Abstract:
A method for aligning an orthopedic implant in a joint replacement includes determining the bone and cartilage deficiency from an undegenerated state caused by wear of a joint. Then a resection of a bone in the joint is made based on the deficiency of bone and cartilage from the undegenerated state and the size of a joint implant so as to locate the joint surface of the implant in the undegenerated cartilage location. The condylar wear from the undegenerated states may be assessed at a distal and posterior location on each of a medial and a lateral femoral condyle. A distal cut is made on the femur at a location adjusting for the condylar wear from the undegenerated state. The distal cut varus-valgus angle is oriented parallel to a plane across the distal femur after adjusting for wear in the distal location on the medial and lateral condyle.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
     The present application is a continuation of U.S. patent application Ser. No. 13/113,414, filed May 23, 2011, which claims the benefit of the filing date of U.S. Provisional Patent Application No. 61/347,045, filed May 21, 2010, the disclosures of which are hereby incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     Over time and through repeated use, bones and joints can become damaged or worn. For example, repetitive strain on bones and joints (e.g., through athletic activity), traumatic events, and certain diseases (e.g., arthritis) can cause cartilage in joint areas, which normally provides a cushioning effect, to wear down. When the cartilage wears down, fluid can accumulate in the joint areas, resulting in pain, stiffness, and decreased mobility. 
     Arthroplasty procedures can be used to repair damaged joints. During a typical arthroplasty procedure, an arthritic or otherwise dysfunctional joint can be remodeled or realigned, or an implant can be implanted into the damaged region. Arthroplasty procedures may take place in any of a number of different regions of the body, such as a knee, a hip, a shoulder, or an elbow. 
     One type of arthroplasty procedure is a total knee arthroplasty (“TKA”), in which a damaged knee joint is replaced with prosthetic implants. The knee joint may have been damaged by, for example, arthritis (e.g., severe osteoarthritis or degenerative arthritis), trauma, or a rare destructive joint disease. During a TKA procedure, a damaged portion in the distal region of the femur may be removed and replaced with a metal or ceramic femoral implant, and a damaged portion in the proximal region of the tibia may be removed and replaced with a tibial implant having an ultra high molecular weight polyethylene (UHMWPE) bearing. In some TKA procedures, a UHMWPE bearing may also be implanted on the posterior surface of the patella, depending on the condition of the patella. 
     Implants that are implanted into a damaged region may provide support and structure to the damaged region, and help to restore the damaged region, thereby enhancing its functionality. Prior to implantation of an implant in a damaged region, the damaged region may be prepared to receive the implant. For example, in a knee arthroplasty procedure, one or more of the bones in the knee area, such as the femur and/or the tibia, may be prepared (e.g., cut, drilled, milled, reamed), to provide one or more surfaces that can align with the implant and thereby accommodate the implant. 
     Accuracy in implant alignment is an important factor in the success of a TKA procedure. A one- to two-millimeter translational misalignment, or a one- to two-degree rotational misalignment, may result in imbalanced ligaments, and may thereby significantly affect the outcome of the TKA procedure. For example, implant misalignment may result in intolerable post-surgery pain, and also may prevent the patient from having full leg extension and stable leg flexion. 
     To achieve accurate implant alignment, prior to preparation (e.g., cutting, drilling, reaming, and/or milling) of a bone, it is important to correctly determine the location at which the preparation will take place and how the bone resections will be oriented. In most surgical methods, an arthroplasty jig is used to accurately position and orient bone resection instrumentation, such as a cutting, drilling, reaming, or milling instrument on bone. The arthroplasty jig may, for example, include one or more apertures and/or slots that are configured to accept and guide such a bone resection instrument. 
     Femoral and tibial preparation instruments for Total Knee Arthroplasty (TKA) are known in the art and conventionally reference the intermedullary (IM) canal or extramedullary (EM) features such as the long axis of the femur and tibia. As such, standard surgical techniques are designed to align the bone preparation to the mechanical axis or anatomic axis of the patient. Typical knee instruments are shown in U.S. Pat. Nos. 4,487,203, 5,037,423 and 6,558,391. 
     Preoperative assessment of bone loss is advantageous for prosthesis design, for example, to reduce the likelihood of prosthesis loosening and to provide a more reliable bone restoration method for preoperative implant design, thereby improving the success rate for such procedures such as total knee arthroplasty (TKA) and partial knee arthroplasty (e.g., a unicompartment knee arthroplasty) and providing a patient-specific bone restoration method to fit an individual patient&#39;s knee features. 
     The current available joint reconstruction and replacement surgeries, including knee, ankle, hip, shoulder or elbow arthroplasty, are mainly based on standard guidelines and methods for acceptable performance. Taking this into account, the positioning and orientation of the arthroplasty work on a joint is based on standard values for orientation relative to the biomechanical axes, such as flexion/extension, varus/valgus, and range of motion. 
     One of the surgical goals of joint replacement/reconstruction should be to achieve a certain alignment relative to a load axes. However, the conventional standards are based on static load analysis and therefore may not be able to provide an optimal joint functionality for adopting individual knee features of OA patients. The methods disclosed herein provide a natural approach for bone restoration, properly balancing the unconstrained joint and ligaments surrounding the joint, and resulting in a placement of a prosthetic implant that generally restores the patient&#39;s knee to a generally pre-degenerated state. 
     In one embodiment, the result of the bone restoration process disclosed herein is a TKA or partial knee arthroplasty procedure that generally returns the knee to its pre-degenerated state whether that pre-degenerated state is naturally varus, valgus or neutral. In other words, if the patient&#39;s knee was naturally varus, valgus or neutral prior to degenerating, the surgical procedure will result in a knee that is generally restored to that specific natural pre-degenerated alignment, as opposed to simply making the knee have an alignment that corresponds to the mechanical axis, as is the common focus and result of most, if not all, arthroplasty procedures known in the art. 
     While success has been reported for traditional instruments and mechanical alignment techniques, alternative alignment methods such as anatomic or “natural” alignment are being developed. The anatomic alignment method references a “natural” or pre-arthritic state of a specific patient&#39;s anatomy. These alternative methods require new instruments designed for referencing resected and un-resected aspects of the femur and tibia. Further, these new instruments will allow for preparation and final implant position in a pre-arthritic and anatomic orientation. The following disclosure describes various instrument embodiments designed to reference resected and un-resected aspects of femoral and tibial bone and to allow for alignment of bone preparation to an anatomic orientation. 
     BRIEF SUMMARY OF THE INVENTION 
     The goal of the present invention is to provide a method and instrumentation directed toward placing a total knee implant in a position which replicates the patient&#39;s pre-arthritic alignment. This philosophy is discussed in U.S. Patent Publication No. 2009/0270868, the disclosure of which is incorporated herein by reference. This reference teaches the use of patient specific cutting guides. The present invention utilizes modified conventional instruments to achieve the same result. Alternately the same instrumentation can be used in traditional methods such as mechanical axis alignment. One aspect of the invention includes providing an anatomic distal femoral resection guide alignment assembly with the ability to adjustably reference the unresected portion of the distal femur when setting the distal femoral resection guide level and varus-valgus orientation. Another aspect provides an alternate embodiment of an anatomic distal femoral resection guide alignment assembly that allows for both reference to the unresected portion of the distal femur and adjustable reference to the anterior cortex of the femoral shaft. Another aspect of the invention is the insertion of an extramedullary rod in the distal femoral cutting block to assist in orienting the flexion/extension angle of the distal femoral resection guide with respect to the anterior thigh and femur. Another aspect of the insertion is the provision of an anterior/posterior (AP) sizer with insertable variable feet which are inserted to compensate for femoral posterior wear. A posterior referencing guide can be provided with variable feet and/or shoes of varying thickness that can be placed on the feet to set the AP and internal/external rotation of the femoral implant. The feet may be rounded in the sagittal plane to better fit the tibial geometry. The AP sizer may be provided with variable thickness boots which are inserted to compensate for femoral posterior wear. 
     An additional aspect of the invention is the provision of a femoral referencing tibial resection alignment system that is designed to allow for reference of the prepared distal femoral bone and, through the use of femoral condyle spacing elements, to also reference the unresected tibial surface. Further, this system allows for visualization of a joint-line in a pre-arthritic or anatomic state. Specifically, the geometry is an offset of the articulating surface of the femoral component. Peg shape is such that it does not destroy the full diameter of the hole to gain fixation during instrument use but does not ruin the full hole for implant preparation. Yet an additional aspect of the invention is the provision of an adjustable slope tibial resection guide with a conical hole that allows for degrees of tibial slope adjustability with a single fixation pin placement. A tibial cutting guide assembly that references the prepared tibial bone and has referencing members that allow for correction/refinement of the tibial cut. Refinements may include tibial slope, varus alignment, valgus alignment or any combination of those mentioned. The tibial guide has markings which indicate the implant size for proper positioning of the guide. 
     Another aspect of the invention is a method for aligning an orthopedic implant in a joint replacement which includes determining the bone and cartilage deficiency from an undegenerated state caused by wear of a joint. A resection of a bone is made in the joint based on the deficiency of bone and cartilage from the undegenerated state and the size of a joint implant. The resection is located to place the joint surface of the implant in the undegenerated cartilage location. If the joint is a knee joint the femoral condylar wear from the undegenerated state is assessed at a distal and posterior location on each of a medial and a lateral femoral condyles. The distal cut is then made on the femur adjusting for the condylar wear from the undegenerated state. The femoral distal cut varus-valgus angle is oriented parallel to the distal femur after adjusting for wear in the distal location on the medial and lateral condyle. Thus, when implanted, the joint very closely approximates the patient&#39;s undegenerated knee, and the transverse axis in the femoral implant is naturally aligned with the transverse axis in the femur about which the tibia flexes and extends on the femur. 
     Another aspect of the invention is a method for aligning an orthopedic implant in a joint replacement including determining the bone and cartilage deficiency from an undegenerated state caused by wear of a joint. A resection of a bone in the joint is based on the deficiency of bone and cartilage from the undegenerated state and the size of a joint implant so as to locate the joint surface of the implant in the undegenerated cartilage location. The method includes assessing the condylar wear from the undegenerated states at a distal and posterior location on each of a medial and a lateral femoral condyle. The distal cut is made on the femur at a location adjusting for the condylar wear from the undegenerated state. The distal cut varus-valgus angle is oriented parallel to a plane across the distal femur after adjusting for wear in the distal location on the medial and lateral condyle. Another aspect of the invention is a resection guide for resecting a proximal tibia which guide references a resected distal femoral surface and includes a tibial condylar member having a body with a proximal surface for contacting a resected planar surface of a distal femur and distal surface. A plurality of modular distal spacer elements are provided which include coupling elements for attaching the spacer elements to the distal surface of the body. A tibial resection guide is coupled to the body of the trial condylar member and is movable with respect thereto in a proximal-distal direction and rotatable with respect to the body about a medial-lateral parallel to the resected planar surface of the femur. The tibial references guide may be provided with a shoe or spacer on a posterior condyle reference portion to adjust for the thickness of cartilage wear. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a perspective view of one embodiment of the anatomic distal femoral resection guide alignment assembly of the present invention; 
         FIG. 2  is a view of the anterior facing surface of a distal femoral reference housing which forms part of the resection guide of  FIG. 1 ; 
         FIG. 3  is a view of the distal facing surface of the distal femoral reference housing of  FIG. 2 ; 
         FIG. 4  is a view of the distal facing end of an AP/internal-external positioner assembly; 
         FIG. 5  is a view of the medial facing side of the AP internal-external positioner assembly of  FIG. 4 ; 
         FIG. 6   a  is a side view of a posterior referencing foot of the assembly of  FIG. 5 ; 
         FIG. 6   b  is a top view of the posterior referencing feet assembly of  FIG. 6   a;    
         FIG. 6C  is a rear view of the posterior referencing feet assembly of  FIG. 6   a;    
         FIG. 7  is a view of the distal facing surface of the AP/IE positioner block of  FIG. 4 ; 
         FIG. 8  is a perspective view of an alternate embodiment of the anatomic distal femoral resection guide alignment assembly; 
         FIG. 9  is a perspective view of one embodiment of an AP sizer assembly; 
         FIG. 10  is a perspective view of an alternate embodiment of an AP sizer assembly; 
         FIG. 11  is a perspective view of yet another embodiment of an AP sizer assembly; 
         FIG. 12  is a perspective view of a femoral referencing tibial resection assembly; 
         FIG. 13  is view of the proximal facing surface of a femoral referencing template; 
         FIG. 14  is a view of the medial facing surface of the femoral referencing template of  FIG. 13 ; 
         FIG. 15  is a view of the medial facing surface of the proximal rod of the tibial resection assembly of  FIG. 12 ; 
         FIG. 16  is a view of the anterior facing surface of an adjustable slope tibial resection guide of the assembly of  FIG. 12 ; 
         FIG. 17  is a cross sectional view of the adjustable slope tibial resection guide along lines B-B of  FIG. 16 ; 
         FIG. 18  is a cross sectional view of a bore through the adjustable slope tibial resection guide of  FIGS. 16 and 17  with a pin extending through the bore; 
         FIG. 19  is a view of the distal facing surface of a femoral spacer; 
         FIG. 20  is a view of the medial facing surface of the femoral spacer of  FIG. 19 ; 
         FIG. 21  is a perspective view of a tibial clean-up resection guide assembly; 
         FIG. 22  is a view of the proximal facing surface of the tibial bone reference block removed from the assembly of  FIG. 21 ; 
         FIG. 23  is a view of the anterior facing surface of the tibial bone reference block of  FIG. 22 ; 
         FIG. 24  is a view of the medial facing surface of the tibial bone reference block of  FIG. 22 ; 
         FIG. 25  is an alternate anatomic distal femoral resection guide similar to  FIG. 1 ; and 
         FIG. 26  is an alternate anatomic distal femoral alignment assembly similar to  FIG. 8 . 
     
    
    
     DETAILED DESCRIPTION 
     As used herein, the term “distal” means more distant from the heart and the term “proximal” means closest to the heart. The term “inferior” means toward the feet and the term “superior” means towards the head. The term “anterior” means towards the front part of the body or the face and the term “posterior” means towards the back of the body. The term “medial” means toward the midline of the body and the term “lateral” means away from the midline of the body. 
     Referring to the drawings,  FIG. 1  illustrates a first embodiment of an anatomic distal femoral resection guide alignment assembly generally denoted as  10  which consists of a distal femoral resection guide  11  for making a distal femur planar cut, an adjustment housing  12 , an AP tower  13  moveable in an AP direction and a distal femoral referencing housing  14  having adjustable pads  22   a . The distal resection guide  11  includes a cutting surface  15  for guiding a saw blade, an aperture  16  for attachment to a standard navigation tracker (not shown), pin holes  17  for inserting fixation pins to an anterior surface of the femur and a connector  18  at which the adjustment housing  12  may be removably connected from resection guide  11 . Connector  18  includes a shaft  18   a  mounted on resection guide  11  which shaft is slidably mounted in housing  12  and can be adjusted with respect thereto to locate the distal cut. 
     The adjustment housing  12  may be removably or permanently connected to the AP tower  13 . As shown, the housing  12  is bolted onto tower  13  by bolts or screws  20   a . Further, the adjustment housing  12  may contain adjustment mechanisms such as rack  20  and pinion  19  that allow for interoperative adjustment of shaft  18   a  in the proximal/distal direction. AP tower  13  is preferably removably attached to distal femoral reference housing  14  via a post  104  slidably mounted in track  105  ( FIG. 2 ). The AP tower  13  is designed to allow movement in the anterior to posterior direction and can be locked in place with a locking mechanism or locking screw  21 . 
     The distal femoral referencing housing  14  contains two adjustable threaded elements  22  that adjust pads  22   a  which contact the distal femur and may be used to reference aspects of the distal femoral surface prior to resection. The pads  22   a  may contain spikes or other features (not shown) for fixation to the surface of the distal femur. The pads  22   a  allow for varus/valgus adjustment of the system by turning elements  22  which are preferably threaded into block  14  and any adjustments may be visualized by markings  23  on elements  22 . 
       FIGS. 2-3  show further aspects of the distal femoral referencing housing  14 .  FIG. 2  shows track  102  for slidably receiving post  104  of AP tower  13 .  FIG. 3  shows a pair of threaded holes  106  and a pair of non-threaded bores  53   a  and  53   b  for bone pins which may be inserted into the femur. Also shown is threaded bore  21   a  which accommodates locking screw  21 . 
     The method of use for the anatomic distal femoral resection guide alignment assembly  10  illustrated in  FIGS. 1-3  will now be described. The proximal surface of the distal femoral referencing housing  14  contacts the unresected distal femoral surface. Here, the distal femoral surface contains cartilage which may be healthy, damaged, or non-existent depending on the progression of degeneration. The cartilage may also vary from the left and right condyles. The surgeon uses the adjustable pads  22   a  to compensate for any distal femoral cartilage wear which may range from 1-3 mm, for example. The surgeon may determine this by measuring a healthy condyle on the same or opposite knee. Once the surgeon has used the adjustable pads  22   a  to compensate for the cartilage degeneration on the distal femoral surface, the appropriate level of distal femoral resection can be adjustably set followed by pinning the distal resection guide  11  to the anterior aspect of the femoral bone via holes  17 . The connector  18  is then uncoupled so a saw may be used to resect the distal femur. 
       FIGS. 4-5  illustrate an AP positioner assembly  40  which includes a handle  41 , positioner body  42  and a pair of posterior referencing feet  43 . Handle  41  consists of a grip portion  44  with a neck  44   a  connected to a body portion  45  which can be removably attached to a distal surface  47  of the positioner body  42  by means of a locking mechanism such as a threaded knob  46 . The positioner body  42  has, with respect to the femur, a flat distally facing surface  47  and a proximally facing surface  48 , attachment slots  49   a  and  49   b  which extend from surface  47  to  48  and removably attachable posterior referencing feet  43 . Referencing feet  43  have flanges  50  which extend through and slidably engage slots  49   a  and  49   b . In this embodiment, proximally facing surface  48  will contact the resected planar distal surface of the femur and the posterior referencing feet  43  reference the posterior aspect of the femoral condyles prior to their resection. The posterior referencing feet  43  are removably connected to the positioner body  42  thru the attachment slots  49   a  and  49   b  and may include a locking mechanism such as a ball detent to hold them in slots  49   a  and  49   b . Further, the posterior referencing feet  43  each have an attachment flange  50  inserted into the attachment slots  49   a  and  49   b . Flange  50  is connected to a known length connection leg  51  and a posterior referencing arm  52 . The connection leg  51  may come in multiple lengths to allow for interoperative adjustments and therefore allow for adjustments in the AP and internal-external positioning of the positioner assembly. Once the desired orientation of the positioner assembly is obtained, the positioner body may be used to align the femoral four in one resection guide. This is done by drilling through the apertures  53   a  and  53   b .  FIGS. 6   a - 6   c  illustrate a side view, a top view and a rear which of the posterior referencing feet  43 . Both the medial and lateral referencing feet may be identical.  FIG. 7  further illustrates the positioner body  42 . 
     The method of use for the positioner assembly  40  illustrated in  FIGS. 4-7  will now be described. The proximally facing surface  48  of positioner body  42  is placed on the resected distal end of the distal femoral bone. At this point the surgeon will insert posterior referencing feet  43  into attachment slots  49   a  and  49   b . The posterior referencing member  52  will contact the unresected posterior cartilage on the right and left condyles of the distal femur and different thickness referencing members  52  of predetermined thicknesses (preferably in 1 mm increments) allow for the surgeon to set alignment (anterior, posterior, and internal/external rotational i.e. axial alignment) of the femoral four in one resection guide which thus aligns the final femoral implant by considering any cartilage wear on the posterior condyles. Given the modularity of the posterior referencing feet  43  and the provision of different length legs  51  allows the surgeon to make alignment modifications to align the instrument to a pre-arthritic orientation state. Shims can also be placed between the anterior surface of the feet  43  and the posterior condyles. Once proper alignment is determined, the surgeon will drill into the bone through apertures  53   a  and  53   b . Sizing of the femoral component using this instrument would be determined by typical implant size specific four-in-one cutting blocks which relate to the available femoral components (not shown, but available in standard knee instrument kits) that interface with the holes in the bone. These holes in the bone which were drilled through bores  53   a  and  53   b  would be used to mount standard four in one cutting guides for making two anterior and two posterior chamfer cuts. 
       FIG. 8  illustrates an alternate embodiment of an anatomic distal femoral resection guide alignment assembly  75 . This assembly includes an anterior cortex referencing pad  76 , a stylus like extension rod member  77 , an AP tower  13   a , a distal femoral referencing housing  14   a  and adjustable pads  22   c  adjusted by screws  22   b . An important aspect of this embodiment is the anterior cortex referencing pad  76  which has an anterior facing surface  78 , a posterior surface  79  which contacts the anterior cortex of the femoral bone and fixation apertures  80  to receive fixation pins (not shown). Extension rod member  77  may be adjusted in the proximal-distal direction by the actuation of handle  84 . Lock  86  is used to lock the member  77  as specific points  88  on a holder  90 . Pad  76  is preferably connected to extension member  77  by a hinge joint  77   a  which forms part of attachment mechanism  81 . Hinge  77   a  allows for rotation of assembly  75  about a medial lateral extending axis. Further, there is an attachment mechanism  81  which allows for a pivotal connection to the stylus like extension member  77 . Similar to embodiments described above, this embodiment of the distal femoral resection guide alignment assembly  75  allows for movement of the adjustment pads  22   c  in a proximal-distal direction with respect to the femur. 
     The method of use for the alternate embodiment of the anatomic distal femoral resection guide alignment assembly  75  illustrated in  FIG. 8  is similar to the methods described for the instrument in  FIGS. 1-3 . The exception if the addition of the anterior cortex referencing pad  76  which allows for positioning of the component at different flexion angles, such as 3-5 degrees. A distal resection cutting guide is not shown in this figure, but it can be envisioned that a distal resection cutting guide similar to  11  having an anteriorly-posteriorly extending planar cutting surface can be removably connected to referencing housing  14   a . Once the appropriate alignment is determined, the distal resection guide would be pinned to the anterior aspect of the bone and a distal bone resection would be made. 
       FIGS. 9-11  illustrate various embodiments of an AP sizer assembly ( 100 ,  100   a ,  100   b ). Each assembly may consist of an AP sizer body ( 101 ,  101   a ,  101   b ) having a plurality of slots corresponding in size to available femoral components, calibrated sizing slots ( 102 ,  102   b ) and removably attachable posterior referencing members ( 103 ,  103   a ,  103   b ). 
     The method of use for different AP sizer assemblies ( 100 ,  100   a ,  100   b ), illustrated in  FIGS. 9-11 . Here various removably attachable posterior referencing spacers ( 103 ,  103   a ,  103   b ) may be used to compensate for any posterior cartilage wear (preferably in 1 mm increments) and an implant size for a femoral component may be determined by using a sizing stylus or sizing slots with an angle wing  99  for instance. Angle wing or blade runner plate  99  allows the surgeon to estimate the femoral implant size. 
       FIG. 12  illustrates a femoral referencing tibial resection alignment system  200 . This instrument references the resected distal femur to set the proximal tibial tibial resection. Alignment system  200  consists of the following: a trial-like femoral referencing member  201 , femoral spacer elements  202 , resection guide tower  203 , proximal rod  204  tibial adjustment housing  205  with adjustment wheel  205   a  and an adjustable slope tibial resection guide  206 . The trial-like femoral referencing member  201 , further illustrated in  FIGS. 13-14 , consists of a proximal facing surface  207 , a distal facing surface  208 , elongate peg members  209 , fixation apertures  210  for receiving bone pins and an extension member  211 . The proximal surface  207  contacts the distal surface of the prepared femoral bone and the elongate peg members  209  are received within previously prepared apertures in the prepared distal surface of the femur. The distal surface  208  contains an attachment mechanism for engaging femoral spacer elements  202 . Femoral spacer elements  202 , further illustrated in  FIGS. 19-20 , have a distal surface  212 , a proximal surface  213  and a connection member  214 . Elements  202  may have various thicknesses between the proximal surface  213  and distal surface  212 . Preferably the thickness increases in 1 mm increments from 1 mm to 3 mm. Extension member  211  engages the resection guide tower  203  and allows for adjustments in the AP direction. In the illustrated embodiment extension  211  slides in a hollow guide  211   a.    
     Further regarding the femoral referencing tibial resection alignment system  200 , the resection guide tower  203  may be removably or permanently connected to the proximal rod  204 . The rod  204 , further illustrated in  FIG. 15 , may consist of markings  220  and thread-like features or ratchet elements  221 . The markings may be spaced at 3 mm. The tibial adjustment housing  205  engages with the rod  204  and may be available in zero (0) and three (3) degree slope embodiments. The tibial adjustment housing is further described in a Stryker owned U.S. Pat. No. 7,033,361, the disclosure of which is incorporated herein by reference. The adjustable slope tibial resection guide  206  is removably attached to the tibial adjustment housing and may consist of a proximal cutting surface  230 , aperture  231  for receiving a navigation tracker, cross pin fixation aperture  232  and two conical holes  233 . Conical holes  233  are further illustrated in  FIGS. 16-18  and allow for tibial slope adjustments from 0-5 degrees with respect to a transverse plane in the AP direction. Here a fixation pin would be inserted thru a conical hole  233 , and the tibial slope which hole  233  can be adjusted and then the adjustable tibial resection guide  206  can be fixed to the proximal tibial bone by inserting an additional fixation pin through aperture  232 . 
     Femoral referencing tibial resection alignment system  200  allows for the adjustable slope tibial resection guide  206  to be placed by referencing both the prepared distal surface of the femoral bone and the un-resected tibial surface. Further the system  200  allows for adjustability in the AP direction and proximal distal direction. 
     The method of use for the femoral referencing tibial resection alignment system  200  illustrated in  FIGS. 12-20  will now be described. The proximal surface  207  of the trial-like femoral referencing member  201  contacts the resected distal femoral bone. Elongate members  209  interface with previously made apertures in the distal femoral bone. Also, the trial-like femoral referencing member  201  may contain posterior referencing feet (not shown) to reference the posterior aspect of the distal femur. Femoral spacer elements  202  come in various thickness, such as 1, 2 or 3 mm, and are used to simulate the femoral condyles while compensating for any tibial cartilage wear, and thus allowing for restoration of the joint to the pre-arthritic state. The surgeon selects the appropriate femoral spacer elements  202  which will contact the unresected surface of the tibial cartilage surface. It should be noted that proper alignment is determined with the knee in extension. Once the surgeon has properly restored the tibial/femoral structure to a pre-arthritic state, the adjustable tibial resection guide  206  can be pinned to the anterior surface of the tibial bone. The tibial resection guide  206  has conical holes  233  which will allow the surgeon to provide a posterior slope to the tibial resection surface. For example, the conical holes  233  may allow for 0-5 degrees of posterior slope, as depicted in  FIGS. 16-18 . 
       FIG. 21  illustrates a tibial resection alignment system  300  which consists of a tibial adjustment member  301  may be removably attached to a tibial resection guide  302 . The tibial adjustment member  301 , further illustrated in  FIGS. 22-24 , preferably includes the following features: a proximal surface  303 , a distal surface  304 , anterior tibial cortex scribe lines  305 , medial/lateral tibial scribe line  306 , fixation aperture  307  and elongate connection features  320 . The distance between the proximal surface  303  and distal surface  304  may be a calculated angle such as 2 degrees varus. Other such geometries can be used such to modify the tibial slope, varus alignment, valgus alignment of any combination. When in use, the distal surface  304  contacts the resected proximal surface of the tibia and elongate connection pins  320  engage connection bores in bores  308  on the tibial resection guide  302 . Further, the anterior tibial cortex scribe lines  305  align with the anterior cortex of the tibial bone and the medial/lateral tibial scribe lines  306  align with the respective medial/lateral tibial cortex. The tibial resection guide  302  can be attached to the proximal tibia bone by inserting fixation pins thru apertures  332 . Further, refinement cuts can be made by utilizing the proximal resection surface  330  and an appropriate surgical saw. Also, a well-known navigation tracker may be assembled to the tibial resection guide  302  at aperture  331 . 
     The method of use for the tibial resection alignment system  300 ,  FIGS. 21-24 , will be now described. If, following a preliminary resection of the tibial surface, the surgeon considers that a “clean-up” or additional cut is desired, the surgeon can attach a tibial adjustment member  301  to a tibial resection guide  302  and make an additional cut. Here, the tibial adjustment member  301  may have various angle references to allow for additional resection in varus, valgus or other alignment. 
     The use of instruments described above during a surgery will now be described. First obtain a patient MRI of the knee. Determine the femoral deficiency and isolate the deficiency into distal medial, distal lateral, posterior medial, and posterior lateral areas based on the MRI. This is done through measuring normal cartilage and documenting wear in the four segments (for example 2 mm wear distal medial, zero wear distal lateral, and zero wear posterior medial and lateral). Alternately, the cartilage/bone loss can be assessed intraoperatively to determine cartilage thickness on the unaffected condyle. Other methods to determine cartilage loss are described in U.S. Patent Publication No. 2009/0270868. 
     Expose knee and slide a ‘Z’ shaped retractor along the anterior cortex of the femur proximal to the trochlea. This retractor helps determine the flexion/extension orientation of the femoral component. Drill a ⅛″ pin parallel to the Z retractor into the distal most aspect of the unaffected femoral condyle (lateral for varus knee, medial for valgus knee). Assemble the distal femoral reference housing  14  of  FIG. 1  by sliding it over the pin via holes  53   a  or  53   b . Set distal resection at 8 mm by adjusting rack and pinion  19  and  20 . The goal of the distal cut is to make a resection referencing the distal femur adjusting for the wear documented from the MRI or the intra-operative measurements. Slide the distal femoral resection guide alignment assembly  10  until the proximal surface of the distal femoral referencing housing  14  is in contact with the unaffected condyle. Adjust the varus/valgus setting until the proximal surface of the distal femoral referencing housing  14  is positioned parallel with the distal femur after adjusting for the wear. (For example, if there is 2 mm distal medial wear, there should be a 2 mm gap between the proximal surface of the distal femoral referencing housing  14  and the femur on the diseased side and a 0 mm gap on the lateral side. Pin the distal resection guide  11  using 2 headless pins through bores  17 , remove all other instrumentation via connector  18 , optionally attach a saw blade capture element, and make the distal cut. Remove the distal cut guide  11  and assemble the rotation/sizing guide of  FIG. 4  and set the rotation to 0 degrees. Set femoral rotation and determine femoral implant size using the posterior referencing technique described above adjusting the posterior references  43  of the guide  40  to account for any posterior wear documented on the MRI using various leg elements. Drill through bores  53   a  and  53   b  in guide. Attach a sizing stylus as shown in  FIGS. 9-11  and/or blade runner plate or wing  99  and determine the femoral size, making sure the orientation of the guide has not changed using spacer  103 . After sizing is complete mount a standard 4 in 1 cutting guide (not shown) using the drilled holes. The cutting guide corresponds to one of the available femoral components. Make the anterior, posterior, posterior chamfer, and anterior chamfer cuts. To verify the femoral preparation compare the four segments that were assessed by the MRI. Distal medial and lateral, and posterior medial and lateral segments should be approximately 6.5 mm minus wear. If there is a large variation consider adjusting femoral preparation before moving on to the tibia. 
     Alternatively to the sizer with the leg elements the embodiment with the shims can be used to set rotation and determine femoral implant size. The difference in the procedure would only be the use of shims to compensate for posterior wear rather than leg elements. 
     For tibial resection assemble the extramedullary tibiofemoral resection guide of  FIG. 12  with the 0 degree slope attachment  206 . In approximately 90° flexion, place guide on tibia and use standard techniques to assess the resection level of the tibia. Place the distal femoral pegs of the distal femoral trial portion into the predrilled holes in the distal femur. To accommodate for tibial compartmental wear (varus knee-medial, valgus knee-lateral) use a corresponding distal shim on the backside of the distal trial portion of the assembly. It is recommended that the remaining cartilage on the worn compartment be scraped off completely to better estimate the cartilage thickness to be accounted for (usually 2 or 3 mm). Then bring the knee slowly into extension, allowing the distal trial portion of the apparatus to sit within the proximal tibial compartments (both medial and lateral). An extra medullary alignment tower and rod can be used to assess limb alignment at this stage (flexion-extension slope and varus-valgus rotation). Proximal tibial stylus is used according to standard protocol to assess and determine the resection level. The key is to have tibia positioned against femur with this assembly in place. Pin the cutting jig  230  onto the proximal tibia, using one headless pin in the most central hole  233  available. With the patient&#39;s leg extended, attach the alignment tower and guide pin to the cutting jig and extend upwardly. Provide traction on the leg to assess the flexion/extension gaps relative to the distal femoral resection. 
     The tibial cutting jig is properly oriented when it indicates a tibial resection parallel to the distal femoral resection. If the cuts are not parallel, slide spacers  202  to induce a varus or valgus angle to the cutting block until the jig and distal femoral resection are parallel. Place a second pin in the cutting guide then remove the tibial alignment jig and resect the proximal tibia. If a tibial recut is required to adjust the varus valgus alignment the recut guide can be used. The appropriate recut guide is used with element  301  attached to the tibial resection guide. Component  301  is seated on the resected tibia and the scribe line is aligned to the anterior tibial cortex as is the medial/lateral scribe line  306 . The resection guide is then pinned to the tibia and the cut can be made through the resection guide slot. 
     Referring to  FIG. 25  there is shown an alternate distal femoral resection assembly which includes a distal femoral referencing housing  414  having adjustable pads  422   a  which can be adjusted by rotating screws  422 . Pads  422   a  engage the medial and lateral distal femoral condyles respectively. The guide includes a tower  413  including a shaft  404  which is held in the distal femoral referencing housing  414  by a thumb screw  421  in the desired anterior posterior position. An adjustment housing  412  is mounted on tower  413  via a post or screw connection  420  in bores  415  of tower  413 . The same distal femoral resection guide  11  as shown in  FIG. 1  is used and is adjusted in the proximal distal direction by an adjustment screw  419  mounted in a housing  412 . 
     Referring to  FIG. 26  there is shown an alternate embodiment of an anatomic distal femoral resection guide alignment assembly including an AP tower  13   b , a distal femoral resection housing  14   c  including the adjustable pads  22   d  adjustable in the manner described above to set the varus/valgus orientation of the distal femoral cut. An anterior cortex referencing pad  76   a  is included which has a pair of pin holes  80   a . Extension of rod  77   b  and the proximal-distal direction is accomplished via movement of handle  84   a  which may be locked in position by trigger lock  86   a  which engages grooves  402  in holder  90   a . Grooves  402  may be marked in 1, 3 or 3 mm increments for reference purposes. Holder  90   a  is mounted on tower  13   b  via post  400  into a bore  403 . The use of the alternate guides of  FIGS. 25 and 26  is essentially the same as that described above. 
     Although the invention herein has been described with reference to particular embodiments, it is to be understood that these embodiments are merely illustrative of the principles and applications of the present invention. It is therefore to be understood that numerous modifications may be made to the illustrative embodiments and that other arrangements may be devised without departing from the spirit and scope of the present invention as defined by the appended claims.