SURGICAL TECHNIQUE - Cortical · Broaching - Initial Non Anatomic Cavity Preparation Following definition of the entry point and intra-medullary canal, the cavity initiator (S) broach

S U R G I C A L T E C H N I Q U E

DePuy believes in an approach to total hip replacement that places equal importance on recovery, function and survivorship.

R E C O V E R Y F U N C T I O N S U R V I V O R S H I P

2 3

The DePuy PROXIMA™ Hip System is indicated for primary hip arthroplasty when the

surgeon wants to conserve bone and soft tissue, and provide physiological loading to the

proximal femur. Ideally the femoral metaphysis should have a good margin of supportive

proximal cancellous bone.

2 3

Surgical Technique

Patient Selection 4

Pre-operative Planning 5

Surgical Approach 6

Neck Resection 7

Acetabular Preparation 8

Canal Entry 9

Broaching - Initial Non Anatomic Cavity Preparation 10

Alignment Check 12

Broaching - Sequential Anatomic Preparation 13

Broaching - Final Anatomic Preparation & Calcar Milling 14

Trial Reduction 15

Final Implantation 16

Ordering Information 18

Surgical Technique Tips & Tricks 20

Contents

4 5

Patient Selection

Within our DePuy Proxima™ Hip surgeon design

team and in the hands of the most experienced

surgeons, DePuy Proxima™ Hip is used as the

standard stem in all cases where an uncemented

implant could be used.

Reproducible fixation and stability has led to its

use in a wider selection of patients, and it is not

merely reserved for the younger more

active patients.

While it is recommended that the prosthesis is

initially implanted in patients with good bone

stock and fairly normal anatomy, this indication

can be broadened with increasing experience.

However, there are clear contra-indications for the

use of DePuy PROXIMA™ Hip:

• Hipdysplasiawithsevereneckanteversionor

severe dysplasia of the proximal femur

• Severeosteoporosis

• Previoushiposteotomies

• Previousproximalfemoralfractures

DePuy PROXIMA™ Hip Surgeon Design Team:

Prof. F. S. Santori

Prof. I. Learmonth

Prof. J. Grifka

Dr. C. Valverde

Prof. Y. H. Kim

4 5

Pre-operative Planning

Pre-operative templating should be carried out to

evaluate femoral and acetabular sizing

(Figure 1). However, the philosophy of this implant

is different from a conventional stem and size

choice is strictly dependent on the bone quality.

The femur should be slightly internally rotated for

the A/P X-ray. Templating should be performed

both in AP and axial views. A true lateral view

should also be obtained to assess the fit of the

implant and filling of the femoral neck.

The DePuy PROXIMA™ Hip philosophy is not to

fill the metaphysis. In the A/P X-ray, the implant

should be positioned centrally within the canal

allowing a good cancellous margin medially

and laterally.

Note: restoration of the patient’s natural

biomechanics can be addressed through

selection of either standard or high offset

implants. Filling of the metaphyseal region of

the proximal femur is not mandatory as long

as the surgeon achieves absolute stability of

the broach in the cancellous bone. In general

a smaller implant is selected in the presence

of good bone stock, where stability is provided

by the strong supportive cancellous bone. In

contrast, in the presence of osteoporosis with

poor unsupportive cancellous bone, a larger

implant is selected where increased cortical

contact provides implant stability.

Figure 1

A/P X-ray template

6 7

Surgical Approach

Exposure may be achieved using a posterolateral,

anterolateral, anterior or the MicroHip™

direct-anterior surgical approach to provide

optimal visualisation of the acetabulum, the

femoral neck and the proximal femur (Figures 2,

3 and 4).

The DePuy PROXIMA™ Hip “Round the

Corner” technique for femoral preparation

allows maximum soft tissue preservation and

protection of the abductor tendon insertions. The

advantages of the ‘Round the Corner’ technique

are even more evident with minimally

invasive surgery.

Note: the high neck cut can cause some

difficulty with acetabular exposure with an

antero-lateral or MicroHip™ direct-anterior

approach. Milling the calcar region before

acetabular reaming may facilitate this phase of

the operation.

Figure 2

Posterolateral approach

Figure 3

Anterolateral approach

Figure 4

MicroHip™ direct-anterior approach

6 7

Neck Resection

Neck resection is higher and more horizontal

than for conventional THR, extending from the

piriformis fossa to the head-neck junction

(Figure 5).

Resection may be performed either prior to

or after dislocation, depending on the chosen

surgical approach. With MicroHip™ or other mini

anterolateral exposures, it is easier to resect the

head in-situ. In such cases, a corkscrew may be

used to assist removal of the femoral head.

A knife may also be used to release any tissues

from around the head and neck.

Once the femoral preparation is finished, neck

preparation may be completed using the calcar

miller with the final broach in place.

Figure 5

8 9

Acetabular Preparation

The key points in acetabular reaming are

as follows:

• Thecreationofahemisphericalcavitywith

uniform bone-implant contact

• Anadequatepress-fitforinitialstability

• Placementoftheprosthesisattheanatomic

centre of rotation of the hip joint, whenever

technically possible

• Thetransverseacetabularligamentprovidesa

useful guide to the orientation and placement

of the cup.

A reamer that is 6 - 8 mm smaller than the

anticipated acetabular component should be

used initially to deepen the acetabulum to the

level determined by preoperative templating. All

reamers should be introduced in 40˚ - 45˚ of

abduction and 15˚ to 20˚ of anteversion (Figures

6 and 7).

Note: if the patient is in a lateral decubitus

position, the pelvis may be slightly flexed.

30˚ to 35˚ anteversion of the reamer handle

and implant impactor is recommended

to achieve the desired 15˚ to 20˚ of cup

anteversion. Please refer to the Pinnacle™

Surgical Technique (Cat No 9068-80-050)

or the DePuy ASR™ Surgical Technique (Cat

No 9998-02-280) for detailed instruction on

acetabular implantation.

Figure 6

Figure 7

Note: to maximise access to the acetabulum with a conservative neck resection, appropriate soft tissue release and adequate retraction should be performed. The use of a special reamer, shown here, avoids impingement on soft tissue.

8 9

Canal Entry

A dedicated DePuy PROXIMA™ canal finder awl

is included in the instrument set. The awl should

be placed in the centre of the postero-lateral

quadrant of the resected neck to open up the

femoral canal (Figure 8). The tip of the awl is

initially directed laterally until the lateral flare

is identified and then turned through 180°

and advanced down the femoral canal. The

proximal metaphyseal cancellous bone may

be compressed by moving the canal finder

medio-laterally (Figure 9).

The box osteotome is used only when very hard

cancellous bone is encountered laterally, but

should never invade the greater trochanter or the

glutei insertion (Figure 10).

Anterior

Lateral

Medial

Posterior

Figure 8

Figure 9

Figure 10

10 11

20˚- 30˚

Figure 11b

Broaching - Initial Non Anatomic Cavity Preparation

Following definition of the entry point and

intra-medullary canal, the cavity initiator (S)

broach is used to define the initial femoral

envelope. “Round the Corner” is the term used

to describe the movement devised to prepare

the proximal femur for insertion of the DePuy

PROXIMA™ Hip. With this technique the surgeon

is able to protect the soft tissues, maintain the

cancellous bone and provide the best possible

load delivery on the lateral flare.

The cavity initiatior (S) broach is first inserted

at an angle of 20˚- 30˚ to the long axis of the

femur (Figure 11a). Once the lateral edge of the

broach is below the greater trochanter, the broach

is progressively aligned to the axis of the femur.

Tilting the broach is achieved by hammering on

the oblique portion of the strike platform and only

a gentle pressure should be applied to the handle

(Figure 11b). Broaching stops when neutral (or

slightly valgus) alignment is achieved (Figure 12).

Excessive force applied to the handle to gain

alignment can cause a proximal femoral crack

and should be avoided. Removal of the broaches

is achieved with the same “Round the

Corner” movement.

Note: the use of the “Round the Corner”

technique is to minimise the required

impaction forces (by avoiding contact with

cortical bone) and to ensure that the cavity

created is the required size and shape

(corresponding to the broach).

Figure 12

Strike Platform Hammering Portion

Strike Platform Hammering Portion

20˚- 30˚

20˚- 30˚

Figure 11a

10 11

Figure 13

Broaching - Initial Non Anatomic Cavity Preparation

The same technique is used with the lateraliser

(L) broach (Figure 13) which develops the lateral

envelope under the greater trochanter. The cavity

starter (S2) broach continues the enlargement of

the femoral cavity and development of the lateral

flare (Figure 14). Alignment is checked frequently,

using the alignment guide, both in the AP and ML

planes (Figures 15 and 16).

Note: there are three non-anatomic broaches

which are used sequentially prior to the

First Anatomic Starter and sizing broaches.

These broaches are marked as S, L, S2.

It is desirable to obtain a few degrees of

valgus with the smaller broaches to facilitate

accurate alignment with the subsequent sizes.

With Minimally Invasive Surgery the leg is

positioned to present the resected neck in the

wound. Precise broaching is then possible.

Figure 14

20˚- 30˚

20˚- 30˚

12 13

Alignment Check

DePuy Proxima™ Hip is a conservative implant

with no diaphyseal stem extension to facilitate

alignment. For this reason an external alignment

system, consisting of a long extensible rod

which can be quickly attached to the broach

handle, has been introduced and should be used

frequently during broaching. The alignment guide

orbits the axis of the femur without pointing at

any particular feature of the femur. Instead, when

used as intended, the guide helps to align the

axis of the broach or the implant with the axis of

the femur by verifying that the axes in question

are parallel to each other. Accurate alignment is

achieved when the axis of the rod is parallel to

the femoral axis in two perpendicular planes

(Figure 15). The broach or the implant is correctly

seated in neutral alignment when the rod of the

alignment guide is parallel to the long axis of the

femur in both the sagittal and coronal planes.

Intraoperatively, the surgeon must identify the

diaphyseal axis of the femur and use it as a

reference. The easiest and most reproducible way

is to use proximal and distal femoral landmarks.

When parallel in the two planes, if the alignment

rod is rotated and superimposed on the medial

side of the greater trochanter (proximal femoral

landmark) the guide will point at the centre of

the knee (distal femoral landmark) and in an

imaginary line drawn between these two points

replicates the diaphyseal axis (Figure 16a). It is

also possible to move the alignment guide to a

perpendicular position against the broach plane

and make sure that the alignment guide points at

the medial femoral condyle (Figure 16b). It is then

parallel with the long axis of the femur.

Note: in cases where there is sclerotic bone, it

may be useful to return to the starter broach or

rasp to obtain initial alignment. It is important

to obtain alignment at this stage before

progressing to a larger broach.

Figure 15

Figure 16a Figure 16b

12 13

Broaching - Sequential Anatomic Preparation

Sequential broaching is carried out with the left

or right first anatomic starter (SL, SR) broach.

The first of the anatomic broaches enlarges the

existing femoral cavity and provides an anatomic

profile. This is further enlarged to the required

size by subsequent broaches (sized).

“Round the Corner” broaching is used to prevent

excessive removal of trochanteric bone, and

allows the broach to follow the natural geometry

of the proximal femur in both the A/P and M/L

planes (Figures 15 and 16).

The broach is introduced at an angle of 20˚- 30˚

to the long axis of the femur and along the medial

curve of the metaphysis. It should be brought

into neutral alignment after the lateral edge of the

broach is below the level of the greater trochanter

(Figure 17).

Care should be taken to preserve or restore

femoral neck anteversion and to follow the

shape of the proximal femur in three dimensions

(Figure 18).

Check that each broach is accurately aligned

after seating. All broaching should be carefully

performed and any aggressive

movements avoided.

A dedicated rasp may be used to help facilitate

initial broaching if sclerotic bone is encountered

anywhere within the region of the

broach envelope.

Note: it is worth reiterating that in the presence

of strong cancellous bone, over correction into

valgus with the smaller broaches is the best

method of avoiding excessive varus with the

final broach.

Figure 17

20˚- 30˚

Figure 18

14 15

Figure 20

Figure 19

Broaching - Final Anatomic Preparation & Calcar Milling

Sequential “Round the Corner” broaching

continues from the size 1 anatomic (1L or 1R)

broach. The final broach should fit the proximal

femur, making sure sufficient good quality

cancellous bone is left and rotational stability is

achieved (Figure 19). The final implant size will

correspond to the final broach used.

The alignment of the broaches should be

checked at regular intervals and adjusted

if necessary. Final seating is achieved by

impacting the broach in the axis of the femur. An

intra-operative X-ray to check for correct sizing

and alignment may be obtained at this stage.

Once the final broach is fully seated and after

leg length discrepancy has been checked, a

calcar miller may be used to level the neck cut

with the level of the DuoFix™ coating (Figure

20). A calcar miller with “captured” cutting-teeth

is available as part of the DePuy PROXIMA™

Hip instrumentation. As previously advised,

with the anterior, anterolateral, and MicroHip™

approaches, preservation of the neck may reduce

acetabular exposure. In such cases, milling the

neck first, may significantly help with acetabular

preparation and cup positioning.

20˚- 30˚

14 15

Trial Reduction

The correct combination of standard or high

offset neck trial and modular head are selected to

reproduce the patient’s natural biomechanics as

determined at pre-operative templating

(Figure 21).

To optimise joint function and to increase stability,

the largest diameter head possible is usually

selected (Figure 22).

A trial reduction is performed and the hip

assessed through a full range of movement to

identify any instability or impingement.

Figure 22

Figure 21

Standard

High Offset

16 17

Final Implantation

The definitive DePuy PROXIMA™ implant is

introduced into the broach envelope with the

same “Round the Corner” technique, using the

stem inserter/impactor (Figure 23). The implant

must follow the path of the last broach. The final

implant should be seated (initially preferably by

hand) as far into the broach envelope as possible

without undue force. Before final impaction, it is

crucial to use the alignment guide to confirm

that the stem is in neutral alignment (Figure

24). Final seating is achieved with impaction in

line with the femur.

Impaction with the inserter/impactor is complete

when the implant cannot progress any further and

the DuoFix™ coating is level with or just proud

of the resected neck. A change in pitch will be

noted by the surgeon during impaction when final

seating has been achieved. Over impaction of the

definitive implant into the canal must be avoided.

A further trial reduction must be performed to

confirm final position.

After trialling is completed, the taper must be

irrigated and cleaned to ensure it is free of debris

before lightly impacting the selected

femoral head (Figure 25).

Figure 25

Figure 23

20˚- 30˚

Figure 24

16 17

18 19

Implants

940050001 DePuy PROXIMA™ Hip Standard Offset L Size 1









940050011 DePuy PROXIMA™ Hip Standard Offset R Size 1









940050022 DePuy PROXIMA™ Hip High Offset L Size 2







940050032 DePuy PROXIMA™ Hip High Offset R Size 2








Ordering Information

PRX001A DePuy PROXIMA™ Hip Broaches

940090011 DePuy PROXIMA™ Hip Broach Left Size 1







940090021 DePuy PROXIMA™ Hip Broach Right Size 1







940070053 DePuy PROXIMA™ Hip First Anatomic Left

940070054 DePuy PROXIMA™ Hip First Anatomic Right

PRX002A DePuy PROXIMA™ Hip Neck Segments

940090031 DePuy PROXIMA™ Hip Neck Segment Std Size 1

940090032 DePuy PROXIMA™ Hip Neck Segment Std Size 2/3



940090042 DePuy PROXIMA™ Hip Neck Segment High Size 2/3



PRX003 Generic Instrumentation

940080001 DePuy PROXIMA™ Hip Canal Finder Awl

940070049 DePuy PROXIMA™ Hip Stem Alignment Guide

940080004 DePuy PROXIMA™ Hip Stem Inserter/Impactor

940080007 DePuy PROXIMA™ Hip MI Calcar Reamer Small

940070050 DePuy PROXIMA™ Hip Cavity Initiator (S) Broach

940080008 DePuy PROXIMA™ Hip Lateraliser (L) Broach

940070051 DePuy PROXIMA™ Hip Cavity Starter (S2) Broach

940080030 DePuy PROXIMA™ Hip Case 2 Complete

940080020 DePuy PROXIMA™ Hip Case 1 Complete

940090009 DePuy PROXIMA™ Hip Broach Handle

18 19

PRX004 DePuy PROXIMA™ Hip Large Sizes







H143 DePuy PROXIMA™ Hip

940090200 DePuy PROXIMA™ Hip Sizes 1-9 X-ray Templates

200231000 Anteversion Osteotome Small

853965 S-ROM® T-Handle

ROP001 Olive Shaped Broach

DePuy International LtdSt Anthony’s RoadLeeds LS11 8DTEnglandTel: +44 (113) 387 7800Fax: +44 (113) 387 7890

Cat No: 9400-70-000 version 3

This publication is not intended for distribution in the USA.

DePuy PROXIMA™ Hip, DePuy ASR™, DuoFix™ and MicroHip™ are trademarks of DePuy International Ltd.Pinnacle™ is a trademark and Articul/eze® , Porocoat® and S-ROM® are registered trademarks of DePuy Orthopaedics, Inc.© 2007 DePuy International Limited. All rights reserved.

Issued: 08/07

Documents

SURGICAL TECHNIQUE - Cortical · Broaching - Initial Non Anatomic Cavity Preparation Following definition of the entry point and intra-medullary canal, the cavity initiator (S) broach