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CHARNLEY®

HIP SYSTEM

This publication is not intended for distribution in the USA.

SURGICAL TECHNIQUE

CHARNLEY Hip System Surgical Technique DePuy Synthes 3

CONTENTS

Pre-operative planning 4

Surgical Approaches 5

Lateral Approach 5

Posterior Approach 6

Femoral Initiation 9

Femoral Initiation 10

Canal Reaming 11

Femoral Neck Resection 12

Acetabular Preparation 12

Acetabular Sizing 13

Cup Implantation 14

Femoral Canal Preparation 14

Broaching 15

Trial Reduction 15

Cement Restrictor Depths 16

Distal Centraliser Selection 16

Stem Implantation 17

Ordering Information 18

DePuy Synthes CHARNLEY Hip System Surgical Technique4

PRE-OPERATIVE PLANNING

AP View

Pre-operative planningThe CHARNLEY Total Hip System offers the surgeon a comprehensive range of pre-operative planning templates with 20% magnification.

Pre-operative templating allows the surgeon to judge the appropriate position, size and neck offset of the implant in order to restore the patient’s normal anatomy.

A radiograph showing the AP view of the proximal femur, internally rotated 15°, provides the most important information: a level for the neck resection which will restore leg length; the appropriate neck offset for a natural position of the femoral head; and the lateral/medial dimensions of the femoral canal which determine the overall size of the implant.

The AP view also presents the position of femur relative to the bony landmarks of the pelvis, and Pre-operative planning the correct anatomical position of the acetabular component relative to landmarks such as the tear drop.

The lateral view showing the amount of femoral bow, helps to confirm the diameter of the femoral canal and highlights abnormalities in this plane which might affect the position of the implant.


SURGICAL APPROACHES

Lateral Approach Figure 2

Figure 1

The CHARNLEY Hip may be implanted using any of the standard surgical approaches for total hip arthroplasty. This technique outlines the surgical procedure for the direct lateral and posterior approaches.

Lateral Approach

In the lateral approach, the patient is positioned square on the table in the supine position or the lateral position. In the supine position the patient is supported under the affected hip to relax the muscles. The hip is flexed, adducted and internally rotated.

Initial IncisionThe initial incision is centred over the greater trochanter. The line of the incision runs distally from the tip of the greater trochanter along the axis of the femur, and proximally, it runs posteriorly in a straight line into the buttock.

With the initial incision made, work down through the subcutaneous tissue over the proximal femur to the fascia lata, which appears at the base of the wound (Figure 1).

Split the fascia lata distally from the greater trochanter, in line with its fibres (Figure 2). The opening is then extended proximally, in line with the initial incision. Equal exposure should be achieved both proximally and distally, to allow the femur to be fully visualised and mobilised during insertion of the prosthesis.

Soft tissue is cleared away and the sciatic nerve may be identified for reference during acetabular preparation.


SURGICAL APPROACHES

Position a CHARNLEY retractor in the deep fascia layer at the anterior rim of the abductor muscles and at the gluteus maximus, and extend the retractor so that the proximal femur is exposed.

With the leg adducted, the greater trochanter is presented into the centre of the wound.

Using diathermy, incise from the tip of the greater trochanter through the anterior third of the tendonous attachment of the gluteus medius, cutting around the trochanter to allow a cuff of tissue for reattachment (Figure 3).

Extend the incision along the line of the femur toward the quadriceps muscles. Further exposure is achieved proximally by splitting the abductor muscles in line with their fibres.

A continuous flap is opened, from the abductors to the quadriceps (Figure 4). This will be reattached on completion of the procedure.

Further exposure is achieved by dividing the abductor muscles in line with their fibres, using blunt dissection (Figure 5).

A blunt nosed retractor is placed over the anterior lip of the joint capsule. Radially incise the anterior capsule, and excise the anterior flap (Figure 6).

With the capsule fully excised, the hip can be dislocated without force. Release the inferior capsule on the neck of the femur, taking care to ensure that the abductor muscles remain attached to the posterior part of the femoral neck.

It is important to fully release both the inferior and posterior capsule so that the femur can be safely delivered into the wound without risk of fracture.

Figure 3

Figure 6Figure 4

Figure 5

Lateral Approach


In the posterior approach, the patient should be in a true lateral position.

With the knees slightly bent, the feet should be near the bottom of the table. A posterior support is used in the low lumbar region. This should be positioned so that it does not interfere with access during surgery.

The anterior support is placed on the anterior, superior iliac spine, slightly towards the abdominal side so that it will not prevent the hip flexing during surgery.

A sand bag is placed in front of the lower ankle, underneath the canvas, to prevent the leg extending. A pillow may be placed between the legs and held in position with a strap, to give the pelvis a more symmetrical position. It is important that with the pillow in position, the operator can feel both heels and the front of the knees, to allow leg length to be measured intraoperatively.

With the patient in this position the pelvis tends to flex approximately 20° into an anteverted position.

Appreciation of this will allow correct orientation of the cup during cementing.

Well padded support is used to support the upper arm.

Standard draping procedure is followed.

Initial IncisionThe landmark for the initial incision is based over the tip of the greater trochanter. With the leg slightly flexed, the incision follows a gentle curve (convex anteriorly) extending approximately 8cm - 10cm (depending on the size of the patient) proximally and distally away from the trochanter.

Posterior Approach

Posterior Approach


SURGICAL APPROACHES

The skin and fat are divided, clearing the deep fascia along the length of the incision.

The deep fascia is opened. Using blunt dissection, the muscles are split in line with their fibres (Figure 7).

The CHARNLEY initial incision retractor is inserted with the C-Arm concave towards the head (Figure 8). The anterior blade is placed on the musculo tendonous junction of the deep fascia, and a similar position is adopted for the posterior blade. The distal free edge of the trochanteric bursa is then exposed. A pair of Mayo scissors is inserted under this free edge and slid proximally along the posterior margin of the femur. The bursa is then lifted, remaining attached only on its proximal and anterior side. This exposes the fat of the short rotator muscles and the free edge of the gluteus medius muscle.

A plane is developed with the Mayo scissors deep to the free edge of the gluteus medius muscle and the greater trochanter. The anterior blade of the initial incision retractor is then inserted into this gap between the posterior edge of the gluteus medius and the greater trochanter (Figure 9).

The fat is swept posteriorly off the short rotators using a swab. At this point, diathermy should not be used in close proximity to the sciatic nerve. The sciatic nerve may be visible in the depth of the posterior part of the wound. If not immediately visible, it may be felt but it is not necessary to expose the nerve.

The tendons from piriformis proximally, superior gemellus, tendon of obturator internus, inferior gemellus and quadratus femoris muscle are now exposed. The quadratus femoris is left undisturbed and a stay suture is passed through the other tendons several times, using a number 1 vicryl suture (Figure 10). This is then attached to an artery forcep.

Posterior Approach

Figure 7

Figure 10Figure 8

Figure 9


FEMORAL INITIATION

The tendons of the short rotators, except for the quadratus femoris, are then cut with a diathermy point between the stay suture and the trochanter (Figure 11). The incision should start proximally and run parallel to the sciatic nerve from the tip of the trochanter to the inferior gemellus muscle. The leg is then rotated internally and the line of the cut turns in an anterior direction toward the assistant. This exposes the posterior capsule.

Figure 12Figure 11

A finger is placed anterior to the sciatic nerve, between the cut tendons and the capsule. The incision is turned into a T-shape by cutting the capsule anteriorly away from the operator’s finger (Figure 12).

At this stage it is usually possible to flex the hip and internally rotate the femur. The head will dislocate and, as the knee is brought into adduction, the neck will come fully into view. It is often necessary to cut the tight capsular fibres around the neck of the femur with diathermy.

The entry point to the femur at piriformis fossa


Accurate positioning of the entry point will avoid implant malalignment. The aim of stem positioning is to centralise the stem in both the AP and lateral projections.

Approach through the piriformis fossa leads to neutral AP and neutral lateral stem positioning within an even cement mantle.

FEMORAL INITIATION

Posterior ViewStem aligned centrally in the canal

Posterior ViewStem in varus

Correctly Aligned Stem

Entry point posterior and lateral at the piriformis fossa. Posterior cortex is resected. Free access is gained to the femoral canal. Correctly aligned stem in line with the long

axis of the femur, allowing for an even cement mantle.

Malaligned Stem

Entry point too anterior and medial

Lateral ViewStem aligned centrally in the canal

Lateral ViewStem in retroversion and tip against

posterior cortex

Medial ViewStem aligned centrally in the canal

Medial ViewStem in retroversion and tip against

posterior cortex

Ensure that the femur is presented well into the wound to provide good access during preparation of the femoral canal.

Access the femoral canal at the piriformis fossa, using the EXCEL™ initiator attached to the ‘T’ handle (Figure 13).

Note: It is important to ensure that the entry point is positioned laterally and posteriorly to ensure correct orientation of the stem within the femoral canal. i.e. the entry point, shaft of initiator and long axis of the femur are coincident.

Figure 13


CANAL REAMING

Figure 14

Attach the EXCEL canal probe to the ‘T’ handle and introduce the probe into the femoral canal in line with the femur (Figure 14).

Maintain a neutral orientation and ensure that the probe does not impinge on the entry hole. If the entry point is correct, the probe should pass down the femur easily.

Introduce the first reamer and begin to enlarge the cavity, progressively increasing the size of reamer until the reaming diameter corresponds to the predetermined implant size (see table).

Reaming Guide

Cat. No. DescriptionDistal Reamer

Diameter (mm)

9622-97-000 Flanged 40 12

9622-96-000 Extra Heavy Flanged 40 12

9623-00-000 Roundback 40 12

9623-01-000 Roundback 40 Narrow 11

9623-40-000 Roundback 45 12

9623-43-000 Flanged 45 12

9623-47-000 Extra Heavy Flanged 45 12

9623-49-000 Long Neck 1 12

9623-50-000 Long Neck 1 Extra Heavy 12


The level of the neck resection is determined during preoperative templating. The cut will be approximately 1cm - 2cm above the lesser trochanter or distal to the articular margin. Centre the neck resection guide along the neutral axis of the femur and mark the 45° resection line using diathermy (Figure 15).

Perform the osteotomy using an oscillating saw, taking care to maintain the correct angle. If the posterior approach is being used, two Trethowan retractors are placed around the femoral neck at this stage.

Cut the ligamentum teres and remove the femoral head.

If a bone plug is to be used in the distal femur to restrict the cement, this may now be taken from the exposed cancellous bone of the proximal femur.

Excise the remaining capsule from around the acetabulum. Ensure that the rim and bed of the acetabulum are clear of soft tissues and osteophytes using the CHARNLEY ring curette and CHARNLEY small curette.

Beginning with the smallest diameter reamer, progressively ream away the remaining soft tissues in the acetabular bed (Figure 16). Remove all remaining articular cartilage and any medial osteophytes until healthy, bleeding subchondral bone is exposed and a symmetrical, hemispherical dome is achieved. The reamer should be introduced in 45° of abduction and 15° of anteversion.

Note: If the posterior approach is employed, it should be remembered that this position puts the pelvis in approximately 20°of anteversion which must be compensated for during acetabular reaming and cup placement.

FEMORAL NECK RESECTION

ACETABULAR PREPARATION

Figure 15 Figure 16


ACETABULAR SIZING

Drill multiple holes in the roof of the acetabulum using the collared CHARNLEY acetabular preparation drill to encourage extensive intrusion of the cement into the interstices of the bone (Figure 17).

Note: Care should be taken to avoid he medial wall of the acetabulum. This is a triangle of bone based on the transverse ligament.

Smooth the edges of the drill holes and remove the debris using a small curette.

Use the spoon to feel for any cysts which may not have been revealed by radiological examination.

Attach the phantom cup and trial flange to the cup introducer and check the size of the acetabulum. Trim the rim of the trial flange so that it just fits within the rim of the acetabulum (Figure18).

Using the trial as a guide, cut the flange of the definitive cup to match.

Lavage and clear the acetabulum of debris.

Figure 17 Figure 18

Long axis of the patient

Shaft of the introducerparallel to the superior andinferior illiac spines.

10˚ of anteversion


CUP IMPLANTATION FEMORAL CANAL PREPARATION

Attach the cup to the cup introducer. Introduce the cement into the acetabular bed and insert the cup (Figure 15). The cement should be fully contained behind the rim of the cup, and the rim well supported by the cement. Align the shaft of the introducer with the anterior superior iliac spine and rotate the handle posteriorly to give 10° - 15° of anteversion. (Using the posterior approach, anteversion of the pelvis requires the cup holder to be orientated at approximately 30° - 35° of anteversion relative to the long axis of the patient.)

Locate the cup pusher on the back of the cup introducer and pressurise the cement. Once the cement has begun to polymerise, the cup pusher can be applied directly to the cup and pressure maintained until polymerisation is complete.

The rim of the acetabulum should be checked for any remaining osteophytes and cement debris which might cause impingement. To protect the cup, cover it with a clean swab. Attention may now be turned to the femur.

Using the leading edge of the anteversion osteotome positioned laterally toward the greater trochanter, enlarge the entry point to the femoral canal and establish 10°- 15° of anteversion for broach alignment (Figure 16).

Reverse the osteotome and extend the entry point medially toward the lesser trochanter. Remove a wedge of cancellous bone approximately the same size and shape as the proximal section of the prosthesis.

Figure 15 Figure 16


BROACHING TRIAL REDUCTION

Attach a broach, smaller than that determined during preoperative templating, to the in line broach handle.

With the broach parallel to the long axis of the femur and at right angles to the tibia, pass the broach down the canal in neutral orientation, with 10°- 15° of anteversion (Figure 17).

To avoid varus alignment with the femoral axis, position the broach laterally toward the greater trochanter.

Progressively increase the size of broach until a cavity is prepared which matches the size planned during pre-operative templating.

When the final broach is seated at the resection line, fit the trial head onto the neck of the broach and reduce the hip (Figure 18).

Check for impingement and joint stability through adduction, rotation and flexion.

Remove the trial head and re-engage the in line broach handle to extract the broach.

Introduce the cement restrictor and ensure that it is firmly seated in the femoral canal at the depth indicated by the size of the definitive implant (see table overleaf).

Using a bone brush and irrigation, ensure that the femoral canal is clear of blood and loose debris.

Figure 17 Figure 18


Prosthesis Description

Broach Description

Cement Restrictor Size (mm)

Cement Restrictor

Depth* (mm)

Flanged 40 F40 12 135

Extra Heavy Flanged 40 F40EH 12 135

Roundback 40 RB40 12 135

Roundback 40 Narrow RB40N 1 1 135

Roundback 45 RB45 12 135

Flanged 45 F45 12 135

Extra Heavy Flanged 45 F45EH 12 135

Long Neck 1 LN1 12 135

Long Neck 1 Extra Heavy LN1EH 12 140

Figure 19

CEMENT RESTRICTOR DEPTHS

DISTAL CENTRALISER SELECTION

* These measurements are taken from the medial edge of the neck osteotomy and allow for 20mm of cement distal to the tip of the prosthesis. If a bone block is to be used, this distance may be varied according to surgeon preference.

Attaching the Centraliser Select the CHARNLEY Centraliser that corresponds to the diameter of the femoral canal (refer to table). After selecting the right size of centraliser, slide it over the distal tip of the stem and push the end over the tip of the stem (Figure 19).

SizeCentraliser 1Canal Size

Centraliser 2Canal Size

Flanged 40 Extra Heavy Flanged 40

13.0-14.5 mm 15.0-16.5 mm

15.0 mm+ 17.0 mm+

Roundback 40Roundback 40 Narrow Roundback 45

13.0-14.5 mm13.0-14.5 mm 13.0-14.5 mm

15.0 mm+15.0 mm+ 15.0 mm+

Flanged 45Extra Heavy Flanged 45

13.0-14.5 mm15.0-16.5 mm

15.0 mm+17.0 mm+


Figure 20

STEM IMPLANTATION

Attach the definitive femoral implant, with its cover in place, to the CHARNLEY introducer. Insert the cement, filling the femoral canal and pressurise the cement. (Effective pressurisation should result in the extrusion of blood through the cortex at the rim of the proximal femur.)

Introduce the implant, in line with the femoral axis i.e. down the piriformis fossa. Remove the implant cover and maintain pressure on the femoral head, using the head pusher, until polymerisation is complete (Figure 20).

Remove all excess cement, taking care not to scratch the femoral head, and irrigate thoroughly to clear away any remaining debris from the joint.

Carry out a final reduction to check joint stability function.

Introduce the first drain into the joint and reattach the tendonous tissue below the flap of the abductor muscles.

Place the second drain behind the trochanter and close the wound.

In the posterior approach, after the first drain has been introduced the short rotator muscles are reattached to the posterior edge of the gluteus medius tendon.


Acetabular Instruments

9626-29-000 Acetabular Prep Drill

9626-30-000 Cup Introducer 22.225mm

9626-00-000 Cup Trial 40mm

9626-01-000 Cup Trial 43mm

9626-02-000 Cup Trial 47mm

9626-03-000 Cup Trial 50mm

9626-05-000 Cup Trial 53mm

2015-24-000 Cup Pusher Handle

9601-18-000 Cup Pusher Head 22.225mm

9628-00-000 Cemented Acetabular Instrument Tray

9628-02-000 Cemented Acetabular Templates

For Complete Code Listings for PINNACLE® please use: PINNACLE Product Code Cataluge DSEM/JRC/0615/0319

Distributed products on behalf of Timesco fo London Ltd,

1 Knights RD, London, E16 2AT UK.

1271-00-500 Utility sciss plastic HDL 7.5” green

Acetabular Implants

CHARNLEY9651-22-038 CHARNLEY LPW Cup 22.225/38

9651-22-040 CHARNLEY LPW Cup 22.225/40

9651-22-043 CHARNLEY LPW Cup 22.225/43

9651-22-047 CHARNLEY LPW Cup 22.225/47

9651-22-050 CHARNLEY LPW Cup 22.225/50

9651-22-053 CHARNLEY LPW Cup 22.225/53

9652-22-040 CHARNLEY Flanged Cup 22.225/40





9653-22-040 CHARNLEY OGEE® Cup 22.225/40

9653-22-043 CHARNLEY OGEE Cup 22.225/43




CHARNLEY Base Broaching Instrument Set

Base Tray9620-40-000 CHARNLEY Neck Osteotomy Guide

2522-00-506 ELITE™ In-Line Broach Handle

9626-14-000 ELITE Femoral Prosthesis Holder

9626-15-000 ELITE Trial Femoral Head 22.225 Std

9629-01-000 CHARNLEY/ELITE Broach RB40 N

9629-02-000 CHARNLEY/ELITE Broach RB40

9629-03-000 CHARNLEY /ELITE Broach FL40

9629-04-000 CHARNLEY/ELITE Broach FL40 EH

9629-06-000 CHARNLEY/ELITE Broach LN1

9625-82-000 CHARNLEY/ELITE Broach RB45

9625-83-000 CHARNLEY/ELITE Broach FL45

9625-84-000 CHARNLEY/ELITE Broach FL45 EH

CHARNLEY EXCEL Femoral Instrument Set

Top Tray9620-45-000 CHARNLEY Curette Small

9620-46-000 CHARNLEY Curette Medium

9620-47-000 CHARNLEY Curette Large

9622-72-000 CHARNLEY Ring Curette

2001-42-000 EXCEL T Handle

2001-18-501 IM Initiator

2354-10-000 Muller Awl Reamer with Hudson End

2105-12-000 Canal Reamer 10




2002-25-000 Anteversion Osteotome Medium

ORDERING INFORMATION


CHARNLEY Broaching Instrument Set

Top Tray9629-00-000 CHARNLEY/ELITE Broach SNS 35

9629-05-000 CHARNLEY/ELITE Broach Magnum 40

9629-07-000 CHARNLEY/ELITE Broach LN1 EH

9629-08-000 CHARNLEY/ELITE Broach LN1 LS

9629-09-000 CHARNLEY/ELITE Broach LN2

9629-10-000 CHARNLEY/ELITE Broach LN2 EH

9629-11-000 CHARNLEY/ELITE Broach LN2 LS

9629-12-000 CHARNLEY/ELITE Broach CDH Extra Small

9629-13-000 CHARNLEY/ELITE Broach CDH

9629-14-000 CHARNLEY/ELITE Broach 3/4 Neck

9625-85-000 CHARNLEY/ELITE Broach Magnum 45

5460-30-000 Cement Restrictor Trial 1







Femoral Implants

9622-96-000 CHARNLEY Extra Heavy Flanged 40

9622-97-000 CHARNLEY Flanged 40

9623-00-000 CHARNLEY Roundback 40

9623-01-000 CHARNLEY Roundback 40 Narrow

9623-40-000 CHARNLEY Roundback 45

9623-43-000 CHARNLEY Flanged 45

9623-47-000 CHARNLEY Extra Heavy Flanged 45

9623-49-000 CHARNLEY Long Neck 1

9623-50-000 CHARNLEY Long Neck 1 Extra Heavy

5460-10-000 Cement Restrictor Size 1







Centralisers9600-92-000 CHARNLEY Size 1 Centraliser (PMMA)

9600-93-000 CHARNLEY Size 2 Centraliser (PMMA)

©Johnson & Johnson Medical Limited. 2016. All rights reserved.

Johnson & Johnson Medical Limited PO BOX 1988, Simpson Parkway, Livingston, West Lothian, EH54 0AB, United Kingdom.Incorporated and registered in Scotland under company number SC132162.

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The third-party trademarks used herein are trademarks of their respective owners.

0086

DePuy (Ireland)LoughbegRingaskiddyCo. CorkIrelandTel: +353 21 4914 000 Fax: +353 21 4914 199

DePuy Orthopaedics, Inc. 700 Orthopaedic DriveWarsaw, IN 46582USATel: +1 (800) 366 8143Fax: +1 (574) 267 7196

DePuy International LtdSt Anthony’s RoadLeeds LS11 8DTEnglandTel: +44 (0)113 270 0461 Fax: +44 (0)113 272 4101

CA#DSEM/JRC/0716/0669 Issued: 07/16

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