ATTUNE™ Knee System

INTUITION™ Instruments
Surgical Technique
Introduction

This surgical technique provides guidelines for the implantation

of the ATTUNE™ Knee System Family of Knee Implants with the
INTUITION™ Instrumentation.

ATTUNE Knee System Implants are available in five configurations:

• Posterior Stabilized Fixed Bearing (PS FB),
• Posterior Stabilized Rotating Platform (PS RP),
• Cruciate Retaining Fixed Bearing (CR FB) and
• Cruciate Retaining Rotating Platform (CR RP)
• Medial Stabilized Fixed Bearing (MS FB)

The Cruciate Retaining (CR) and Medial Stabilized (MS) configurations

can also be used for Cruciate Sacrificing (CS) applications.

2 Surgical Technique • INTUITION™ Instruments

Table of Contents

Surgical Technique Key Surgical Steps Summary 6

Incision and Exposure 8

Pinning 9

Pinning Technique 10

Distal Femoral Resection 11

Distal Femoral Resection - Instrument Assembly 12

Distal Femoral Resection 14

Tibial Alignment and Resection - Instrument Assembly 18

Tibial Alignment and Resection 20

Extension Gap Assessment and Balancing 25

Femoral Rotation 27

Measured Femoral Sizing and Rotation 28

Balanced Femoral Sizing and Rotation 34

Femoral Preparation 43

Posterior Condyle Preparation 48

Femoral Resection - PS Femoral Notch Cuts 50

Trial Reduction 52

Soft Tissue Considerations for

Cruciate Retaining Application 54

Trial Components 55

Tibial Preparation 61

Patella Resection and Preparation –

Instrument Assembly 64

INTUITION™ Instruments • Surgical Technique 3

Table of Contents

Patella Resection 66

Patella Preparation 68

Lug Hole Preparation 71

Tibial Base Implantation 73

Femoral Component Implantation 75

Tibial Insert Implantation 78

Final Patella Preparation 81

Patella Component Implantation 82

Closure 83

Appendix Appendix 1:
Optional Patella Drilling Technique 84

Appendix 2:
Optional Minimally Invasive Instrument Technique 85

Appendix 3:
Optional Lamina Spreader Technique 90

Appendix 4:
ATTUNE Tibial Insert Trials and Trial Handle 93

Appendix 5:
Revision Fixed Bearing (FB) Tibial Base 94

Appendix 6:
Optional Balancing Block Technique 105

Appendix 7:
Optional All Poly Tibial Components Technique 115

Appendix 8:
Optional INTUITION Essential Instruments Technique  124

4 Surgical Technique • INTUITION™ Instruments

Table of Contents

Sizing Charts Flexion/Extension Gap Chart 128

Modular Tibial Component Sizing Chart 129

Compatibility Data 130

Symbols on Surgical Instruments 131

■ Notes
▲ Warnings

INTUITION™ Instruments • Surgical Technique 5

Key Surgical Steps Summary

Incision and Exposure Femoral Alignment and

Distal Resection

Measured Femoral Sizing and Rotation

Femoral Preparation

Balanced Femoral Sizing and Rotation

Femoral Lug Hole Preparation Patella Resection and

Final Patella Preparation

6 Surgical Technique • INTUITION™ Instruments

Key Surgical Steps Summary

Tibial Alignment and Extension Gap Assessment

Proximal Resection and Balancing

Trial Reduction Tibial Preparation

■ Note:
All resections are done using a 1.19 mm
Saw Blade to maximize accuracy
through the Slotted Cutting Guides.

Final Component Implantation

INTUITION™ Instruments • Surgical Technique 7

Incision and Exposure

The INTUITION Instruments are designed for both

standard open and minimally invasive approaches to the
knee.

Incision and exposure should be performed using the

surgeon’s preferred technique.

■ INFORMATION
Excise any hypertrophic synovium and a portion of the
infrapatellar fat pad to allow access to the medial,
lateral, and intercondylar spaces. Before proceeding,
consider removing prominent osteophytes, particularly
medial and lateral osteophytes, as they can affect soft
tissue balancing.
Accurate patella alignment is important for proper
placement and tracking. It is recommended not to drill
the patella lug holes prior to the trialing step so that
correct rotation and position of the patella trial may be
assessed. Many of the instruments on the following
pages are made of polymer materials. As with any
composite or polymer-based instrument, it is important
to allow adequate drying time after cleaning.

8 Surgical Technique • INTUITION™ Instruments

Pinning

The ATTUNE Knee System has 3.15 mm diameter pins to

increase the stability and functionality of the instruments.
The INTUITION Instruments are designed to be used
with the ATTUNE pin pack that contains Universal Pins
and Threaded Headed Pins. Threaded Non-Headed Pins
are also shown below.

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 Drill. These pins are best used to
secure blocks against a flat surface such as cut bone.
Threaded Headed Pin

The Threaded Non-Headed Pin is also available and is

designed to be inserted and removed with a Power Drill.

Threaded Non-Headed Pin

Pin Jack

■ INFORMATION Power Driver

Steinmann Pins are compatible with all pin holes

throughout the INTUITION Instruments. It is
recommended to use Threaded Headed Pins through
the divergent holes in the A/P Chamfer Block to provide
sufficient stability against the distal femoral cut.

INTUITION™ Instruments • Surgical Technique 9

Pinning Technique

Correct Pinning Incorrect Pinning

Do not overtighten.
Overtightening may change the angle or cause the pin
to strip.

Headed Pins are best used to secure blocks against a flat

surface such as cut bone. Non-Headed Pins are
recommended for use with cutting blocks against a
curved surface such as with the Distal Cut Block.

10 Surgical Technique • INTUITION™ Instruments

Distal Femoral Resection

If the Balanced Sizer is intended to be used, then the

position of the IM hole is important as it determines the
Pivot point for femoral rotation. It should be selected to
be 3 - 5 mm medial to the apex of the intercondylar notch
and 7 - 10 mm anterior to the origin of the Posterior
Cruciate Ligament (PCL).

Drawing a centering mark or Whiteside’s Line and the

pre-operative X-ray may be useful to assist precise
location of the IM hole.

In the proper position, the Step Drill should pass easily

into the femoral canal.

Use the step feature of the Step Drill to increase the

diameter of the hole. This will allow depressurization of
the canal when the IM Rod is inserted.

▲ CAUTION
If using the Balancing Block technique, described in
Appendix 6, ensure that you do not use the stepped
portion of the Step Drill.

INTUITION™ Instruments • Surgical Technique 11

Distal Femoral Resection – Instrument Assembly

Distal Femoral Jig Assembly

Order of Assembly:
1. R
 otate the Resection Knob of the Outrigger 3. R
 otate the Resection Knob clockwise to set the desired
counterclockwise until the padlock symbol is aligned resection level.
with the arrow.
4. Engage the Distal Femoral Cutting Block with the
2. Insert the Outrigger Slide into the Outrigger. Outrigger Slide and the Cutting Block Clip.

Resection
Knob

Outrigger
Pull Back

Outrigger Slide

Cutting Block Clip

Distal Femoral
Cutting Block

12 Surgical Technique • INTUITION™ Instruments

Distal Femoral Resection – Instrument Assembly

A 9 mm resection will match the

thickness of the implant. The arrow
on the Outrigger, near the Resection
Knob, indicates the resection level Distal Resection
when using the Cutting Slot. Each Depth
click moves the Distal Femoral
Cutting Block 1 mm proximal or distal.

4 mm difference between a
Slotted and Non-Slotted
resection

Resection Knob adjusts

distal resection depth

INTUITION™ Instruments • Surgical Technique 13

Distal Femoral Resection

Set the desired Valgus angle (left or right - 0 degrees to 9

degrees) on the Distal Femoral Jig by pulling the Varus/
Valgus (V/V) Dial toward the Femoral Handle, rotating it
clockwise or counterclockwise to the appropriate setting.

Distal Plate
V/V Fixation
Indicator Pin Holes
Cap
V/V Dial

■ INFORMATION
Be sure that the Varus/Valgus Dial is FULLY disengaged
by sliding it back from the Distal Plate before rotating it.

14 Surgical Technique • INTUITION™ Instruments

Distal Femoral Resection

Insert the IM Rod into the femoral canal to the level of the
isthmus. Disengage the Distal Femoral Jig from the
Handle by pushing on the V/V Indicator Cap and slide the
Jig toward the femur until the distal plate contacts the
distal femur. The Jig may be pinned temporarily using pin
holes in the distal resection plate.

Position the Distal Femoral Cutting Block on the

anterior femur by rotating it until it is seated on the
anterior condyles.

INTUITION™ Instruments • Surgical Technique 15

Distal Femoral Resection

Secure the Cutting Block to the femur with two Divergent Pin Hole
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.

Removal of the Distal Femoral Jig

Disengage the Distal Femoral Cutting Block from the
Outrigger Slide by pressing the Red Cutting Block Clip.
Pull the entire instrument distally.

To further adjust the distal resection depth once the

Distal Femoral Jig is removed, use the distal or proximal
pin holes, that move the block 2 mm in either direction.

Pull Distally

Cutting Block Clip

16 Surgical Technique • INTUITION™ Instruments

Distal Femoral Resection

Resect the distal femur.

Remove the Distal Femoral Cutting Block. Depending on
surgeon preference, the Pins may be removed or left in
place to allow for a recut if required.

INTUITION™ Instruments • Surgical Technique 17

Tibial Alignment and Resection – Instrument Assembly

Tibial Jig Assembly

With the Height Adjustment Knob fully
unscrewed on the Tibial Proximal Uprod, attach
the Tibial Distal Uprod to the Proximal Uprod. Proximal Central
Then attach the Tibial Ankle Clamp to the Distal Marking
Right Tibial
Uprod. Assemble the appropriate Cutting Block
Cutting Block
to the Tibial Proximal Uprod.

Cutting Block Options

Extramedullary Tibial
Proximal Uprod

Left Tibial Cutting Block

Posterior Slope
Adjustment

Height Adjustment
Knob
Right Tibial Cutting Block

Symmetrical Cutting Block

18 Surgical Technique • INTUITION™ Instruments

Tibial Alignment and Resection – Instrument Assembly

Tibial Jig Assembly

Extramedullary Tibial
Ankle Clamp

Indicator Line

A/P
Adjustment
Mechanism

A/P Ratchet

V/V Adjustment Extramedullary Tibial

Mechanism Distal Uprod

Complete
Assembly

INTUITION™ Instruments • Surgical Technique 19

Tibial Alignment and Resection

Set the tibial posterior slope as depicted on the Proximal

Uprod of the Tibial Jig, according to the
recommendations depending on the appropriate implant
configuration.

Place the knee in 90 degrees of flexion. Place the Ankle

Clamp around the malleoli. Set Varus/Valgus rotation by
aligning the proximal central marking on the Tibial Cutting
Block with the medial one third of the tibial tubercle.

The axis of the Proximal Uprod should be positioned with Pinch

reference to the tibial axis. Lever

Note that the figures on the Jig will only deliver that angle
if the rest of the Jig is set up correctly as pictured here. 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 moving the A/P
adjustment mechanism.

■ INFORMATION
Fixed Bearing Tibial slope Recommendations:
For a cruciate retaining configuration a range of 5-7
degrees of tibial posterior slope is recommended,
attempting to match the patient’s slope. In PCL
retaining TKA, not adding adequate slope may
potentially limit the post operative flexion.
When the posterior cruciate ligament is removed, it is
recommended to set the tibial posterior slope at 3
degrees.
Rotating Platform Tibial slope recommendations
When the Posterior Stabilized Femur is used, a tibial
posterior slope of 3 degrees is recommended for the
rotating platform tibial tray.
When the Cruciate Retaining Femur is used (irrespective
of whether the PCL has been retained or sacrificed), a
posterior tibial slope of 5-7 degrees is recommended,
attempting to match the patient’s slope

20 Surgical Technique • INTUITION™ Instruments

Tibial Alignment and Resection

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 towards
the ankle, exposing the Through-Slot. Posterior slope
adjustment is the equivalent to using Cutting Blocks with
slope built into them.

Through-Slot

A/P
Ratchet
A/P Boss

Side Slot

Use the Varus/Valgus Adjustment Mechanism to align

the Tibial Proximal Uprod parallel to the long axis of the V/V Adjustment
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.

■ INFORMATION
Indicator Line
In ankles with a large soft tissue envelope in which the
soft tissue prevents achieving 0 degrees of alignment at
the neutral position, the Distal Uprod can be moved
posterior to reveal the Through-Slot to achieve a
0 degree slope.

INTUITION™ Instruments • Surgical Technique 21

Tibial Alignment and Resection

Stylus Attachment
Attach the Adjustable Tibial Stylus to the Cutting Block Resection Knob
through the slot feature.

Pointer

Foot

Resection through the Slot

If planning to resect through the slot, position the foot of
the Stylus marked “slot” into the Slot Feature
of the Cutting Block.

Resection on top of the Cutting Slot

If planning to resect on top of the Cutting Block, place the
foot marked “non-slot” into the Slot Feature.

Rotate the Resection Knob to set the resection level on the

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

Rest the pointer of the Adjustable Tibial Stylus on the

lowest point of the tibial plateau. Then lock the Height
Adjustment Knob on the Proximal Uprod.

4 mm difference
between a Slotted and
■ INFORMATION
Non-Slotted resection
The minimum composite thickness of the tibial
implant (4 mm base + 5 mm insert) is 9 mm.

22 Surgical Technique • INTUITION™ Instruments

Tibial Alignment and Resection

After the height has been set, pin the block through the
holes marked by a center line using two Universal Pins.

If necessary, remove the Stylus for better access,

ensuring that the Height Adjustment Knob is locked. The
resection level can be adjusted by using the distal or
proximal pin holes, which move the block 2 mm in either
direction. If desired, the Cutting Block can be more
securely fixed with an additional Universal or Non-
Headed Pin placed through the distal angled hole.

Distal
Angled
Hole

Temporary Fixation
Pin Slot

INTUITION™ Instruments • Surgical Technique 23

Tibial Alignment and Resection

Optional: To assess tibial slope prior to performing the

tibial resection, place the Alignment Handle into the slot
feature of the Tibial Cutting Block, and insert the
Alignment Rod. Alignment can be checked by ensuring
that the Alignment Rod remains parallel with the tibial
axis. A second Alignment Rod may be inserted through
the Alignment Handle in the M/L plane to help ensure
that the tibia is not cut in Varus or Valgus.

Additionally, the two Alignment Rods may be assembled

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

Resect the tibia.

■ INFORMATION
Place retractors to protect the PCL and
collateral ligaments during tibial resection
if a CR implant is chosen.

24 Surgical Technique • INTUITION™ Instruments

Extension Gap Assessment and Balancing

Spacer Base

Shim

Spacer Block

Posterior Stabilized Cruciate Retaining

For the PS technique, connect the ATTUNE Spacer Base For the CR technique, evaluate the CR extension gap
and desired Shim to the Spacer Block to assess both the as described in the previous paragraph. To assess the CR
extension and flexion gaps. When the ATTUNE Spacer flexion gap connect the CR Flexion Base and desired
Base is attached, both ends of the Spacer Block are equal Shim to one end of the Spacer Block. The CR Flexion
thickness and can each be connected to a different Shim Base compensates for the 1 mm difference in thickness of
to allow successive evaluation of multiple thicknesses. As the posterior condyles of the CR implant.
an example, if the surgeon is unsure as to whether the
gap will correspond to a 5 mm or 6 mm insert, the 5 mm PS CR
Shim can be connected to one end and the 6 mm Shim to Distal Condyle Thickness 9 9
the other.
Posterior Condyle Thickness 9 8

■ INFORMATION
The Spacer Block is designed to accommodate both CR thicknesses. The labels on the Shims indicate the
and PS techniques. In the PS implant the distal and thickness of the insert they represent when assembled
posterior condyles are the same thickness, resulting in to the Spacer Block, and can be read off the top of the
no compensation required for extension and flexion Shim when it is attached to the Spacer Block. Although
balancing. In the CR implant the posterior condyle is any size Shim will assemble to the Spacer Block, the size
1 mm thinner than the distal condyles. The Spacer Block 5/6 Shim is recommended as it most closely matches
connects to Shims on both ends to evaluate multiple the shape of the Spacer Block.

INTUITION™ Instruments • Surgical Technique 25

Extension Gap Assessment and Balancing

To check the extension gap, fully extend the leg and

place the appropriate end of the Spacer Block between
the two resected surfaces. The Block should fit snugly in
the extension space. The extension gap should be
rectangular with the leg in full extension. If the extension
gap is not balanced, adjust the angle of either the tibial or
the femoral cut, or perform appropriate soft-tissue
releases to achieve balance.

If desired, perform a gentle Varus/Valgus stress test with

the Spacer Block in place. Typically 1 mm to 3 mm of
opening both medially and laterally is desirable.

If desired, the two piece Alignment Rod can be inserted

into the Spacer Block to assess alignment.

The Spacer Block can also be used to assess the flexion

gap after resecting the posterior femoral condyles.

26 Surgical Technique • INTUITION™ Instruments

Femoral Rotation

There are multiple ways of setting the femoral rotation,

such as the Measured Sizer or Balanced Sizer*
Balanced and appropriate external rotation of the femoral
component is important for tibiofemoral stability in flexion
and patello-femoral tracking/function.

Depending on the surgeon’s preference, rotation may be

set with reference to either key anatomical landmarks via
the measured resection approach, or by balancing the
soft tissues in flexion with the goal of generating a
rectangular flexion gap. A secondary check to key
anatomical landmarks should also be made to avoid
malrotation of the femoral component.

Balanced Sizer Measured Sizer

■ INFORMATION
Proper soft tissue balance is important for successful Knee Replacement. It is
especially important in a Rotating Platform (RP) knee construct to reduce the
risk of spin out of the tibial insert.
*As of February 10, 2022, the Balanced Sizer is not available in the United States

INTUITION™ Instruments • Surgical Technique 27

Measured Femoral Sizing and Rotation

Measured Sizing and Rotation Guide

Size Locking Knob

Stylus

Anterior Down Pin Hole

Anterior Down Pin Hole

Femoral Size Markings

Femoral Rotation Lever

Posterior Up Pin Hole
Fixation Pin Holes
Posterior Up Pin Hole
Anatomic Reference Mark
Feet

Rotation Markings

■ INFORMATION
Choosing the anterior down pin holes will provide a provide a fixed posterior reference with a fixed
fixed anterior reference with a constant anterior cut, posterior cut. All variability in bone cuts from size to size
regardless of the size of the A/P Chamfer Block. All will occur on the anterior cut.
variability in bone cuts from size to size will occur on the
The Measured Sizer instrument is named to indicate its
posterior cut.
use for a Measured Resection surgical philosophy and is
Conversely, choosing the posterior up pin holes will not a measurement device.

28 Surgical Technique • INTUITION™ Instruments

Measured Femoral Sizing and Rotation

Placement of Sizing Guide Whiteside's Line

Mark the A/P Axis (Whiteside’s line) and/or the
transepicondylar axis on the resected distal femur.

Transepicondylar Axis

Place the Measured Sizing and Rotation Guide against the

resected surface of the distal femur with the posterior
feet of the Guide contacting the posterior condyles. If
desired, secure the Guide with a Threaded Headed Pin
through the fixation hole.

Threaded Headed Pin through

the Fixation Hole

INTUITION™ Instruments • Surgical Technique 29

Measured Femoral Sizing and Rotation

Setting Rotation Squeeze the Lever and

Adjust the degree of external rotation to be parallel to the simultaneously rotate
transepicondylar axis and perpendicular to Whiteside’s
line by squeezing the Femoral Rotation Lever and rotating
the anterior section while holding the feet of the device
against the posterior condyles.

Whiteside's Line

Transepicondylar
Axis

Right Side Left Side

The rotation markings indicate the degree of external femoral

rotation with reference to the posterior condyles

30 Surgical Technique • INTUITION™ Instruments

Measured Femoral Sizing and Rotation

Slide the anterior section down.

Size Locking
Adjust the superior-inferior position of the Stylus to
Knob
indicate the proper femoral component size. The position
of the Stylus will have an effect on the femoral
component sizing. Pick the M/L position of the Stylus to
match the highest point of the anterior femur at the
appropriate size indication on the Stylus scale. The
position of the Stylus will then be located near the exit
point of the Saw Blade.

Read the scale from the distal side of the Size Locking
Knob.

The line through the center of the Anterior Anterior Down Pin
Down Pin Holes indicates the size of the Holes indicating
femur. Lock the size position by twisting Size 5
the Size Locking Knob.

▲ CAUTION
Be very careful not to apply a large force when
contacting the anterior femur with the Stylus,
avoiding excessive deflection of the Stylus
which may bias the sizing.

INTUITION™ Instruments • Surgical Technique 31

Measured Femoral Sizing and Rotation

Pin Insertion
Insert Universal or Non-Headed Pins
through the top pin holes for anterior
■ INFORMATION down referencing
When the PCL is resected, the flexion gap can increase.
The ATTUNE PS femoral implant helps compensate for
this with a posterior condylar thickness that is 1mm
larger than the bony resection.
When using an ATTUNE CR femoral implant and a fully
resected PCL, the functionality of the system can be
used to help compensate for an increase in flexion gap:
• When using anterior down pin holes and between
sizes, it may be advisable to upsize the implant (see
page 28)
• When using the posterior up pin holes, the implant
can be posteriorized by 1.5mm (see page 43)
• Prior to making any cuts the flexion gap can always
be checked with a spacer block (see page 44)
• The anterior cut can be checked with an angel wing
(see page 45).
• Additional guidance on managing the flexion/
extension see page 128.

OR
Insert Universal or Non-Headed Pins through the
bottom pin holes for posterior up referencing
(For further information see page 28).

32 Surgical Technique • INTUITION™ Instruments

Measured Femoral Sizing and Rotation

Removal of Sizer
1. R
 emove the Threaded Headed Pin, if utilized.

2. Release the Knob by rotating counterclockwise.

3. T
 he Stylus is loosened, then pushed forward on
the anterior face of the femur so that it is no
longer contacting the bone surface (as the
anterior surface slopes downward). The Sizer is
pulled off the femur and the two components
removed together.

4. Remove the Sizing/Rotation Guide, leaving the

Universal or Non-Headed Pins in the distal femur. 1.

2. Threaded Headed Pin

3.

4.

INTUITION™ Instruments • Surgical Technique 33

Balanced Femoral Sizing and Rotation

Balanced Sizing/Rotation Guide Assembly

To accommodate differences in the flexion gap assessment
between the CR and PS Femoral Implants, two different feet
are available. Attach the appropriate CR or PS Balanced Sizer
Foot to the Balanced Sizing/Rotation Guide.

Tensioning Knob

Locking Knob

Stylus

Sizing Scale

Pin Holes

Insert Thickness Scale

Foot IM Rod Hole

34 Surgical Technique • INTUITION™ Instruments

Balanced Femoral Sizing and Rotation

Balanced Sizing and Rotation Guide

The Balanced Sizer performs several key functions:
1. Sizes the femur
2. Sets rotation of the femoral component based on
ligament tension
3. Enables assessment of the flexion gap in comparison to
the previously determined extension gap

Before using the Balanced Sizer, clear osteophytes to

remove any impingement of soft tissues especially in the
posterior capsule. Evaluate the extension gap using the
Spacer Block. After making the primary cuts and
determining the extension gap, record the insert
thickness that corresponds to the extension gap for future
reference.

Attach the IM Rod Handle to the Balanced Sizer IM Rod

and insert the Rod into the intramedullary canal.

Use the handle as a Slap Hammer to secure the Tapered

Plug and stabilize the IM Rod.

■ INFORMATION
The Balanced Sizer technique is anterior referencing
only. The Tapered Plug may not fit flush against the
bone, but should be tight.
The IM Rod should not be inserted past the isthmus to
ensure that the angle of the rod is not affected.
Ensure that the IM canal has been prepared up to the
wider diameter of the Step Drill.

INTUITION™ Instruments • Surgical Technique 35

Balanced Femoral Sizing and Rotation

Sizing the Femur

1. Slide the main body and foot of the Balanced Sizer onto 2.
the IM Rod with the knee flexed at 90 degrees, ensuring
that the feet clear the posterior condyles.
2. Turn the Tensioning Knob in a counterclockwise
direction (in the direction of the SZ arrow) until the Foot
contacts the posterior femoral condyles. Once the Foot
contacts the posterior femoral condyles the sizer should
not be able to rotate about the IM Rod.

1.

Slide the Sizing Guide and Stylus over the main body
of the Balanced Sizer until the Stylus touches the
anterior femur.
Locking Knob should
be loose at this point
of the process

■ INFORMATION
Once the Foot of the Balanced Sizer has
contacted the posterior femoral condyles, be
careful not to excessively rotate the Tensioning
Knob in the direction of the SZ arrow as this
could result in disassembling the device.

36 Surgical Technique • INTUITION™ Instruments

Balanced Femoral Sizing and Rotation

Confirm that the Guide is firmly placed against the

distal femoral cut with the knee flexed at 90 degrees.

Adjust the superior-inferior position of the Stylus to

indicate the proper femoral component size. The Sizer fits against
position of the Stylus will have an effect on the distal femoral
femoral component sizing. Pick the M/L position of cut surface
the Stylus to match the highest point of the anterior
femur at the appropriate size indication on the Stylus
scale. The position of the Stylus will then be located Stylus tip touches
near the exit point of the Saw Blade. the highest point
on the anterior
femur

Foot of Sizer
contact
posterior
condyles of
femur

INTUITION™ Instruments • Surgical Technique 37

Balanced Femoral Sizing and Rotation

Then determine the femoral component size indicated by

lining up the black SZ line on the main body of the
balancer with the white numbers on the sizing scale.

▲ CAUTION Size 5
Be very careful not to apply a large force when
contacting the anterior femur with the Stylus.
At this point in the procedure do NOT lock the
assembly by turning the Locking Knob. The
Locking Knob should only be turned to lock the
assembly after completion of balancing and in
preparation of pin placement.

38 Surgical Technique • INTUITION™ Instruments

Balanced Femoral Sizing and Rotation

Interpreter for Balanced Sizer

The optional Interpreter performs two functions:
1. It allows the surgeon to visualize the position and
rotation of the posterior cut prior to placing
reference pins.
2. The window feature aides in reading the insert
thickness scale relative to the femoral component
size selected.

The Interpreter is assembled to the sizer

such that the size required is displayed
through the window.

INTUITION™ Instruments • Surgical Technique 39

Balanced Femoral Sizing and Rotation

Setting Femoral Rotation

Turn the Tensioning Knob in a clockwise (in the direction
of the mm arrow) direction until the flexion gap matches
the previously evaluated extension gap.

To determine the tibial insert thickness read the insert

thickness scale (denoted by the black markings on the
main body) across from the previously determined
femoral size indication (denoted by the high contrast
white markings on the sizing scale). e.g. This image
indicates an 8 mm tibial insert for a size 5 femoral
component.

8 mm tibial insert
■ INFORMATION thickness for a size 5
Ensure that the Sizer has good contact with the distal femoral component
femur.
The leg should be at 90 degrees and the Sizer Foot
should rest on the proximal tibia.
As tension is applied the femur rotates, therefore it is
important to review and adjust the Stylus to the
recommended position which is the highest point on the
anterior femur relative to the appropriate size.

40 Surgical Technique • INTUITION™ Instruments

Balanced Femoral Sizing and Rotation

To assess the ligament tension, hold the tibia firmly and use
the Tensioning Knob to apply a Varus/Valgus stress while
observing lift-off between the Foot and the tibial cut.

If further tension is required, turn the Tensioning Knob in a

clockwise direction until the next thickness of insert is
reached and conduct a further assessment of the
ligaments using a Varus/Valgus stress test. If the
predicted insert thickness in flexion is not matching the
previously evaluated extension thickness, then the
surgeon may need to consider moving the femoral
component position by 1.5 mm in an anterior or posterior
direction, or upsizing or downsizing the femoral
component, using the A/P Chamfer Block.

Refer to the “Flexion/Extension Gap Chart” section for Check for

further gap balancing information. lift-off

▲ CAUTION
Over-rotation of the lateral condyle in the anterior
direction could result in excessive external rotation of
the femoral component and could be an indication of
over-tightening.
The posterior feet of the Interpreter may be used to
visualize the position and rotation of the posterior Posterior
resection. resection level

INTUITION™ Instruments • Surgical Technique 41

Balanced Femoral Sizing and Rotation

Verify the appropriate position of the Stylus,

then, lock the assembly in place by rotating
the Locking Knob clockwise. Insert Universal
Pins into the Pin Holes on each side of the
Sizing Scale.

Insert
Pins

Remove the Balanced Sizer. First unlock the

Locking Knob and release the tension by
turning the Tensioning Knob in a
counterclockwise direction. Attach the Rod
Handle and remove the IM Rod with the
Tapered Plug, engage the Tapered Plug with
the guide to remove it from the bone.

42 Surgical Technique • INTUITION™ Instruments

Femoral Preparation

A/P Chamfer Block

Sulcus window as a visual reference

for sulcus placement
+1.5 mm Hole

Center Line Hole

-1.5 mm Hole

Anterior Down
Referencing Pin Holes

Posterior Up
Referencing Pin Holes

Modular Posterior Saw Narrow Size

Capture to aid balancing Reference Cutout
flexion space with The cutout indicates the width
Spacer Blocks of the narrow size of implants

■ INFORMATION
The ATTUNE femoral components increase in size by a This creates the intra-operative flexibility to position
consistent 3 mm in the A/P direction. The A/P Chamfer the femoral component based on the surgeon’s
Blocks allow the surgeon to adjust the A/P position of assessment of the flexion gap and the desired
the femoral component by 1.5 mm in either direction. posterior condylar offset. See page 124 for more
information on gap balancing.
If there is no cutout, a narrow component is not
available for that size. Narrow components are
available for sizes 3, 4, 5 and 6.

INTUITION™ Instruments • Surgical Technique 43

Femoral Preparation

A/P and Chamfer Cuts

Select the A/P Chamfer Block that matches
the femur size. Place the Block over the two
anterior or posterior Universal or Non-Headed Alignment Slots
Pins through the pin holes marked with a
center line.

The flexion space can be checked by using a Spacer

Block placed below the A/P Chamfer Block with the
Modular Posterior Saw Capture removed.

■ INFORMATION
When using the anterior offset pin holes, changing the Then remove the anterior reference pins. This enables
size of the femoral component will alter the posterior the femoral implant size to be adjusted without altering
femoral condyle resection. the flexion gap.
To evaluate femoral size adjustments without altering the Alternatively, the Block can be moved 1.5 mm up or
posterior femoral cut, place the A/P Chamfer Block onto down (one hole location) to adjust the flexion gap, if
the anterior Universal Pins and insert two additional pins necessary.
through the posterior up holes on the Block.

44 Surgical Technique • INTUITION™ Instruments

Femoral Preparation

■ INFORMATION
Good pinning technique is critical to achieving
accurate bone cuts during the anterior and posterior
resections. The recommended technique is to avoid
stripping the Threaded Headed Pins in the divergent
pin holes and to retain the straight pins during anterior
and posterior resections for added stability.
Angel
Wing
Use an Angel Wing to confirm the location of
the cut and the degree of rotation. The Block
can also be used at this stage to assess the
M/L width of the implant size for both the
standard or narrow sizes.

Insert Threaded Headed Pins into the

divergent pin holes on the medial and lateral
aspects of the A/P Chamfer Block.

INTUITION™ Instruments • Surgical Technique 45

Femoral Preparation

■ INFORMATION
INTUITION Instrument A/P Chamfer Blocks were
designed to ensure the femoral trial and implant seats
fully on the distal femur by preparing the chamfer cuts
with additional clearance.
Therefore, a small “gap” may be observed between the
femoral trial/implant and the chamfer cuts, particularly
the anterior chamfer. This gap is intentional by design to
ensure that fixation is achieved with the distal, anterior,
and posterior surfaces. In this way, the position of the
femoral component can be best controlled with regards
to flexion and extension gaps.

Recommended: Re-attach the appropriate size

Modular Posterior Saw Capture to the A/P Chamfer
Block to provide for capture guidance on all cuts.

46 Surgical Technique • INTUITION™ Instruments

Femoral Preparation

Place Retractors to protect the medial and lateral

collateral ligaments and the popliteal tendon. Then resect
the anterior and posterior femur, as well as the anterior
chamfer if posterior referencing or posterior chamfer if
anterior referencing.

Remove the Universal or Non-Headed Pins and cut the

remaining anterior or posterior chamfer. Remove the
Threaded Headed Pins and the A/P Chamfer Block.

▲ CAUTION
It is recommended to revisit the anterior and posterior
femoral cuts after the initial resection to avoid the effect
of Saw Blade skiving.

■ INFORMATION
The posterior Saw Captures are open medially and
laterally to accommodate complete saw cuts. To
reduce the risk of inadvertent Saw Blade kickout,
point the Blade slightly toward the midline before
starting the Saw.

INTUITION™ Instruments • Surgical Technique 47

Posterior Condyle Preparation

Removal of Excess Bone

To avoid impingement in flexion, remove any Dotted lines indicate
excess bone between the posterior tibial the outer edges of the
implant and the posterior femoral condyles in final component
flexion. To aid in osteophyte and excess bone
removal, select the Femoral Finishing Guide Reference Window
that corresponds to the femoral trial
component size. Push the instrument onto the
resected distal femur and position
mediolaterally, using the lateral anterior
profile of the instrument as a guide. The inner
Cutouts indicate
surface of the windows represents the
narrow size
anterior medial aspect of the implant and the
outside profile of the anterior face represents
the anterior lateral aspect of the implant.

Fix the instrument flush to the distal cut using

4.7 mm diameter Base Pins.
For optimal stability,
place Base Pins as shown

■ INFORMATION
The cutouts on the sides of the Femoral Finishing Guide
show where the outer edge of the narrow component is
located. If there is no cutout, a narrow component is not Base Pin
available for that size. Narrow components are available
for sizes 3, 4, 5 and 6.

48 Surgical Technique • INTUITION™ Instruments

Posterior Condyle Preparation

Removal of Excess Bone (Cont.)

With the Femoral Finishing Guide in place, verify
that any excess bone or residual osteophytes in
the posterior recesses have been removed. If not, Curved
use a Curved Osteotome or Gouge to remove Osteotome
any remaining bone that can be seen beyond the
end of the Femoral Finishing Guide feet.

Always work carefully under direct vision to avoid

damage to the neurovascular structures in the
popliteal fossa.

CR Sulcus Femoral Preparation

When implanting an ATTUNE CR component, use the
Femoral Finishing Guide to perform the sulcus cut. Using
the Sulcus Cut Ramp as a guide, remove bone from the
sulcus with the Rasp, a 0.5 in. Saw or Osteotome.

Then remove the Femoral Finishing Guide.

Sulcus Cut
Ramp

INTUITION™ Instruments • Surgical Technique 49

Femoral Resection – PS Femoral Notch Cuts

When implanting an ATTUNE PS

component, use the Notch Guide to
perform the notch cut. The profile
of the Notch Guide provides
anterior and distal references to the
width of the implant. In addition,
windows in the Notch Guide
provide additional reference. Reference Window

The inner surface of the windows Dotted lines indicate

represents the anterior medial the outer edges of
aspect of the implant and the the final component
outside profile of the Notch Guide
represents the anterior lateral
aspect of the implant. The The tongue of the
references are designed to confirm Notch Guide is
optimal component size and extended to provide
position. The tongue of the Notch a long cutting surface
Guide is extended to provide a long for an 18 degree cut
cutting surface for an 18 degree cut.

Position the Notch Guide on the

resected anterior and distal surfaces
of the femur as far laterally as
possible while assuring that the
lateral border of the implant does
For optimal stability, place
not overhang the lateral femoral
Threaded Headed Pins as shown
cortex. Pin the Guide in place using
the Threaded Headed Pins.

■ INFORMATION
The cutouts on the sides of the Notch Guide show
where the outer edge of the narrow component is
located. If there is no cutout, a narrow component is not
available for that size. Narrow components are available
for sizes 3, 4, 5 and 6.

50 Surgical Technique • INTUITION™ Instruments

Femoral Resection – PS Femoral Notch Cuts

Perform the notch cut.

18 Degree Cut

Reference Window
Width Reference

Narrow Size
Reference Cutout

▲ CAUTION
When completing the notch cut, be careful
to avoid excessive angulation of the Saw
Blade or penetration past the posterior
femoral cortex to avoid injury to the
neurovascular structures.
Avoid undercutting the condyles.

INTUITION™ Instruments • Surgical Technique 51

Trial Reduction

Position the appropriate Femoral Trial onto

the femur by hand. Use the ATTUNE System
Impactor to impact the trial as necessary.

Femoral Component Indicators

Color
CR Coded
Marking
PS

Narrow Size Reference Cutout

■ INFORMATION
If the trial is not seating properly, the bone cuts may
need to be rechecked. Excessive impaction required is a
signal that under-resection has occurred of the A/P
Chamfer cuts, or of the Sulcus cut in a CR configuration. ■ INFORMATION
In a PS configuration, this could also be an indication of The cutouts on the sides of the Femoral Trial show
underresection of the Notch Guide cuts. Femoral Trial where the outer edge of the narrow component is
M/L width of box is representative of implant and located. If there is no cutout, a narrow component is not
cement mantle. The Femoral Trial should be fully seated available for that size. Narrow components are available
prior to joint reduction. for sizes 3, 4, 5 and 6.

52 Surgical Technique • INTUITION™ Instruments

Trial Reduction

Femoral Trial Gripper

(Optional Instrument)
Insertion
Position the appropriate Femoral Trial onto the femur by
hand or using the Femoral Trial Gripper. Squeeze the
Femoral Trial Gripper slightly until the prongs align with
the lug holes of the Femoral Trial. Continued pressure
should be applied to the Gripper to maintain a secure grip
between the Gripper and the Femoral Trial.

If the Femoral Trial Gripper is used to position the

Femoral Trial, remove the Gripper and use a Femoral
Impactor to fully seat the trial.

Extraction
To extract the Femoral Trial, place a Femoral Trial Gripper
in the lug holes and remove by hand. Optionally, use a
Mallet to lightly tap the extraction surface until the Trial is
removed.

▲ CAUTION
The Femoral Trial Gripper should not be used to fully
seat the Trials as the prongs protrude past the distal
surface of the Trial.
The Femoral Trial Gripper can be used for
Sizes 3 - 10 only.
When extracting the Trial, rocking it medio-laterally
may cause condylar fracture. Such rocking should
be avoided.

INTUITION™ Instruments • Surgical Technique 53

Soft Tissue Considerations for
Cruciate Retaining Application

As with any cruciate retaining total knee replacement, if

the surgeon plans to preserve the PCL, attention to PCL
balance is extremely important for proper kinematics of
the knee.1

A knee that is tighter in flexion than extension may require

one or a combination of the following: PCL release,
increasing the amount of tibial slope, or downsizing the
femoral component.

During trialing, the surgeon should select the trials that

provide the greatest stability in flexion while still allowing
full extension. Indications of an excessively tight flexion
space may include one or more of the following:
• Femoral trial lifting off
• Tibial trial lift-off or booking
• Excessive rollback of the femoral component on
the tibia

If there is any indication of imbalance, it is not uncommon

to perform a gradual release of the PCL.

54 Surgical Technique • INTUITION™ Instruments

Trial Components

Tibial Trial Posterior Low-Profile

Tibial Pin
Attach the Alignment Handle to the appropriate size
Tibial Base Trial and place onto the resected tibial surface.
Assess the position of the base to maximize tibial
coverage while avoiding overhang. Alternatively, the Low-
Profile Tibial Pin Puller can be used to posteriorly pin the
Low-Profile Tibial Pin Puller
Base Trial to the proximal tibia using the Posterior Low-
Profile Tibial Pins. For Fixed Bearing, the rotation of the
Tibial Base Trial is typically centered on the junction
between the medial and central third of the tibial tubercle. FB Float Evaluation Bullet
(Fixed Bearing)

Rotating Platform Spiked Evaluation Bullet

(Rotating Platform)
For Rotating Platform tibial components, secure the
Impaction Handle to the Spiked Evaluation Bullet and
insert the Bullet into the cutout of the Base Trial. Tap
down lightly on the Impaction Handle to secure the Base Central Mark
Trial to the proximal tibia.

Fixed Bearing
For Fixed Bearing tibial components, snap the Fixed
Bearing (FB) Float Evaluation Bullet into the cutout of the
Base Trial by hand. The FB Float Evaluation Bullet is used
when allowing normal internal/external rotation of the
tibial component during a range of motion to dictate the
optimal placement of the Base Trial. The bone can be Retention
marked for the Base Trial orientation reference. Feature

■ INFORMATION
When implanting a Rotating Platform, it is
recommended to use the Impaction Handle to guide the
Spiked Evaluation Bullet. Either Rotating Platform or
Fixed Bearing tibial components can be trialed before
preparing the tibia. Pinned Tibial Base Trials sizes 1 and 2
do not have posterior pinholes.

INTUITION™ Instruments • Surgical Technique 55

Trial Components

Select the Tibial Articulation Surface Trial that matches

the femoral size and style (CR or PS for either Rotating CR Articulation PS Articulation
Platform or Fixed Bearing), and attach the corresponding Surface Surface
size Shim of the appropriate thickness (5 mm, 6 mm,
7 mm, 8 mm, 10 mm, 12 mm, 14 mm and 16 mm for CR
and PS, and in addition 18 mm for PS, for core sizes 3 - 8).

The thickness markings on the insert trials and the final

insert implant indicate the insert thickness without the
base thickness included. For further information, see
the chart on page 129. For alternative technique please
see Appendix 4.

Shim

Articulation Surface Indicators

Fixed Bearing
Rotating Platform

56 Surgical Technique • INTUITION™ Instruments

Trial Components

The Shims are reversible to accommodate both Rotating

Platform and Fixed Bearing implants. Ensure that the
Articulation Surface Trial and Shim are securely engaged,
as these two components make up the Insert Trial. Attach
Rotating
the assembly into the Tibial Base Trial.
Platform
Check for Bal Seal™ Spring damage. If damage is
observed, replace the damaged component.

Fixed Bearing

Bal Seal Spring

Damage

INTUITION™ Instruments • Surgical Technique 57

Trial Components

Remove the Alignment Handle from the Tibial Base Trial

and, with the trial prosthesis in place, extend the knee
carefully, noting the anteroposterior and mediolateral
stability, and the overall alignment in the A/P and M/L
planes. If there is any indication of instability, use the next
thicker Shim and repeat the check. Select the trial
assembly that provides the greatest stability in flexion
while still allowing full extension.

If using the ATTUNE CR femoral trial with the PCL

removed and there is residual instability in flexion due to
the patient’s soft tissue balance, switching to an ATTUNE
PS femoral implant and PS insert will decrease the flexion
gap by an addition 1mm. To do this, remove the bone for
the femoral box as described on page 50. The tibial slope
recommendation for all ATTUNE FB Inserts used without
the PCL is the same, 3 degrees of posterior tibial slope.

Verify that the posterior femoral condyles are sufficiently

prepared to prevent impingement on the tibial insert in
deep flexion.

58 Surgical Technique • INTUITION™ Instruments

Trial Components

Re-attach the Alignment Handle to the Tibial Base Trial

and then attach the two-part Alignment Rod to the
Alignment Handle and confirm the overall alignment. For
a Fixed Bearing component, mark the position of the
trial component on the anterior tibial cortex.

Alternatively, the Low-Profile Tibial Pin Puller can be

used to anteriorly pin the Base Trial to the proximal tibia
using the Anterior Low-Profile Tibial Pins.

Anterior Low-Profile
Tibial Pin

INTUITION™ Instruments • Surgical Technique 59

Trial Components

Fully flex the knee, and remove the Insert Trial. The Tibial
Trial Extractor can be used to aid in the removal of the
Insert Trials.

Insert the Tibial Trial Extractor between the Tibial Base

Trial and the Shim, and lever the handle upwards toward
the femur in order to remove the Insert Trial.

Tibial Trial
Extractor

▲ CAUTION
Do not insert the Tibial Trial Extractor between the Shim
and the articulation surface to prevent damage to the
connection feature.
When removing the Tibial Trials with the Tibial Trial
Extractor, avoid engaging the Keel Punch to prevent
damage to the Tibial Trial Extractor.

60 Surgical Technique • INTUITION™ Instruments

Tibial Preparation

Re-attach the Universal Handle to the Tibial Base Trial

and re-insert it on the resected tibial surface, (aligning it
with the mark on the bone for a Fixed Bearing Tibial
Construct).

Attach the Tibial Drill Tower to the Tibial Base Trial by Base Pins
inserting the spikes on the underside of the Tower (Optional)
through the two inside holes on the anterior aspect of the
Base Trial. The spikes provide fixation for both the Drill
Tower and the Base Trial. If additional fixation is desired,
place Base Pins through the two outside holes on the
anterior aspect of the Base Trial.

If desired, use the appropriate size Tibial Drill Stop.

Use the Tibial Drill to ream the tibia to where the line
marked on the side of the Drill aligns to the top surface of
the tower. The Line marking corresponds to the Tibial
Base size. Bone debris from drilling could prevent the Keel
Punch from seating completely in the Base Trial. To
prevent this, flush out the cavity after drilling.

Optional Drill Stop

▲ CAUTION
Care should be taken not to protrude through the
medial tibial cortex if using the medial Base Pin.
Care should be taken not to overdrill. An optional Drill
Stop is available.

INTUITION™ Instruments • Surgical Technique 61

Tibial Preparation

Attach the correct size Keel Punch to the Impaction

Handle, and insert the assembly into the Tibial Drill Tower.
Impact the assembly into the cancellous bone until the
Keel Punch is seated flush on the Tibial Base Trial. Use the
anterior window in the tower to monitor the progress of
Keel Punch
the Keel Punch while impacting.

62 Surgical Technique • INTUITION™ Instruments

Tibial Preparation

When the Keel Punch is fully seated, the Impaction

Handle will automatically disengage from the Keel Punch,
allowing the Impaction Handle and the Tibial Drill Tower
to be removed together.

■ INFORMATION
Optional: If desired, perform a final trial reduction
by inserting the appropriate trial components and
repeating the previous trial evaluation. The FB Prep
Evaluation Bullet or RP Prep Evaluation Bullet can Integrated Insertion
be used in place of the Keel Punch to aid in the and Removal
insertion and extraction of the insert trials during a
final trial reduction.

RP Prep Evaluation
Bullet

FB Prep Evaluation
Bullet

INTUITION™ Instruments • Surgical Technique 63

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

64 Surgical Technique • INTUITION™ Instruments

Patella Resection and Preparation
– Instrument Assembly

Patella Drill Clamp

Medialized Dome Patella

Button and Button Medialized Anatomic
Holder Assembly Patella Button and
Button Holder
Drill Trial Assembly

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

■ 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.

INTUITION™ Instruments • Surgical Technique 65

Patella Resection

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

66 Surgical Technique • INTUITION™ Instruments

Patella Resection

Perform the resection using an Oscillating Saw through

the Saw Capture.

Patella Wafer
If desired, place a Patella Wafer on the resected surface
by hand to protect the patellar bone bed.

■ INFORMATION
When resecting the patella, care should be taken to
avoid Saw Blade excursion into the Femoral Trials or
Implants.

INTUITION™ Instruments • Surgical Technique 67

Patella Preparation

Patella Implant Options

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 Medialized Anatomic Patella
and tracking.

The following steps will aid in accurate alignment of both

patella designs, but is particularly critical for the
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

68 Surgical Technique • INTUITION™ Instruments

Patella Preparation

Patella Drill Trialing

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.

For an alternative technique, see Appendix 1.

INTUITION™ Instruments • Surgical Technique 69

Patella Preparation

Patella Drill Trialing

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

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

Correct trial handle alignment Incorrect trial handle alignment

■ 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 femoral component, 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.

70 Surgical Technique • INTUITION™ Instruments

Lug Hole Preparation

Use the Patella Modular Clamp to secure the Drill Trial if

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

Medialized Dome
Patella Drill Trial

Medialized Anatomic
Patella Drill Trial

INTUITION™ Instruments • Surgical Technique 71

Lug Hole Preparation

Femoral Lug Hole Preparation

Drill the femoral lug holes through the Femoral Trial using
the Patella Femoral Lug Drill. It is recommended to
perform this step after patella trialing to ensure adequate
medial/lateral placement.

▲ 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.

72 Surgical Technique • INTUITION™ Instruments

Tibial Base Implantation

Cementing Technique
During cementing of implants, movement of the
components should be minimized while the cement
is curing.

Prepare the sclerotic bone to ensure a continuous

cement mantle with good cement interdigitation of
2 mm - 4 mm. This can be done by drilling holes and
cleansing the bone with pulsatile lavage, taking care to
dry the bone afterwards. Pack residual small cavity bone
defects with cancellous autograft, allograft, or synthetic
bone substitutes.

In the presence of sclerotic bone on the proximal tibia, Base Protector

take additional care to ensure that the tibial base will be
able to fully seat. Sclerotic bone around the edge of the
prepared bone cavity may need to be removed with a
rongeur prior to cementation to ensure the base can be
fully seated.

Apply a thick layer of cement to the bone, the implant

surface or to both.

Cement should be applied to the cleaned and dried

prepared tibial plateau. Also, it is critical to ensure that
cement fully surrounds the cone of the tibial base implant.

For additional information on cementing, please refer to

the “Guidance for Cementing Total Knee Replacements”
document. During cementing of implants, movement of
the components should be minimized while the cement
is curing.

▲ CAUTION ▲ CAUTION
Blood lamination can reduce the mechanical properties Application of the cement to the roughened implant
of the cement3; therefore, it is vital to choose cement surface early in the dough state has been demonstrated
that reaches its working phase quickly. If applying to increase the fixation strength of the cement to the
cement to both the implant and bone, implantation implant.2
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.

INTUITION™ Instruments • Surgical Technique 73

Tibial Base Implantation

Carefully insert the Tibial Base, avoiding malrotation using

the ATTUNE System Impactor.

Per the illustration above, the tibial base implant should

be directly impacted to the bone prior to mating with
the polyethylene tibial insert as shown in the Tibial
Insert Implantation section (page 78). The polyethylene
tibial insert should not be attached to the tibial base
prior to tibial base implantation. With the Tibial Base
inserted, impact it with several blows from the Mallet
to the top of the ATTUNE System Impactor in order to
pressurize the cement. Then use a Curette to remove
all extruded cement.
ATTUNE System Impactor

▲ CAUTION
To prevent damage to the bearing surface, do not
remove the Base Protector before impacting the base.
Care must be taken not to pull cement from under the
edge of the implant in order to ensure the edges
remain sealed.

74 Surgical Technique • INTUITION™ Instruments

Femoral Component Implantation

In a cemented application, before insertion, place cement

onto the femoral component and the femur. Rotate side knob Rotate thumb
clockwise to lock wheel to bias the
Place the femoral component onto the bone by hand or, if grip arms outward
preferred, use the Femoral Introducer.
Grip Arm
Position the femoral component on the Introducer by
rotating the red Central Thumb Wheel on the Introducer
to move the Grip Arms outward. Then push the femoral
component against the impaction shoes, and rotate the
Central Thumb Wheel to move the Grip Arms inward so
that the arms engage in the slots on the femoral
component. Rotate the Side Knob clockwise to lock and
secure the implant.

Begin inserting the femoral component by engaging the Grip Arm

Femoral Lugs in the lug holes of the distal femur, and
deliver several Mallet blows to the Introducer.
Impaction Shoe
To release the Femoral Introducer, rotate the Side Knob
counterclockwise and rotate the red Central Thumb
Wheel to move the Grip Arms outward.

▲ CAUTION
Application of the cement to the roughened implant
surface early in the dough state has been demonstrated
to increase the fixation strength of the cement to the
implant.2

INTUITION™ Instruments • Surgical Technique 75

Femoral Component Implantation

For final femoral component impaction use the ATTUNE

System Impactor.
Condylar Impaction

Use a combination of condylar and notch impaction to

seat the femoral component. Then use a Curette to
remove all extruded cement.

ATTUNE System
Impactor

Notch Impaction

76 Surgical Technique • INTUITION™ Instruments

Femoral Component Implantation

Tibial Trial Extraction

The Tibial Trial Extractor is designed to aid in the removal
of insert trials. The instrument can be used with the Tibial
Base Implant as well as with the Tibial Base Trials.

With the knee in flexion, the surgeon inserts the Tibial Tibial Trial
Trial Extractor first on the medial side, underneath the Extractor
Shim and Articulation Surface construct. After inserting
one side of the Tibial Trial Extractor, the surgeon then
levers up the Insert Trial.

Next, the surgeon pivots the Tibial Trial Extractor

such that both ends are underneath the Shim and
Articulation Surface construct, followed by pushing the
Tibial Trial Extractor into the joint and underneath the
Tibial Insert Trials as far as possible.

The surgeon then should lift the handle of the Tibial Trial
Extractor UPWARDS. This upward movement works with
the geometry of the condyles to aid in removal of the
Tibial Insert Trials.

INTUITION™ Instruments • Surgical Technique 77

Tibial Insert Implantation

A trial reduction may be performed using Insert Trials.

Rotating Platform
For a Rotating Platform implant, place the RP Trial Post
into the implanted base component. Then place the Insert
Trial over the post and perform the trial reduction. For
Rotating Platform components, verify rotational stability
with PCL tension. Remove loose fragments or
particulates from the Final Tibial Base.

For Rotating Platform tibial components, insert the final

Tibial Insert.

▲ CAUTION
Once cement is cured, the trials can be used to verify
stability throughout the range of motion. Refer to
page 54 (Soft Tissue Considerations for CR Application).

78 Surgical Technique • INTUITION™ Instruments

Tibial Insert Implantation

Fixed Bearing
For Fixed Bearing components, place the Insert Trial on
the Tibial Base. Verify that the Insert Trial does not tilt up
off the front of the base during the range of motion test.
This could indicate that the PCL is too tight. Remove
loose fragments or particulates from the Final Tibial Base.

For Fixed Bearing tibial components, angle the Tibial Insert

posteriorly and slide the posterior tabs into the posterior
undercuts of the Tibial Base.

Insert slides back

and then down

▲ CAUTION
Once cement is cured, the trials can be used to verify
stability throughout the range of motion. Refer to
page 54 (Soft Tissue Considerations for CR Application).

INTUITION™ Instruments • Surgical Technique 79

Tibial Insert Implantation

The Fixed Bearing Tibial Insert is impacted into place on

the Tibial Base, using the Fixed Bearing Insert Impactor.

Position an Impactor at approximately 60 degrees on the

insert so that the notch rests on the anterior edge of the Fixed Bearing
center of the insert. Use a Mallet to strike the Fixed Insert Impactor
Bearing Insert Impactor. Confirm seating by
circumferential inspection. Move the leg into extension,
and then lift the leg back into flexion for final removal of
excess cement.
60˚

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.

80 Surgical Technique • INTUITION™ Instruments

Final Patella Preparation

Connect the Patella Clamp Button Holder to the Patella

Medialized Anatomic
Drill Clamp.
Patella Button

Medialized Dome Silicone Button

and Patella Clamp Button Holder

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.

INTUITION™ Instruments • Surgical Technique 81

Patella Component 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

■ 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.

82 Surgical Technique • INTUITION™ Instruments

Closure

Close the knee in layers using the surgeon’s

preferred technique.

INTUITION™ Instruments • Surgical Technique 83

Appendix 1: Optional Patella Drilling Technique

Mark the apex of native patella. In most cases duplication

of the median crest is recommended.

■ INFORMATION
Prior to resecting the patella a small hole can be drilled
through the apex of the native patella bone (1 - 2 mm
deeper than the intended amount of resection). Once
the patella has been resected the remainder of the hole
will be present on the resected bone surface.
The Drill Trial has a small hole through the center of the
apex, representing the peak of the patella implant. This
hole can be visually aligned with the pre-drilled hole on
the resected patella surface to aid in anatomic
placement of the trial.

84 Surgical Technique • INTUITION™ Instruments

Appendix 2: Optional Minimally Invasive (MI)
Instrument Technique

Overview of the ATTUNE MI

Instruments
This appendix highlights the key differences between the
standard and MI instruments. The standard ATTUNE
INTUITION Instruments are pictured in blue for
comparison to the ATTUNE MI Instruments.

Minimally Invasive (MI) Stylus

The MI Stylus has a side loading point in the anterior
aspect allowing surgeons to introduce the Sizer body first
and then assemble the Stylus. This feature also allows for
easy removal of the device.

Care should be taken in larger sized femurs or femurs

with excessive osteophytes on the anterior cortex. The
step feature has a low clearance so attention should be
paid to the anterior cortex for any bone impingement. In
these cases, the standard Stylus would be recommended
to be used.

The tip of the Stylus has a step feature to allow for easy
placement under the Vastus Medialis Obliquus (VMO) for
small incisions. The height and length of the Stylus remain
the same as the standard Stylus.

To assemble, the short arm on the left hand side should

be placed underneath the lowest collar which will sit flush
against the base allowing for the Stylus to be pushed
forward.

ATTUNE Knee INTUITION Standard Instrument size comparison

INTUITION™ Instruments • Surgical Technique 85

Appendix 2: Optional Minimally Invasive
Instrument Technique

MI Distal Femur Cutting Block MI Divergent

The MI Distal Femur Cutting Block is smaller by 12 mm in Pin Holes
Pin Holes +2, 0, -2
the M/L (medial/lateral) and 6 mm in the A/P (anterior/
posterior) dimension as compared to the standard Distal
Femur Cutting Block. The clusters of 3 pin holes are 2
mm closer in M/L and therefore, these two Blocks are not
interchangeable.

Divergent pin holes are located above and inside the

cluster of 3 pin holes.

■ INFORMATION 6 mm 6 mm

Note that due to the close proximity of the holes, the Pin
Jack head may interfere with the pins.

SIGMA™ High Performance Instrument

Knee System MI Angel Wing
The main features of the MI Angel Wing include a
reduced length by 20 mm and a geometric profile for
ease of use including an increased width and angle of
curvature.

ATTUNE Knee INTUITION Standard Instrument size comparison

86 Surgical Technique • INTUITION™ Instruments

Appendix 2: Optional Minimally Invasive
Instrument Technique

MI Tibial Drill Tower

The height is the same for both towers allowing for the
same Drill to be used as well as the Drill Stops. The M/L
width has been reduced by 9 mm (matching the width
of the Size 1 Tibial Tray) as compared to the standard
INTUITION Instrument Tibial Drill Tower and the
posterior wall thickness has also been reduced by
1.5 mm. The MI Tibial Drill Tower accepts sizes 1-5 Keel
Punches only.

4.5 mm
1.5 mm

ATTUNE Knee INTUITION Standard Instrument size comparison

INTUITION™ Instruments • Surgical Technique 87

Appendix 2: Optional Minimally Invasive
Instrument Technique

ATTUNE MI Spacer Block

ATTUNE MI Spacer Base
ATTUNE MI CR Flexion Base
The MI Spacer Block has an offset handle to allow
surgeons to avoid patella tendon impingement and allow
better access to the joint space. With the offset handle,
this device allows for medial or lateral access. The overall
length has been reduced by 18 mm.

The MI Spacer Block should be used with Shim sizes

3-4. The material is stainless steel to maintain rigid
properties. There are two holes to accept the Alignment
Rod. Both ends are modular unlike the standard Spacer
Blocks allowing for more flexibility. One base for CR
Extension/PS Flexion Extension and one base for CR
Flexion is available.

ATTUNE Knee INTUITION Standard Instrument size comparison

88 Surgical Technique • INTUITION™ Instruments

Appendix 2: Optional Minimally Invasive
Instrument Technique

SIGMA High Performance Instrument

Lastly, when pinning the MI Tibial Cutting Blocks in place,
0 Degree Left/Right MI Tibial the medial pin should be inserted first and the lateral pin
Cutting Blocks second. If a pin was placed in the vertical slot, it should
be removed before inserting the lateral pin.
The block geometry has been optimized to complete
cuts while avoiding patella impingement.

The Cutting Blocks contain a convergent pin hole to

prevent lift-off during cutting and an anatomic reference
line to ensure correct alignment on the tibial tubercle.

The Cutting Blocks can be used with an extra medullary

(EM) approach, have +2/-2 mm adjustability, and a vertical
pin slot to lock down the Varus/Valgus angle.

It is important to note that the pin holes on these Blocks are

different than the other INTUITION Instruments and SIGMA
High Performance Instrument Tibial Blocks. The pin holes on
the MI Tibial Cutting Blocks are positioned more medially
and perpendicular to the angled tibial bone surface (see
Image 2 below). This medialization allows the Block to be Image 1
used in very small incisions.In Image 1, the Alignment Handle ATTUNE Standard Block
and Alignment Rod can be used for alignment. However,
because of the medial orientation of the MI Cutting Block in
Image 2, the Alignment Handle and Alignment Rod cannot
be used in conjunction with this Block.

When assessing alignment with the MI Cutting Blocks, the

medial third of the tibial tubercle should be referenced
using the line on top of the Block. This, along with the
alignment features on the Tibial Jig, will provide the
necessary points of reference to precisely align the Block.

It is also important to remember that the MI Tibial Cutting

Blocks will not work with the SIGMA High Performance
Instrument IM Tibial Jig nor the SIGMA HP Knee System
Spiked Uprod. The reason for this is due to the position of
the lateral pin holes. The lateral pin holes will be covered
up by the HP Spiked Uprod and HP IM Tibial Jig Image 2
assembly, making pinning impossible on the lateral side. SIGMA High Performance Instrument MI Block

ATTUNE Knee INTUITION Standard Instrument size comparison

INTUITION™ Instruments • Surgical Technique 89

Appendix 3: Optional Lamina Spreader Technique

The following technique describes the use of Lamina

Spreaders to assess soft tissue balance, femoral sizing,
and setting femoral rotation using the ATTUNE Knee
System INTUITION Instruments.

Extension Space Balancing

After the distal femoral and proximal tibia resections are
made, consider removing prominent osteophytes,
particularly medial and lateral osteophytes, as they can
affect soft tissue balancing. Use the Spacer Block or
Lamina Spreaders medially and laterally to assess a
rectangular gap in extension. The Spacer Block can be
used to determine the appropriate thickness of the tibial
insert in extension. Introduce the Alignment Rod through
the Spacer Block in order to assess alignment.

If the alignment is correct and medial or lateral tightness

remains after removal of osteophytes, selective releases
can be performed at this time if the surgeon chooses.

Flexion Space Balancing

Lamina Spreaders may be used with the knee flexed to
90 degrees to set the femoral rotation in flexion.

Lamina
Spreader

90 Surgical Technique • INTUITION™ Instruments

Appendix 3: Optional Lamina Spreader Technique

Marking the Bone

There are three ways to mark the femur to orient the femoral rotation.

Parallel to the Tibia Tibial Jig Tibial Cutting Guide

Option 1: Option 2: Option 3:

With appropriate tension placed on The Tibial Cutting Guide can be A perpendicular line can be drawn
the medial and lateral soft tissues, a extended to reach the resected from the resected tibial surface by
transverse line that is parallel to the femoral bone surface as a guide to using the edge of an Osteotome or a
tibia can be marked across the distal mark a line parallel to the tibial General Medical Ruler.
femur a fixed distance from the resection surface.
resected tibial surface by using the
edge of an Osteotome or a General
Medical Ruler.

Whiteside's Line

As a secondary check, these lines can be compared

against key anatomical landmarks to avoid malrotation of Transepicondylar
the femoral component. Axis

INTUITION™ Instruments • Surgical Technique 91

Appendix 3: Optional Lamina Spreader Technique

Placing the Measured Sizer

The Measured Sizing and Rotation Guide is then placed
on the distal femur. The Measured Sizer allows placement
in 0, 3, 5, or 7 degrees of external femoral rotation based
on the posterior femoral condyles and can be adjusted on
the bone.

Dependent on the method chosen to mark the femur, the

Sizer can now be rotated so that the horizontal
(the white line between the posterior reference holes) or
vertical (the metal Uprod) lines on the Measured Sizer are
parallel to the horizontal or vertical lines previously drawn
on the femur.
Right Side Left Side

Squeeze the
lever and
simultaneously
rotate

Setting Rotation
Adjust the degree of external rotation by squeezing
the Femoral Rotation Lever and rotating the anterior
section while holding the feet of the device against the
posterior condyles.

Checks for excessive rotation can be made against

Whiteside’s line, the transepicondylar axis or the rotation
markings on the Measured Sizer.

Size the femur and insert the pins according to the

technique described in the main body of this surgical
technique.

92 Surgical Technique • INTUITION™ Instruments

Appendix 4: ATTUNE Tibial Insert Trials and Trial Handle

The ATTUNE Tibial Insert Trials and the ATTUNE Tibial

Insert Trials and Trial Handle shall be used in conjunction
with the INTUITION Instruments surgical technique for
trial reduction while implanting an ATTUNE Knee.

It is the surgeon’s choice to use the modular or one-piece PS Rotating Platform CR Rotating Platform
insert trials. ATTUNE Tibial Insert Trial variations are
shown on the right.

The ATTUNE Tibial Insert Trials are a solid construct

and will indicate the equivalent size and thickness of the
Tibial Insert Implant. The ATTUNE MS Tibial Insert Trial is
distinguished by its black background patch that contains PS Fixed Bearing CR Fixed Bearing
“MS”, trial size, and Left/Right designation.

MS Fixed Bearing

The ATTUNE MS FB Tibial Insert Trials are left and

right side specific, indicated by an “L” or “R” marked
adjacent to the size on the medial lip of the implant.
When trialing, the marking on the trial insert will be
immediately below the marking on the femoral trial,
indicating that the correct left or right match of the
component is being used.

Size and L/R Aligned Size and L/R Mis-Aligned

INTUITION™ Instruments • Surgical Technique 93

Appendix 4: ATTUNE Tibial Insert Trials and Trial Handle

The ATTUNE Trial Handle is an instrument that is

designed to work with the ATTUNE Tibial Insert Trials in
the trial reduction.

Select the ATTUNE Tibial Insert Trial that matches the

femoral size and style (CR or PS for either Rotating
Platform or Fixed Bearing), and the appropriate
thickness (5 mm, 6 mm, 7 mm, 8 mm, 10 mm, 12 mm,
14 mm and 16 mm for CR and PS, and in addition 18 mm
for PS, for core sizes 3 - 8).

Articulation Surface Indicators

Fixed Bearing
Rotating Platform

■ INFORMATION
Continue with trialing and the remainder of the
surgical work-flow as described in the main body of
this surgical technique.

94 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

The following technique describes the use of the ATTUNE

Revision Fixed Bearing (FB) Tibial Base, alone or with a 50
mm Cemented Stem following the Extramedullary Tibial
Resection described on page 19, for patients who might
need supplemental fixation. Pre-operative planning
templates are provided for these constructs and should be
used to confirm tibial baseplate size/position/slope relative
to stem position within the canal.

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 increase 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 Angled Pinning Parallel Pinning
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 Anterior Profile
to aid in fixating the Prep Plate. Tibial Prep Plates for Sizes
1 - 3 have an anterior protrusion with an indicated line for
the anterior profile of the definitive implant. Example of anterior protrusion for Sizes 1 - 3

▲ CAUTION
Care should be taken when seating the Pins so as not
to perforate the Tibial Cortex.
■ INFORMATION
■ INFORMATION The Revision Tibial Prep Plates are 6 mm thick and are
Final Tibial Base Rotation can also be determined during not reflective of the actual Tibial Base Implant or Tibial
trialing with the Femoral Trial and Revision Tibial Insert Base Trial thicknesses. The Prep Plates should not be
Trial in place. utilized to determine definitive Insert thickness.

INTUITION™ Instruments • Surgical Technique 95

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Tibial Preparation
With the Revision Tibial Prep Plate in place, attach the
Revision Tibial Prep Tower by inserting the spikes of the
Tower through the two inside holes on the anterior aspect
Revision Tibial
of the Plate.
Prep Tower

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.

■ INFORMATION
The Tibial Cemented Stem Reamer prepares for a line-
to-line fit with the pre-assembled End Cap or the
14 x 50 mm Cemented Stem Implant.

96 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Tibial Preparation
Assemble the Modular Stop on the Revision Tibial Assembly of
Cemented Stem Reamer to align with the “FB-0” mark for Modular Stop
the Revision Tibial Base alone or the “FB-50” mark when to Reamer
utilizing the 50 mm Cemented Stem. Once assembled,
advance the Reamer until the Modular Stop is flush with
the top of the Revision Cemented Reamer Bushing.

Revision Tibial
Cemented Stem Reamer

Modular Stop

Revision Cemented
Reamer Bushing

Revision Prep Tower

■ 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.

Modular Stop assembled to the Cemented Stem

Reamer at the FB with 50 mm Stem mark

INTUITION™ Instruments • Surgical Technique 97

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

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.

■ 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.

98 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Tibial Preparation
Assemble the corresponding 50 mm Stem Trial to the
end of the Revision Cemented Conical Reamer. If
preparing for a Revision Tibial Base without the Stem
FB Line
Extension utilize the Conical Reamer without the Stem
Trial. Assemble the Modular Stop to align with the “FB”
line on the Revision Cemented Conical Reamer.

To prepare for the conical section of the Revision Tibial

Base, advance the Conical Reamer through the Revision
Prep 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.

■ 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.

▲ CAUTION
Avoid contacting the sharp edges of the Reamer flutes
when attaching the Modular Stop.
Do not reverse ream.

INTUITION™ Instruments • Surgical Technique 99

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Straight Tibial Trial Assembly

Choose the appropriate size of Revision FB Base Trial
that corresponds to the Tibial Prep Plate and assemble
the Fixed Bearing Stem Adaptor Trial when utilizing the
50 mm stem or assemble the Fixed Bearing Adaptor
Tighten the construct using
Trial when a Stem Extension will not be utilized. Either
the Torque Limiting
adaptor should be assembled utilizing the temporary
Screwdriver and System
snap attachment.
Hex Attachment.

“click”

Assemble the Cemented Stem Trial to the

end of the FB Stem Adaptor Trial.
FB Base Trial construct
with a 14 x 50 mm
Cemented Stem Trial

If preparing for a Revision FB Tibial Base without the

Stem Extension, assemble the FB Adaptor Trial to the
appropriate FB Base Trial and tighten the construct
with the Torque Limiting Screwdriver Assembly. Seat
FB Base Trial with
the Revision Tibial Base Trial construct into the
FB Adaptor Trial
prepared bone.

■ INFORMATION ■ INFORMATION

DO NOT USE the ATTUNE Impaction Handle with the FB Adaptor Trial is utilized when the Revision FB Tibial
Revision Tibial Base Trial construct. Base will be implanted without the addition of the Stem
Extension.

100 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Keel 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 or ATTUNE Impaction Handle.

Revision Keel Punch

Impact the Revision Keel Punch into the cancellous bone

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

Remove any Pins prior to extracting the Trial Assemblies.

Revision
Tibial
Base Trial

■ INFORMATION
The Revision Tibial Base Trial will interface with all
ATTUNE CR and PS Knee (or System) INTUITION
Instrument Tibial Insert Trials.

INTUITION™ Instruments • Surgical Technique 101

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Revision FB Tibial Base and 14 x 50 mm Poly Plug

Cemented Stem Implant Assembly Remover

■ INFORMATION Tibial Straight

Stem Wrench
Note: The protective covering should be retained on
the Tibial Base during Assembly and Seating of the
Tibial Base. FB End Cap Remover

If utilizing the Revision FB Tibial Base without the

50 mm Cemented Stem, retain the pre-assembled
End Cap on the Revision FB Base and proceed to
Tibial Base Cementing and Impaction.

Remove the End Cap from the Revision Tibial Base

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

Thread the 50 mm Cemented Stem Implant into the

Tibial Base until hand tight.

Stem Implant

102 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Revision FB Tibial Base and 14 x 50 mm

Stem
Cemented Stem Implant Assembly Wrench
Implant Assembly Wrench
Assemble the Assembly Wrench Adaptor to the Implant
Assembly Wrench with the Stem Wrench facing
outwards.

Assembly
Wrench
Adaptor

Place the Tibial Straight Stem Wrench over the Keels of

the Revision Tibial Base Implant.

INTUITION™ Instruments • Surgical Technique 103

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Revision FB Tibial Base and 14 x 50 mm

Cemented Stem Implant Assembly
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 an angle
of approximately 90 degrees between the Implant Implant Assembly
Assembly Wrench and Tibial Straight Stem Wrench. This Wrench
will make it easier to apply the desired torque.

Gradually bring hands together to rotate the Implant

es
Assembly Wrench until the marker is within the torque 9 0 de gre
range marking.
Tibial Straight
Stem Wrench

Torque
Range
Marking

▲ CAUTION
Do not apply so much torque that the marker fully
passes the torque range marking.

104 Surgical Technique • INTUITION™ Instruments

Appendix 5: Revision Fixed Bearing (FB) Tibial Base

Preparation and Seating the Tibial

Construct
Consider the use of a cement restrictor.

Apply a thick layer of cement to the bone, the implant

surface or to both.

Cemented
It is critical to ensure that cement fully surrounds the cone
Stem
of the Revision FB Tibial Base Implant and the Cemented
Stem (if applicable). For additional reference see the
Guidance for Cementing Primary Total Knee
Replacements document.

Carefully insert the Revision Tibial Base Implant using the

ATTUNE System Impactor, avoiding malrotation.
ATTUNE System
Per the illustration above, the tibial base implant should be Impactor
directly impacted to the bone prior to mating with the
polyethylene tibial insert as shown in the Tibial Insert
Implantation section (page 78). The polyethylene tibial
insert should not be attached to the tibial base prior to
tibial base implantation. Impact to seat the Revision Tibial
Base Implant and to pressurize the cement. Then use a
Curette to remove all extruded cement.

▲ CAUTION
To prevent damage to the bearing surface, do not
remove the Base Protector before impacting the Base.
Care must be taken not to pull cement from under the ■ INFORMATION
edge of the implant in order to ensure the edges The ATTUNE Revision FB Tibial Base is compatible with
remain sealed. both CR and PS ATTUNE FB Primary Tibial Inserts.

INTUITION™ Instruments • Surgical Technique 105

Appendix 6: Optional Balancing Block Technique

The following technique describes the use of the INTUITION

Instrument Balancing Blocks as an alternative method to
assess soft tissue balance in flexion.

Balancing Blocks can be used after proximal tibial resection

(as described on pages 18 - 24), Distal Femoral Resection
(pages 11 - 17), Femoral Sizing (pages 28 - 42), and Extension
Gap Balancing (pages 25 - 26) have been completed.

IM Rod Knob

Stylus

Handles (optional)

Balancing Block
(Sz 3 - 10)

Pivot

Femoral Positioner (CR or PS)

Handles (optional)

Shims (5 - 8, 10, 12, 14, 16 mm)

■ INFORMATION ▲ CAUTION
Additional Shims from the Revision Kit (18 mm and When drilling the IM hole, ensure that you do not use
20 mm) can be used if required. the stepped portion of the Step Drill.

106 Surgical Technique • INTUITION™ Instruments

Appendix 6: Optional Balancing Block Technique

Femoral Positioning and Rotation

+1.5 mm Hole

Center Line Hole

-1.5 mm Hole

Anterior Down Saw Slots

Referencing Pin Holes

Posterior Up
Referencing Pin Holes

Narrow Size
Reference Cutout
The cutout indicates the
width of the narrow size
of implants

■ INFORMATION
The ATTUNE Knee System femoral components increase in size
by a consistent 3 mm in the A/P direction. The A/P Chamfer
Blocks allow the surgeon to adjust the A/P position of the femoral
component by 1.5 mm in either direction.
This creates the intra-operative flexibility to position the femoral
component based on the surgeon’s assessment of the flexion
gap and the desired posterior condylar offset. See page 25 for
more information on gap balancing.
If there is no cutout, a narrow component is not available for that
size. Narrow components are available for sizes 3, 4, 5 and 6.

INTUITION™ Instruments • Surgical Technique 107

Appendix 6: Optional Balancing Block Technique

Balancing Block Assembly

Order of Assembly:
1. P
 lace the Knob between the anterior horns of the
Balancing Block. Place hand behind the Knob to prevent
it from sliding off the Block.

2. Insert the Pivot through the bottom of the Block, tilting

the construct slightly to allow the Pivot to slide
upwards. Maintain the slightly tilted orientation in order
to prevent the Pivot from sliding out of the Block.

3. Insert the IM Rod through the exposed Pivot and turn

the Knob clockwise. The IM Rod prevents the Pivot
from free-spinning, allowing the Pivot and Knob
threads to engage.

4. Adjust the initial location of the Pivot to the desired

height.

Pivot

108 Surgical Technique • INTUITION™ Instruments

Appendix 6: Optional Balancing Block Technique

Use the INTUITION Instrument Measured Sizer to

measure the resected distal femur (as described on page
28), allowing the surgeon to select the appropriate size
Balancing Block to load onto the bone.

Select the Balancing Block that matches the femur size

indicated by the Measured Sizer. Insert the IM Rod
through the Pivot, ensuring placement through the front
face. The IM Rod has a collar to prevent it from passing
through and into the IM canal.

Prior to loading on to the bone, adjust the IM Rod height

by rotating the Knob until the IM Rod approximately
aligns with the markings on the Balancing Block. This
position provides a starting point from which the Block
can be adjusted anteriorly or posteriorly by approximately
4.5 mm to achieve the desired ligament tension. Please
note that changing the A/P position of the Balancing
Block will affect the amount of bone resected.

Markings

INTUITION™ Instruments • Surgical Technique 109

Appendix 6: Optional Balancing Block Technique

Insert the Block and IM Rod assembly in to the IM canal,

ensuring that the Block sits flush with the distal femur.
The rotating Pivot provides the ability for the Block to
rotate about the IM Rod and seat flush on the distal cut
for the selected varus/valgus angle as allowed by the
Distal Femoral Jig.

Insert the Stylus through the anterior cutting slot of the

Balancing Block, ensuring the Stylus is placed on the
lateral side. Slide the Stylus to adjust the superior-inferior
position and position it so that it comes into contact with
the highest point of the anterior femur. Check that the
Stylus indicates the same size of the Balancing Block
using the Stylus scale. The position of the Stylus tip will
indicate the approximate exit point of the Saw Blade.

■ INFORMATION
The Stylus has a friction fit to keep it from sliding
unintentionally after placed in its desired position.
Also, it is important to note that the Stylus sizing is most
accurate when the Stylus foot is positioned straight into
the cut slot of the Block and the Stylus arm is positioned
straight out, not obliquely.

110 Surgical Technique • INTUITION™ Instruments

Appendix 6: Optional Balancing Block Technique

Internal/external rotation is determined with the knee at

90 degrees of flexion so that the posterior surface of the
Balancing Block is parallel to the resected tibial plateau.
Select the appropriate Shim thickness to match the
extension gap and assemble it to the CR or PS Femoral
Positioner as appropriate. Introduce the Femoral
Positioner and Shim into the joint space, engaging the
posterior slot of the Balancing Block.

The knee may need to be slightly flexed or extended until

the Femoral Positioner lies flat on the resected tibial
surface.

If Lamina Spreaders are preferred, these can be placed

and tensioned under the medial and lateral sides of the
Balancing Block.

Lamina Spreader

Alternatively, the Spacer Block can be used instead of the

Femoral Positioner and placed under the posterior edge
of the Balancing Block.

Spacer Block

INTUITION™ Instruments • Surgical Technique 111

Appendix 6: Optional Balancing Block Technique

Assess the A/P position of the Block after it is loaded

onto the distal femur. Anterior position can be assessed
either by inserting the Stylus or an Angel Wing through
the anterior cutting slot. Posterior resection can be
checked visually by observing the placement of the
posterior cutting surface relative to the posterior
condyles. The Block can also be used at this stage to
assess the M/L width of the implant size for both the
standard or narrow sizes.

■ INFORMATION
When using the anterior offset pin holes, changing the
size of the femoral component will alter the posterior
femoral condyle resection.
To evaluate femoral size adjustments without altering
the posterior femoral cut, place the A/P Chamfer Block
onto the anterior Universal Pins and insert two
additional pins through the posterior up holes on the
Block. Then remove the anterior reference pins. This
enables the femoral implant size to be adjusted without
altering the flexion gap.
Alternatively, the Block can be moved 1.5 mm up or
down (one hole location) to adjust the flexion gap, if
necessary.

112 Surgical Technique • INTUITION™ Instruments

Appendix 6: Optional Balancing Block Technique

Once the Balancing Block size is

finalized, tension and rotation can be
assessed. To assess the ligament
tension, hold the tibia firmly and
stress the leg both in a varus and
valgus direction to observe lift-off
between the Femoral Positioner/Shim
and the resected tibial surface. If the
ligament tension observed is not as
desired, an alternative Shim thickness
may be required.

■ INFORMATION
Alternatively, the optional Handles can be used to
stress the Balancing Block medially and laterally to
observe lift-off.

INTUITION™ Instruments • Surgical Technique 113

Appendix 6: Optional Balancing Block Technique

The knob on top of the Block can be turned clockwise to

move the Block posteriorly or put more tension on the
collateral ligaments. The knob can be turned
counter clockwise to move the Block anteriorly or put
less tension on the collateral ligaments. Please note how
this affects the anterior and posterior cut positions
relative to the femur. If desired, tibial alignment can also
be assessed by inserting the Alignment Rod through the
hole in the Femoral Positioner.

Conduct a final check of the anterior resection level with

the Angel Wing. All adjustments should be made prior to
pinning the Block.

Pin the Balancing Block to the distal femur through either

the neutral anterior or posterior pin holes, using
Threaded, Non-Headed or Universal Pins.

▲ CAUTION
If the Shim size is changed, it may no longer match
the extension gap and so the distal cut may need to
be reassessed.

114 Surgical Technique • INTUITION™ Instruments

Appendix 6: Optional Balancing Block Technique

Femoral Finishing
Secure the Block using Threaded Headed Pins through
the convergent pin holes and remove both the IM Rod
(using the IM Rod Handle - as used with the Balanced
Sizer, page 34) and the Femoral Positioner.

If desired, there is an option to add a Modular Saw

Capture to the Block through an attachment on the
posterior side.

Resection of the femur can then be carried out, as

described on pages 46 - 47 of this technique. The saw
slots have an internal angle that accommodates a steep
cut angle, facilitating completion of the cut. The
remaining steps of the workflow are consistent with the
core technique (page 48 onwards).

Vibration of the Saw Blade may cause the pivot knob to

rotate during sawing. An assistant may hold the knob in
place while sawing, or the knob and pivot can be
removed from the site if they do separate.

▲ CAUTION
It is recommended to complete the femoral cuts at a
steep angle to ensure that the central portion of the
bone, behind the central column in the Balancing Block,
is cleared.

INTUITION™ Instruments • Surgical Technique 115

Appendix 7: Optional All Poly Tibial
Components Technique

The following technique describes the use of the All Poly Tibial Components (CR & PS), following the extramedullary
Tibial Resection described on page 19. Pre-operative planning templates are provided for these implants and should be
used to confirm All Poly Tibial Component size/position/slope relative to the stem position within the canal.

CR All Poly PS All Poly

Tibial Component Tibial Component

The All Poly Tibial Component is compatible with respective CR/PS ATTUNE Femoral Implants. Unlike the modular
inserts, the All Poly Tibial Components have been designed to accommodate plus or minus 1 size of the respective
femoral component.

ATTUNE™ CR & PS All Poly Tibial Component ATTUNE™ ATTUNE™

Medialized Medialized
Anatomic Dome Patella
Patella
IMPLANT/SIZE

1 1 2 29 32 35 38 41
ATTUNE™ CR & PS Femoral
2 1 2 3 29 32 35 38 41
3/3N 2 3 4 29 32 35 38 41
4/4N 3 4 5 32 35 38 41
5/5N 4 5 6 32 35 38 41
6/6N 5 6 7 32 35 38 41
7 6 7 8 35 38 41
8 7 8 9 35 38 41
9 8 9 10 38 41
10 9 10 38 41
Example: The size 5 All Poly Tibial Component can accommodate a size 4,5 or 6 femoral component

116 Surgical Technique • INTUITION™ Instruments

Appendix 7: Optional All Poly Tibial
Components Technique

Trial Sizing Example: The trialing for the All Poly Tibial Component utilizes the existing modular Tibial Base Trials and
Tibial Insert Trials from the INUTITION Instruments Primary Instruments. The below diagram is an example of how to
utilize the modular trials to replicate a Monobloc All Poly Tibial Component using modular Tibial Base and Insert Trials
for the final construct configuration.

Size 5
Trial Femoral Component

Size 4 Size 5 Size 6

Trial Tibial Insert Trial Tibial Insert Trial Tibial Insert

Size 4 Size 5 Size 6

Trial Tibial Base Trial Tibial Base Trial Tibial Base
= = =
Size 5 Size 5 Size 5
Femoral Component Femoral Component Femoral Component

Size 4 All Poly Tibia Size 5 All Poly Tibia Size 6 All Poly Tibia

■ INFORMATION ▲ CAUTION
Alternatively, solid insert trials may be utilized for Insert Trials utilized for trial reduction MUST match the
trial reduction. tibial base to replicate final implant.

INTUITION™ Instruments • Surgical Technique 117

Appendix 7: Optional All Poly Tibial
Components Technique

Trial Reduction
Size and place the Tibial Base Trial on the resected tibia.

Ensure that the Tibial Base Trial is +/- 1 size of the

Femoral Trial.

FB Float
Evaluation Bullet
Insert the FB Evaluation Bullet into the Base Trial by hand. (Fixed Bearing)

Introduce the Trial Insert that identically matches the size

of the selected Tibial Base Trial.

Perform trial reduction and evaluation.

118 Surgical Technique • INTUITION™ Instruments

Appendix 7: Optional All Poly Tibial
Components Technique

Tibial Preparation

■ INFORMATION
Initial tibial preparation for All Poly Tibial Component
utilizes same instruments and procedures for the
modular Fixed Bearing ATTUNE Tibia described on
page 61.

Remove the Fixed Bearing Evaluation Bullet.

Attach the Primary Tibial Drill Tower to the Tibial Base

Trial by inserting the spikes through the Tibial Base Trial.

Use the Tibial Drill to ream the tibia to where the line
marked on the side of the drill aligns to the top surface of
the tower. Optionally, the Tibial Drill Stop can be used.

Optional Drill Stop

INTUITION™ Instruments • Surgical Technique 119

Appendix 7: Optional All Poly Tibial
Components Technique

▲ CAUTION
The proceeding steps commit to using an All Poly
Tibial Component. These steps prepare the Tibia to
accommodate the longer stem of the All Poly Tibial All Poly Tibia
Implant. Drill Bushing

Insert the appropriate size All Poly Tibia Drill Bushing into
the Tibial Drill Tower (available sizes 1-2, 3-5, 6-8, 9-10).

Use the All Poly Tibia Drill to ream the tibia until the
shoulder on the drill is flush with the top of the
All Poly Tibia Drill Bushing.

All Poly Tibia

Drill Shoulder

All Poly Tibia

Drill Bushing

All Poly Tibia Drill

120 Surgical Technique • INTUITION™ Instruments

Appendix 7: Optional All Poly Tibial
Components Technique

■ INFORMATION
The All Poly Tibial Component has the same Keel profile
and uses the same Keel Punch as the modular Fixed
Bearing ATTUNE Tibial Base Component.

Keel Punch Impaction Handle

Attach the correct size Keel Punch to the Impaction

Handle and insert the assembly into the Drill Tower.
Impact the assembly until the Keel Punch is seated flush
on the Tibial Base Trial.

If desired, perform a final trial reduction by introducing

the Tibial Trial Insert that identically matches the size of
the selected Tibial Base Trial and repeating the trial
evaluation.

INTUITION™ Instruments • Surgical Technique 121

Appendix 7: Optional All Poly Tibial
Components Technique

Cementing Technique
Cement final components per the ATTUNE Knee
Primary Technique (see page 73).

For additional information on cementing, please refer to

the “Guidance for Cementing Total Knee Replacements”
document.

Apply a thick layer of cement to the bone, the implant

surface or to both.

Insert the Tibial Component into the prepared tibia,

avoiding malrotation.

With the All Poly Tibial Component inserted, impact the

Tibial Component using the appropriately sized All Poly
Tibia Impactor with several blows from a mallet
(available sizes 1-2, 3-5, 6-8, 9-10).

All Poly Tibia

Impactor

Remove all extruded cement and allow cement to cure.

122 Surgical Technique • INTUITION™ Instruments

Appendix 7: Optional All Poly Tibial
Components Technique

All Poly Tibial Labeling and Trial Thickness

All Poly Tibial

All Poly Tibial
Trial Insert Tibial Base Labeling and
+ Implant
and Shim Thickness Trial Thickness Trial
Thickness
Thickness

Thickness - 5 mm Labeling Thickness - 5 mm

4 mm
5 mm

9 mm
5 mm + 4 mm 5 mm 9 mm

6 mm + 4 mm 6 mm 10 mm

7 mm + 4 mm 7 mm 11 mm

8 mm + 4 mm 8 mm 12 mm

10 mm + 4 mm 10 mm 14 mm

12 mm + 4 mm 12 mm 16 mm

INTUITION™ Instruments • Surgical Technique 123

Appendix 8: Optional INTUITION Essential
Instruments Technique

The following appendix describes the use of INTUITION Essential Instruments as an alternative Instruments
configuration to INTUITION Instruments.

Essential Instruments feature renewed Tray layouts but contain the same INTUITION Instruments within the Trays with
the exception of some components which were removed. This Appendix details out the key features of Essential
Instruments and provides a list of the eliminated components which may be supplied separately if desired. Reference
the main body of the ATTUNE Knee System Surgical Technique for the information on related Surgical Steps.

Essential Cemented General Instruments

■ INFORMATION
INTUITION Essential Instruments can support different implant configurations and workflows (CR, PS,
Cemented, Cementless, Balanced or Measured Resections approach, VELYS™ Robotic-Assisted Solution). Each
configuration may feature different supporting Instruments Trays, which can be also configured differently
depending on the user preferences.

■ INFORMATION
The following steps should be followed from the ATTUNE Knee System Surgical Technique when using the Essential
Cemented General Instruments Tray:
• Extension Gap Assessment and Balancing, pages 25 - 26
• Measured Femoral Sizing and Rotation, pages 28 - 33
• Trial Components, pages 55 - 60
• Tibial Preparation, page 61 - 63

Eliminated Instruments

Instruments Tray Part Number Description

2544-01-005 ATTUNE Femoral Introducer
2544-01-342 ATTUNE FB Preparation Evaluation Bullet Size 1 - 10
2544-01-343 ATTUNE RP Preparation Evaluation Bullet Size 1 - 10
Tibial Prep and Impaction
2544-01-344 ATTUNE Posterior Pin
2544-01-345 ATTUNE Anterior Pin
2544-01-346 ATTUNE Low-Profile Tib Pin Puller
2545-00-060 ATTUNE Pin Jack
Shims and General Instruments
2545-00-065 ATTUNE Pin Impactor

124 Surgical Technique • INTUITION™ Instruments

Appendix 8: Optional INTUITION Essential
Instruments Technique

Essential Balanced Sizer

■ INFORMATION
Essential Balanced Sizer is provided in Half Tray layout and is ordered separately from Femoral Sizing and
Finishing Instruments if required.

■ INFORMATION
The following steps should be followed from the ATTUNE Knee System Surgical Technique when using the Essential
Balanced Sizer Tray:
• Balanced Femoral Sizing and Rotation, pages 34 - 42

Essential Femoral Prep (CR or PS, Size 3-8)

■ INFORMATION
Essential Femoral Prep features Size-Specific Half Tray layout which works universally with CR and PS Femoral
Trials and Femoral Finishing Instruments.
Note that 18 mm and 20 mm Shims have been excluded from Essential Femoral Prep Tray.
Essential Femoral Prep Tray features optional space for a Pin Driver. The Pin Driver can be alternatively supplied in
the Essential Cemented General Instruments Tray or Essential Cemented Tibial Prep & Impaction for VELYS™
Robotic-Assisted Solution depending on the preferred instruments configuration.

■ INFORMATION
The following steps should be followed from the ATTUNE Knee System Surgical Technique when using the Essential
Femoral Prep Instruments Tray:
• Femoral Preparation, pages 43 - 47
• Posterior Condyle Preparation, pages 48 - 49
• Femoral Resection - PS Femoral Notch Cuts, pages 50 - 51
• Trial Reduction, pages 52 - 53
• Soft Tissue Considerations for Cruciate Retaining Application, page 54
• Trial Components, pages 55 - 60

INTUITION™ Instruments • Surgical Technique 125

Appendix 8: Optional INTUITION Essential
Instruments Technique

Essential Cemented Patella Prep

■ INFORMATION
Essential Cemented Patella Prep features Half Tray layout and eliminates a number of instruments. Full list of
Eliminated instruments is provided in the table below. Essential Cemented Patella Prep can be supplied with either
Dome or Anatomic Patella Trials and Drill Trials depending on the preferred instruments configuration.

■ INFORMATION
The following steps should be followed from the ATTUNE Knee System Surgical Technique when using the Essential
Cemented Patella Prep Tray:
• Patella Resection, pages 66 - 67
• Patella Preparation, pages 68 - 70
• Lug Hole Preparation, page 71 - 72
• Final Patella Preparation, page 81
• Patella Component Implantation, page 82

Eliminated Instruments

Instruments Tray Part Number Description

2545-01-040 ATTUNE Patella Resection Guide
Patella Preparation
2545-01-054 ATTUNE Patella Resection Guide Shim

126 Surgical Technique • INTUITION™ Instruments

Appendix 8: Optional INTUITION Essential
Instruments Technique

Essential Cemented Tibial Prep & Impaction for

VELYS™ Robotic-Assisted Solution
■ INFORMATION
Essential Cemented General Instruments Tray eliminates a number of Instruments. Full list is provided in the table
below.

■ INFORMATION
The following steps should be followed from the ATTUNE Knee System Surgical Technique when using the Essential
Cemented Tibial Prep & Impaction for VELYS™ Robotic - Assisted Solution Instruments Tray:
• Trial Components, pages 55 - 60
• Tibial Preparation, pages 61 - 63

Eliminated Instruments

Instruments Tray Part Number Description

2544-01-005 ATTUNE Femoral Introducer
2544-01-344 ATTUNE Posterior Pin
Tibial Prep and Impaction 2544-01-345 ATTUNE Anterior Pin
2544-01-346 ATTUNE Low-Profile Tib Pin Puller
2544-01-009 ATTUNE FB Insert Impactor

INTUITION™ Instruments • Surgical Technique 127

Flexion/Extension Gap Chart

Loose Extension Tight Extension Stable Extension

Cause: Cause: Cause:

Flexion and extension gaps are too Flexion gap is larger than the Flexion gap is larger than extension
large extension gap gap
Loose Flexion

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

• Thicker tibial insert • Posterior capsular release • Decrease the tibial slope and
• Recut distal femur and use use a thicker tibial insert
thicker insert • Recut the distal femur and use a
• Posteriorize the femoral thicker tibial insert
component by 1.5 mm • Larger femoral component
• Posteriorize the femoral
component by 1.5 mm
Cause: Cause: Cause:
Extension gap is larger than flexion Flexion and extension gaps are too Flexion gap is too small
gap small
Possible Solution(s):
Tight Flexion

Possible Solution(s): Possible Solution(s): • Check for osteophytes

• Check for osteophytes • Thinner tibial insert • Downsize femoral component
• Downsize femoral component • Resect additional tibia • Anteriorize the femoral
and use thicker insert component by 1.5 mm
• Increase tibial slope • Increase tibial slope
• Recess PCL off of femur or tibia • Recess PCL off of femur or tibia

Cause: Cause: Cause:

Extension gap is too large Extension gap is too small Balanced gaps
Stable Flexion

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

• Downsize femoral component • Posterior capsular release • No solution required
and increase insert thickness • Recut distal femur
• Increase tibial slope and use • Larger femoral component and
thicker tibial insert thinner insert

128 Surgical Technique • INTUITION™ Instruments

Modular Tibial Component Sizing Chart

Trial Insert Tibial Tibial Implant Construct

+ =
and Shim Thickness Insert Thickness Base Thickness Thickness

10 mm
6 mm

6 mm

4 mm

Shim Thickness and

Final Insert Thickness are equal

5 mm 5 mm + 4 mm = 9 mm
6 mm 6 mm + 4 mm = 10 mm
7 mm 7 mm + 4 mm = 11 mm
8 mm 8 mm + 4 mm = 12 mm
10 mm 10 mm + 4 mm = 14 mm
12 mm 12 mm + 4 mm = 16 mm
14 mm 14 mm + 4 mm = 18 mm
16 mm 16 mm + 4 mm = 20 mm

18 mm (PS only) 18 mm (PS only) + 4 mm = 22 mm (PS only)

20 mm (PS only) 20 mm (PS only) + 4 mm = 24 mm (PS only)

Thickness dimensions are all the same, whether using Cruciate Retaining (CR), Posterior Stabilized (PS) or Rotating
Platform or Fixed Bearing combinations.

INTUITION™ Instruments • Surgical Technique 129

Compatibility Data

Modular Compatibility
ATTUNE™ ATTUNE™ ATTUNE™ ATTUNE™ FB & RP Tibial Base ATTUNE™ ATTUNE™
CR & PS CR, PS, and CR & PS RP Medialized Medialized
Femoral Medial Tibial Insert Anatomic Dome Patella
Stabilized FB Patella
SIZE Tibial Insert
SZ

Pink 1 1 1 1 2 3 29 32 35 38 41
Dark Blue 2 2 2 1 2 3 4 29 32 35 38 41
Grey 3/3N 3 3 1 2 3 4 5 29 32 35 38 41
Black 4/4N 4 4 2 3 4 5 6 32 35 38 41
Green 5/5N 5 5 3 4 5 6 7 32 35 38 41
Yellow 6/6N 6 6 4 5 6 7 8 32 35 38 41
Light Blue 7 7 7 5 6 7 8 9 35 38 41
Red 8 8 8 6 7 8 9 10 35 38 41
Purple 9 9 9 7 8 9 10 38 41
Brown 10 10 10 8 9 10 38 41
Ref. Number: 103262475

All Poly Tibial Compatibility

ATTUNE™ CR & PS All Poly Tibial Component ATTUNE™ ATTUNE™
Medialized Medialized
Anatomic Dome Patella
Patella
IMPLANT/SIZE

1 1 2 29 32 35 38 41
ATTUNE™ CR & PS Femoral
2 1 2 3 29 32 35 38 41
3/3N 2 3 4 29 32 35 38 41
4/4N 3 4 5 32 35 38 41
5/5N 4 5 6 32 35 38 41
6/6N 5 6 7 32 35 38 41
7 6 7 8 35 38 41
8 7 8 9 35 38 41
9 8 9 10 38 41
10 9 10 38 41

130 Surgical Technique • INTUITION™ Instruments

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 or Text Definition Symbol or Text Definition

Cleaning position here L Lateral (for Patella Trials)

Dismantle for cleaning M Medial (for Patella Trials)

Unlock LL Left Lateral

Lock RL Right Lateral

L Left SULCUS Sulcus

R Right FLEXION Flexion

LEFT Left EXTENSION Extension

RIGHT Right SZ Size

ATTUNE Knee Cruciate

CR TIB Tibia
Retaining Implant

ATTUNE Knee Posterior

PS ! Caution
Stabilized Implant

RP Rotating Platform DEG Degrees

Cemented/Press-fit
FB Fixed Bearing
Stem Assembly Icon

INTUITION™ Instruments • Surgical Technique 131

Essential Product Information

ATTUNE™ KNEE SYSTEM – FIXED BEARING KNEE

IMPORTANT NOTE: DePuy’s Single Use devices have not been designed to undergo or withstand any form
of alteration, such as disassembly, cleaning or re-sterilization, after a single patient use. Reuse
This Essential Product Information sheet does not include all of the information necessary can potentially compromise device performance and patient safety.
for selection and use of a device. Please see full labeling for all necessary information.

CAUTION: The following conditions, singularly or concurrently, tend to impose severe

INTENDED USE loading on the affected extremity thereby placing the patient at higher risk of failure of the
Total knee arthroplasty is intended to provide increased patient mobility and reduced pain knee replacement:
by replacing the damaged knee joint articulation in patients where there is evidence of 1. Obesity or excessive patient weight.
sufficient sound bone to seat and support the components. Total knee replacement may be 2. Manual labor.
considered for younger patients if, in the opinion of the surgeon, an unequivocal indication 3. Active sports participation.
for total knee replacement outweighs the risks associated with the age of the patient, and
if limited demands regarding activity and knee joint loading can be assured. This includes 4. High levels of patient activity.
severely crippled patients with multiple joint involvement for whom a gain in knee mobility 5. Likelihood of falls.
may lead to an expectation of significant improvement in the quality of their lives. 6. Alcohol or drug addiction.
7. Other disabilities, as appropriate.
INDICATIONS
Candidates for total knee replacement include patients with a severely painful and/or In addition to the above, the following physical conditions, singularly or concurrently, tend
severely disabled joint resulting from osteoarthritis, post-traumatic arthritis, rheumatoid to adversely affect the fixation of knee replacement implants:
arthritis, or a failed previous implant. 1. Marked osteoporosis or poor bone stock.
2. Metabolic disorders or systemic pharmacological treatments leading to progressive
CONTRAINDICATIONS deterioration of solid bone support for the implant (e.g., diabetes mellitus, steroid
therapies, immunosuppressive therapies, etc.).
The following conditions are contraindications for total knee replacement: 3. History of general or local infections.
1. Active local or systemic infection. 4. Severe deformities leading to impaired fixation or improper positioning of the implant.
2. Loss of bone or musculature, osteoporosis, neuromuscular compromise or vascular 5. Tumors of the supporting bone structures.
deficiency in the affected limb in sufficient degree to render the procedure 6. Allergic reactions to implant materials (e.g. bone cement, metal, polyethylene).
unjustifiable (e.g., absence of musculoligamentous supporting structures, joint
neuropathy). 7. Tissue reactions to implant corrosion or implant wear debris.
3. Severe instability secondary to advanced loss of osteochondral structure or the 8. Disabilities of other joints (i.e., hips or ankles).
absence of collateral ligament integrity. A higher incidence of implant failure has been reported in paraplegics and in patients with
cerebral palsy or Parkinson’s Disease.
NOTE: Diabetes, at present, has not been established as a contraindication. However,
because of the increased risk for complications such as infection, slow wound healing, etc., When the surgeon determines that knee replacement is the best medical option available
the physician should carefully consider the advisability of knee replacement in the severely and decides to use this prosthesis in a patient who has any of the above conditions or who
diabetic patient. is simply young and active, it is imperative that the patient be instructed about the strength
limitations of the materials used in the device and for fixation and the resultant need to
substantially reduce or eliminate any of the above conditions.
WARNINGS AND PRECAUTIONS
The surgical and postoperative management of the patient must be carried out with due
CAUTION: consideration for all existing conditions. Mental attitudes or disorders resulting in a patient’s
• ATTUNE™ CR Tibial Insert size should be the same size as the selected ATTUNE CR failure to adhere to the surgeon’s orders may delay postoperative recovery and/or increase
Femoral Component size. ATTUNE CR Tibial Inserts should be within 2 sizes of the the risk of adverse effects including implant or implant fixation failure.
ATTUNE Tibial Base. Excessive physical activity or trauma to the replaced joint may contribute to premature
• ATTUNE PS Tibial Insert size should be the same size as the selected ATTUNE PS failure of the knee replacement by causing a change in position, fracture, and/or wear of
Femoral Component size. ATTUNE PS Tibial Insert should be within 2 sizes of the the implants. The functional life expectancy of prosthetic knee implants is, at present, not
ATTUNE Tibial Base. clearly established. The patient should be informed that factors such as weight and activity
• ATTUNE CR All Polyethylene Tibia sizes must be within 1 size of the selected ATTUNE levels may significantly affect wear.
CR Femoral Component size.
• ATTUNE PS All Polyethylene Tibia sizes must be within 1 size of the selected ATTUNE
MRI SAFETY INFORMATION
PS Femoral Component size.
• ATTUNE Patella Component: The ATTUNE Fixed Bearing Knee System has not been tested for safety and compatibility in
– Sizes 38mm and 41mm may be used with all femoral component sizes. the MR environment. The devices have not been tested for heating or migration in the MR
– Size 29mm may only be used with femoral component sizes 1 through 3. environment. Scanning a patient who has this device may result in patient injury.
– Size 32mm may only be used with femoral component sizes 1 through 6. The risks associated with other passive implants in an MR environment have been evaluated
– Size 35mm may only be used with femoral component sizes 1 through 8. and are known to include heating, migration, and image artifacts at or near the implant site.
• Implants and trial components from different manufacturers or implant systems should
never be used together.
• Knee prosthesis components should never be reimplanted. Even though the implant
appears undamaged, the implant may have developed microscopic imperfections which
could lead to failure.
• Always use a trial prosthesis for trial purposes. Trials should not be assembled with
any components intended for permanent implantation. Trials must have the same
configuration size, as the corresponding components to be permanently implanted.
• Do not alter or modify implants in any way.
• Avoid drilling multiple pin holes in the proximal tibia which may affect the compressive
strength of the tibia.

132 Surgical Technique • INTUITION™ Instruments

Essential Product Information

ATTUNE™ KNEE SYSTEM – ROTATING PLATFORM

IMPORTANT WARNINGS AND PRECAUTIONS
• The correct selection as well as the correct seating/placement of the prosthetic implant is
This Essential Product Information sheet does not include all of the information necessary for
extremely important. During surgery, particular attention to tracking of the patella is also
selection and use of a device. Please see full labeling for all necessary information.
required for a successful result. Thus, failure to use the optimum size implant, failure to
adequately seat the component adjacent to adequate bone and failure to ensure that the
component is stable may result in dislocation, subsidence, fracture, suboptimal extensor
INTENDED USE
mechanism function, or loosening of the components. The proper size selection, the choice
Total knee arthroplasty is intended to provide increased patient mobility and reduced pain by of and careful use of the components and the use of trial prostheses are imperative.
replacing the damaged knee joint articulation in patients where there is evidence of sufficient • The ATTUNE CR or PS RP Tibial Insert should be the same size as the selected ATTUNE
sound bone to seat and support the components. Total knee replacement may be considered CR or PS Femoral Component. The ATTUNE CR or PS RP Tibial Inserts articulate with the
for younger patients if, in the opinion of the surgeon, an unequivocal indication for total knee ATTUNE RP Tibial Bases. ATTUNE CR or PS RP Tibial Inserts should be within 2 sizes of
replacement outweighs the risks associated with the age of the patient, and if limited demands the RP Tibial Base.
regarding activity and knee joint loading can be assured. This includes severely crippled • ATTUNE RP Total Knee components, instruments and trial prostheses should not be used
patients with multiple joint involvement for whom a gain in knee mobility may lead to an together with those of another manufacturer. Because dimensional compatibility cannot
expectation of significant improvement in the quality of their lives. be assured, adverse outcomes can result from the use of components from different
manufacturers.
• A postoperative management program is vital. It is recommended that the program
INDICATIONS be modified according to the condition of the patient and the extent of soft tissue and
ligament reconstruction.
The Rotating Platform (RP) Total Knee System is indicated for cemented use in cases of
osteoarthritis and rheumatoid arthritis. The rotating platform prosthesis is indicated for primary • The safety and effectiveness of the cemented use of the RP Total Knee in patients under 41
total knee arthroplasty or the revision of failed knee prostheses. years of age have not been established.
• The implantation of the RP tibial insert and femoral component will not in itself guarantee a
The CR RP device configuration is indicated for use in knees whose posterior cruciate ligament high level of post-operative flexion. The degree of post-operative flexion is multi-factorial.
is intact, absent, or in such condition as to justify its sacrifice. These factors include, but are not limited to, surgical technique, patient build, pre-operative
flexion and age.

CONTRAINDICATIONS
NOTE: DePuy’s Single Use devices have not been designed to undergo or withstand any form
The use of the RP Total Knee System is contraindicated in: of alteration, such as disassembly, cleaning or re-sterilization, after a single patient use. Reuse
can potentially compromise device performance and patient safety.
• the presence of osteomyelitis, pyrogenic infection or other overt infection of the knee joint.
Every effort should be made to rule out the possibility of preoperative sepsis in a patient
who has one or more of the following abnormalities: MRI SAFETY INFORMATION
• fever or local inflammation;
The ATTUNE Rotating Platform Knee System has not been tested for safety and compatibility
• rapid destruction or bone resorption apparent on x-rays; in the MR environment. The devices have not been tested for heating or migration in the MR
• elevation of the erythrocyte sedimentation rate or white blood cell count unexplained environment. Scanning a patient who has this device may result in patient injury.
by other disease or a marked shift in the white blood cell
differential count. The risks associated with other passive implants in an MR environment have been evaluated
• patients with any active infection at sites such as the genitourinary tract, pulmonary system, and are known to include heating, migration, and image artifacts at or near the implant site.
skin or any other site. Should a patient have any infection prior to implantation, the foci of
the infection must be treated prior to, during and after implantation.
PRECAUTIONS
• patients with loss of musculature or neuromuscular compromise leading to loss of function
in the involved limb or in whom the requirements for its use would affect recommended The surgeon should discuss all physical and psychological limitations inherent to the use of this
rehabilitation procedures. device with the patient pre-operatively. Particular discussion should be directed to the issues of
• patients with severe osteoporosis or other metabolic bone diseases of the knee; premature weight bearing, activity levels and the necessity for periodic medical follow-up.
• patients with any of the following conditions:
Surgeons should not begin the clinical use of any knee prosthesis before they have thoroughly
• lesions of the supporting bone structures (e.g. aneurysmal or simple bone cysts, giant
familiarized themselves with its specific implantation technique. Certain methods may change
cell tumor or any malignant tumor),
with time as further clinical experience is gained. Such changes are presented at regularly
• systemic and metabolic disorders leading to progressive deterioration of solid bone scheduled surgical instruction courses for which periodic attendance is advised. Surgical
support, technique brochures, course schedules, and course recordings are available from DePuy.
• the presence of severe instability secondary to advanced loss of osteochondral
structure or the absence of collateral ligament integrity, fixed deformities greater than Particular attention should be paid to the handling of the components.
60° of flexion, 45° of genu varus or valgus, (see HANDLING section for further information).
• known drug or alcohol addiction,
• skeletally immature individuals and the presence of allergic reaction to implant metals
or polyethylene are also contraindications for the use of all device configurations of the
RP Total Knee System.

INTUITION™ Instruments • Surgical Technique 133

134 Surgical Technique • INTUITION™ Instruments
INTUITION™ Instruments • Surgical Technique 135
References
1. S
 cott, R.D. & Chmell, M.J. (2008). Balancing the posterior cruciate ligament during cruciate retaining fixed and mobile-bearing total knee arthroplasty.
Description of the pull-out lift off and slide-back tests. The Journal of Arthroplasty, 23(4), 605-608.
2. S
 hepard, M.F., Kabo, J.M., Liebermann, J.R. (2000). Influence of cement technique on the interface strength of femoral components.
Clinical Orthopaedics and Related Research, Number 381, 26-35.
3. Jansson, V., Zimmer, M., Kühne, J. H., Ishida, A. (1993). Blood lamination in bone cement–effect of cementing technique. Der Unfallchirurg, 96 (7): 390-394.

Please also refer to the package insert(s) or other labeling associated with the devices identified in this surgical technique for additional information.
CAUTION: Federal Law restricts these devices to sale by or on the order of a physician.
Some devices listed in this surgical technique may not have been licensed in accordance with Canadian law and may not be for sale in Canada.
Please contact your sales consultant for items approved for sale in Canada.
Not all products may currently be available in all markets.

DePuy Orthopaedics, Inc. DePuy International, Ltd. DePuy Ireland UC

700 Orthopaedic Drive St Anthony’s Road Loughbeg, Ringaskiddy
Warsaw, IN 46582 Leeds LS11 8DT Co. Cork, Ireland
USA England Tel: +35 (321) 491 4000
Tel: +1 (800) 366-8143 Tel: +44 (0) 113 270 0461 Fax: +35 (321) 491 4199
Fax: +1 (800) 669-2530

www.depuysynthes.com

Please refer to the instructions for use for a complete list of indications, contraindications, warnings and precautions.
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© DePuy Synthes 2022. All rights reserved.
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