris into the surgical or angled blow on any side of the cemented tibial
site. broach inserter/extractor handle.
Figure 88
Figure 90
Persona Standard Implant Patella Size & Thickness

26 mm x 7.5 mm* 35 mm x 9.0 mm
29 mm x 8.0 mm 38 mm x 9.5 mm
32 mm x 8.5 mm 41 mm x 10.0 mm
*The
26 mm patella must always be inset.
See package insert for complete details.
Figure 89 Figure 91
Prepare the Patella Resect the Patella

If the surgeon determines that the condition of the Please refer to the appropriate surgical technique if
patient’s patella is satisfactory, it is not necessary other patella instrumentation is to be used to resect
to resurface the patella. The geometry, depth, and the patella.
length of the patella groove on the femoral component
accommodates the unresurfaced patella. Refer to the sizing chart for patella dimensions (Figure
89). Use a 3.2 mm drill to drill the highest portion of
Note: These instruments are designed for onlaying the medial facet perpendicular to the articular surface
all-poly patella only. approximately 12 mm deep centered on the medial
sagittal ridge (Figure 90). This acts as a guide for
Place the leg in extension, evert the patella to at least proper medialization of the patella.
90 degrees. Stabilize the patella, using two inverted
towel clips. Incise the soft tissue around the patella Technique Tip: At least 10 mm of bone must remain
down to the insertion of the quadriceps and patella to ensure that the pegs of the patella implant do not
tendons. Before making any bone cuts, determine the protrude through the anterior surface (Figure 91).
maximum thickness of the patella by using the femur
caliper to measure the most prominent anterior-to-
posterior dimension (Figure 88).
Note: The femur caliper has a tolerance of ± 0.25 mm.

Depress
collar
Rotate
Figure 93
Figure 92 Figure 94
Prepare the Patella (cont.)

Use the patella osteotomy guide with the stylus set for Apply the patella osteotomy guide medially and
the desired amount of resection. Depress the button laterally with the jaws at the osteochondral juncture
on the stylus while twisting to set the stylus at the with the handles of the jig oriented toward the foot.
desired resection level (Figure 92). If the patella is very Apply the guide with the jaws parallel to the dorsal
worn, resect less bone. surface of the patella, while positioning the patella
osteotomy guide stylus over the most prominent point
Note: Assure that the patella osteotomy guide on the patella. Make the resection with a 1.27 mm
stylus is referencing the most prominent point on (.050 inch) thick saw blade (Figure 93). Resect the
the patella before resecting. patella flat so that a smooth surface remains.
Note: To facilitate unlocking the patella osteotomy

guide from the patella, apply slight gripping
pressure on the handles of the patella osteotomy
guide and depress the release lever to unlock the
patella osteotomy guide (Figure 94).
Figure 96
Figure 95 Figure 97
Finish the Patella

Using the patella sizing template, select the maximum- Insert the appropriately-sized patella peg drill guide
sized patella that does not overhang, centered into the patella clamp in the proper orientation (Figure
over the 3.2 mm drill hole as a reference for proper 96). Place the patella clamp with the patella peg drill
medialization (Figure 95). guide over the cut surface of the patella, centered
slightly toward the medial facet over the 3.2 mm drill
Note: Do not drill through the center hole of the hole with the clamp oriented so two of the holes are
patella sizing template. biased toward the medial side of the patella (Figure
Note: Eccentric placement of the patella 3-4 mm 97).
medially allows for better patella tracking.
Figure 98 Figure 99
Finish the Patella (cont.)

Use the 6.4 mm patella/femoral drill to drill through Note: To facilitate unlocking the patella clamp
the 3 peg holes in the patella peg drill guide (Figure from the patella, apply slight gripping pressure on
98). the handles of the patella clamp and depress the
release lever to unlock the patella clamp (Figure
99).
Figure 100 Figure 101
CR Femoral Finishing
and Final Trial Reduction
After bone preparation is complete and prior to Note: Ensure the shoulder of the drill is seated at
femoral peg hole preparation, perform a final trial the bottom of the femoral provisional counterbore.
reduction, as described above, to check component
position, patellar tracking, range of motion, and joint Note: Ensure oval hole of the femoral provisional is
stability. Once desired medial-lateral placement has free of debris prior to inserting slaphammer.
been attained, drill the peg holes for size 3 through 12 When using the stemmed tibia provisional, assemble
femoral implants through the CR femoral provisional the stemmed tibia provisional to the tibial provisional
with the 6.4 mm patella/femoral drill (Figure 100). extractor and insert in the prepared tibia bone. For
If a screw was used to provide adjunct fixation, remove additional fixation of the fully seated provisional, insert
the screw from the anterior flange in the CR femoral two 25 mm x 3.2 mm screws (2.5 mm female hex)
provisional. with the 2.5 mm male hex driver through the 2 screw
fixation holes in the medial and lateral compartments
Note: The slaphammer can be used to remove on the stemmed tibia provisional.
size 3 through 12 CR femoral provisionals (Figure
101). Rotate the slaphammer a ¼ turn outward. If the stemmed tibia provisional was used, assemble
Alternatively, the femoral inserter/extractor can the tibial provisional extractor to the stemmed tibia
be re-attached to the CR femoral provisional to provisional to remove the stemmed tibia provisional
remove it from the bone. If necessary, place the prior to implanting the components.
round end of the slaphammer in the extraction
hole of the femoral inserter/extractor to facilitate
removal.
Implant Components Tibial Plate

Note: Prior to cementing implants remove Sublux the tibia anteriorly to allow adequate clearance
provisionals and use pulse lavage to remove to insert the tibial implant into the prepared bone. Do
unwanted debris from the resected bone surfaces not apply substances other than bone cement to the
and the joint space. tibial implant (i.e. do not dip implant into antibiotics
or other substances). Keep the implant clean and free
In this step, the final components are implanted, and of debris prior to cementing. Place a layer of cement
the tibial articular surface is secured to the implanted on the underside of the tibial baseplate, around the
tibial baseplate. When using cemented components, keel, on the resected tibial surface, and in the tibial IM
it is recommended to use two batches of cement. canal. Assemble the quick connect handle to the tibial
After the implants have been chosen, make a final impactor head (Figure 102). Unlock collar and hold,
check to ensure that all components are compatible. insert handle into impactor head, release collar, and
If the resected surfaces of the tibia and/or femur are rotate handle until an audible “click” is heard. Position
sclerotic, drill multiple holes with a small drill (2.0 the tibial plate onto the tibia and use the tibial impactor
mm – 3.2 mm) to improve cement intrusion. Mix the to impact it until fully seated (Figure 103). Thoroughly
first batch of cement. Mix the cement following the remove any excess cement in a consistent manner.
manufacturer’s guidelines for cement prep including Allow the cement to fully cure before performing a trial
but not limited to mix, work, and set time. range of motion or inserting the articular surface.
Figure 105
Implant Components (cont.)

Femoral Component
With the knee in 70 –90 degrees of flexion, retract Alternatively, assemble the quick connect handle
the soft tissue in the desired manner. Place a layer of to the femoral impactor head (Figure 105). Use this
cement on the underside of the prosthesis and in the assembly to fully seat the femoral implant (Figure
holes drilled in the femur. Attach the femoral inserter/ 106). Remove retractors, and check the medial and
extractor to the femoral component (Figure 104). lateral sides to make sure the femoral implant is fully
Insert the femoral component onto the distal femur impacted distally. Remove any excess cement in a
by translating the component laterally until the lateral thorough and consistent manner.
peg aligns with the drill hole in the lateral femoral
condyle. Take care to avoid scratching the implant
component surfaces. After the femoral component is
placed on the femur and the femoral inserter/extractor
is removed, the femoral inserter/extractor can be used
to fully seat the implant onto the femur. If this method
is used, the femoral inserter/extractor handle must
be in the closed and locked position. Ensure that soft
tissue is not trapped beneath the implant.
Figure 108

Articular Surface
The articular surface inserter applies both downward Note: Do not impact or lever the articular surface
and rearward forces to aid in the insertion of the inserter tool when it is attached to the tibial plate
articular surface onto the tibial baseplate. Choose as this may disrupt the fixation of the tibial plate
the correct tibial articular surface based on size, side, to the bone and/or cause damage to the implant
constraint, and thickness as determined by the trial or instrument. Also, do not impact the articular
range of motion. Place the articular surface onto the surface.
tibial baseplate. Apply pressure anterior to posterior
Note: Insert an articular surface only once. Never
to properly engage the tibial component and tibial
reinsert the same articular surface onto a tibial
articular surface for final seating. This is necessary
baseplate.
to allow the inserter to properly engage the tibial
component and tibial articular surface for final seating Alternatively, the articular surface can be locked into
(Figure 107). Steady the surface of the baseplate with the tibial plate as described above, prior to tibial plate
one hand by applying downward pressure near the implantation. If CR femoral implants are used, the
posterior cruciate cutout. Engage the hook on the tibial implant should be implanted prior to the femoral
articular surface inserter with the mating slot in the implant to facilitate the removal of excess cement
front of the baseplate and close the lever with your from the posterior aspect of the tibia, prior to femoral
index finger. This locks the inserter to the tibial plate implantation.
(Figure 108). Squeeze the handle of the articular Note: Only in vivo assembly of the ultracongruent
surface inserter to seat the articular surface (Figure articular surface is recommended because the
109). Open the lever and remove the articular surface design of the ultracongruent articular surface
inserter. precludes cement removal from the PCL cutout
area at the tibial baseplate/bone interface.
Figure 110

Articular Surface (cont.)
Assemble the quick connect handle to the tibial To remove an articular surface from the baseplate,
impactor head. Unlock collar and hold, insert quick engage the hook on the articular surface removal
connect handle into tibial impactor head, release collar, instrument with the mating slot on the front of the
and rotate handle until an audible “click” is heard. baseplate and squeeze the handle to disengage the
Position the tibial plate/articular surface construct articular surface from the baseplate. The articular
onto the tibia and use the tibial impactor to impact it surface removal instrument should not be used for
until fully seated (Figure 110). Thoroughly remove any provisional removal.
excess cement in a consistent manner.
Note: Do not impact or lever the articular surface
extractor tool when it is attached to the tibial plate
as this may disrupt the fixation of the tibial plate to
the bone and/or cause damage to the implant or
instrument.
Figure 111

Patellar Component Surgeon Notes and Tips
Please refer to the appropriate surgical technique Take care that the retractors do not inadvertently
if other patella instrumentation is to be used to dislodge the tibial baseplate, particularly on the
accomplish the patella implantation. posterolateral corner. Verify that the femoral
component is fully seated before closing the wound.
All-Polyethylene Patella Confirm that no portion of the quadriceps mechanism
has been pinned beneath the femoral component.
With the knee in 70 –90 degrees of flexion, apply
cement to the anterior surface and pegs of the
patellar component while in a doughy consistency. Close Incision
Alternatively, this step can be performed with the knee Freely irrigate the wound with the solution of choice
in extension. Locate the drilled peg holes and use the to assure unwanted debris is removed from the
patella clamp assembly to insert and secure the patella joint space prior to closure. A drain may be placed
in place. Fully open the jaws of the patella clamp and intracapsularly. Then close the wound with sutures
align the tooth to the anterior surface of the patella and apply a bandage. Please refer to package
and the patella clamp head to the posterior surface insert for complete product information, including
of the implant (Figure 111). Use the patella clamp to contraindications, warnings, precautions and adverse
apply enough pressure to fully seat the implant on effects.
the patellar surface. Remove any excess cement in a
thorough and consistent manner.
Optional Techniques
2 Degree Valgus Recut Guide 2 Degree Varus Recut Guide
If a 2 degree valgus correction cut is needed, place If a 2 degree varus correction cut is needed, place
the valgus recut guide on the resected tibial plateau, the varus recut guide on the resected tibial plateau,
aligning with the previously defined A/P axis of the aligning with the previously defined A/P axis of the
tibia (Figure 112). Once it has been determined that tibia (Figure 113). Once it has been determined that
the desired correction cut will be attained, slide the the desired correction cut will be attained, slide the
medial portion of the valgus recut guide so it is flush lateral portion of the varus recut guide so it is flush
with the medial portion of the tibial cortex to provide with the lateral portion of the tibial cortex to provide
a planar recut of the tibia. Affix with 3.2 mm trocar- a planar recut of the tibia. Affix with 3.2 mm trocar-
tipped pins with the pin and screw inserter. tipped pins with the pin and screw inserter.
Note: The fixation holes for the valgus recut guide Note: The fixation holes for the varus recut guide
are at oblique angles to improve fixation of the are at oblique angles to improve fixation of the
guide. guide.
Perform resection, remove trocar-tipped pins and the Perform resection, remove trocar-tipped pins and the
valgus recut guide. varus recut guide.
Compatibility Charts
CR: Persona CR Femoral/Persona CR Articular Surface and Tibial Compatibility

Tibial TASP Top &
Size Bottom Color 3 4 5 6 7 8 9 10 11 12
A
Orange 3-6 / A B
B
C
Yellow 3-9 / C D
D
E
Green 3-11 / E F
F
G
Blue 7-12 / G H
H
J Gray 9-12 / J
UC: Persona CR Femoral/Persona UC Articular Surface and Tibial Compatibility

Tibial TASP Top &
Size Bottom Color 3 4 5 6 7 8 9 10 11 12
A
Orange 3-4 / A B
B
C
Yellow 3-7 / C D
D
E
Green 4-11 / E F
F
G
Blue 7-12 / G H
H
J Gray 9-12 / J
Note: Use Persona Ti-Nidium Femoral Components only with Vivacit-E articular surfaces.
MC: Persona CR Femoral/Persona MC Bearing and Tibial Compatibility

Femoral Size
Tibial TASP Top &
Size Bottom Color 1 2 3 4 5 6 7 8 9 10 11 12
A Orange
1-2 / A B 3-4 / A B
B
C Yellow
4-5 / C D 6-7 / C D 8-9 / C D
D
E Green
4-5 / E F 6-7 / E F 8-11 / E F
F
G Blue
8-11 / G H 12 / G H
H
J Gray 12 / J
References
1. Bellemans J, Colyn W, Vandenneucker H, Victor J. “The Chitranjan 5. Howell S, Howell S, Kuznik K, Cohen J, Hull M. Does a kinematically
Ranawat Award: Is Neutral Mechanical Alignment Normal for All aligned total knee arthroplasty restore function without failure
Patients? The Concept of Constitutional Varus.” Clin Orthop Relat Res. regardless of alignment category? Clin Orthop Relat Res 471(3): 1000,
470: 45, 2012 2013.
2. Victor J, Bassens D, Bellemans J, Gursu S, Dhollander A, Verdonk P, 6. Riviere, C, Iranpour, F, Auvinet, E, et al. 2017. Alignment options
“Constitutional Varus Does Not Affect Joint Line Orientation in the for total knee arthroplasty: A systematic review. Orthopaedics &
Coronal Plane.” Clin Orthop Relat Res (2014) 472:98–104, 2014. traumatology, surgery & research: OTSR 103: 1047-1056.
3. Hutt J, Masse V, Lavigne M, Vendittoli P. “Functional Joint Line Obliquity 7. Courtney PM, Lee GC. Early Outcomes of Kinematic Alignment in
after Kinematic Total Knee Arthroplasty.” International Orthopaedics Primary Total Knee Arthroplasty: A Meta-Analysis of the Literature. J
(SICOT). 40: 29, 2016. https://doi.org/10.1007/s00264-015-2733-7 Arthroplasty 2017;32:2028-2032.
4. Deep K, Collateral Ligament Laxity in Knees: What Is Normal? Clin 8. Yoon JR, Han SB, Jee MK, Shin YS. Comparison of kinematic and
Orthop Relat Res. 472:3426–3431, 2014. mechanical alignment techniques in primary total knee arthroplasty:
A meta-analysis. Medicine (Baltimore) 2017;96-39:e8157.
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be redistributed, duplicated or disclosed, in whole or in part, without the
express written consent of Zimmer Biomet.
This material is intended for health care professionals. Distribution to any
other recipient is prohibited.
For indications, contraindications, warnings, precautions, potential
adverse effects and patient counseling information, see the package
insert or contact your local representative; visit www.zimmerbiomet.com
for additional product information..
Check for country product clearances and reference product specific
instructions for use. Not for distribution in France.
Zimmer Biomet does not practice medicine. This technique was
developed in conjunction with health care professionals. This document
is intended for surgeons and is not intended for laypersons. Each surgeon
should exercise his or her own independent judgment in the diagnosis
and treatment of an individual patient, and this information does not
purport to replace the comprehensive training surgeons have received.
As with all surgical procedures, the technique used in each case will
depend on the surgeons medical judgment as the best treatment for
each patient. Results will vary based on health, weight, activity and
other variables. Not all patients are candidates for this product and/or
procedure. Caution: Federal (USA) law restricts this device to sale by or
on the order of a surgeon. Rx only.
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Persona® Personalized Alignment™

Total Knee Arthroplasty

Expose and Assess the Knee..................................................................................... 6

Resect Distal Femur................................................................................................... 7

Size Femur and Establish External Rotation........................................................... 14

Complete Femoral Resections and Measure Thicknesses...................................... 17

Locate the A/P Axis of the Tibia............................................................................... 23

Resect Proximal Tibia.............................................................................................. 24

Check Extension Gap............................................................................................... 32

Check Flexion Gap................................................................................................... 33

Establish Size of the Tibia........................................................................................ 33

Initial Trial Reduction............................................................................................... 35

Restore V/V and I/E Laxity...................................................................................... 42

Drill and Broach Tibia.............................................................................................. 45

Prepare the Patella.................................................................................................. 50

CR Femoral Finishing and Final Trial Reduction...................................................... 54

Introduction Native Laxity Defined

Cautionary Statement The Personalized Alignment Surgical Technique

Shipped Sterile/ Quantity

25 mm x 2.5 mm Sterile 2 Yes

75 mm x 3.2 mm Sterile 4 Yes

Hex Headed Screw Sterile 2 Yes

MIS Quad-SparingTM Sterile 1 Yes

Preoperative Planning Expose and Assess the Knee

Figure 3b Figure 5a Figure 5b

Resect Distal Femur

Drill the IM canal using the 8 mm IM step drill (Figures

Resect Distal Femur (cont.)

Resect Distal Femur (cont.)

Figure 10 Figure 12a

Figure 11 Figure 12b

Resect Distal Femur (cont.)

Note: Setting rotation of the adjustable valgus

Note: For additional fixation, or in lieu of using the

Resect Distal Femur (cont.)

Figure 15a Figure 15c

Resect Distal Femur (cont.)

Resect Distal Femur (cont.)

Figure 17a Figure 18

Size Femur and

Note: Remove any osteophytes that interfere with

Size Femur and

Size Femur and

Select the posterior referencing 4-in-1 femoral cut

Note: These instruments make a 9 mm resection of

Complete Femoral Resections

Complete Femoral Resections

Complete Femoral Resections

Complete Femoral Resections

Note: If the 2 mm shift holes are to be used, assure

The shift block can be used to shift the posterior

Figure 32a Figure 32b Figure 32c

Complete Femoral Resections

Complete Femoral Resections

Locate the A/P Axis of the Tibia

Outline the nearly elliptical boundary of the lateral

Resect Proximal Tibia

3. Push down the lever on the EM proximal tube

Resect Proximal Tibia (cont.)

Figure 41 Figure 42 Figure 43