cemented hip portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/llnwmb8/int mobile/synthes...
TRANSCRIPT
![Page 1: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/1.jpg)
v
Focus on:
C-STEM™ AMT and
MARATHON™ Cemented Cup
Cemented HipPortfolio
1
Zinc # DSEM/JRC/0417/0797
![Page 2: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/2.jpg)
Cemented prosthesis are engineered to
be a reliable method of hip replacement.
Alongside our cementless portfolio,
cemented prostheses can offer surgeons
and payers a total solution to treat their
patients whilst providing cost effective
treatment.
Cemented portfolio value proposition
2
Zinc # DSEM/JRC/0417/0797
![Page 3: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/3.jpg)
What’s our portfolio?
3
PREMIUM
C-STEM AMT/ C-STEM original
MARATHON XLPE Cemented Cup
HYBRID
C-STEM AMT
PINNACLE® Cementless Acetabular Cup
Latest ODEP ratings can be found at www.odep.org.uk
VALUE
CORAIL®
Cemented
ELITE Plus Ogee Cemented Cup
REVERSE HYBRID
CORAIL®
Cementless
MARATHON XLPE Cemented Cup
Zinc # DSEM/JRC/0417/0797
![Page 4: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/4.jpg)
4
(ARTICUL/EZE™ Mini Taper)
C-STEM™ AMT
Zinc # DSEM/JRC/0417/0797
![Page 5: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/5.jpg)
C-STEM original design concepts
5
• Reduced distal tip dimension
• Polished finish
• Reduced lateral shoulder
• Long medial bearing surface
Zinc # DSEM/JRC/0417/0797
![Page 6: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/6.jpg)
Loading of the hip joint
6
Zinc # DSEM/JRC/0417/0797
![Page 7: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/7.jpg)
The answer – load transfer through a triple taper
7
• Cobra Flange from the CHARNLEY® and extend it down the length of the implant
• 3rd Taper - runs from the lateral shoulder to the medial apex
• Generates proximal load transfer
• Third taper works with two more conventional tapers and overall stem geometry to increase stability
• Axially1
• Torsion1
1. Starke. G. An assessment of the C-STEM II femoral component. FRD/UCT Centre for research in
computational and applied Mechanics, University of Cape Town, South Africa
Cobra Flange
Zinc # DSEM/JRC/0417/0797
![Page 8: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/8.jpg)
The Triple Taper – a little more detail
8
• The 3 tapers are:
• Taper 1 - M/L (Coronal)
• Taper 2 – A/P (Saggittal)
• Taper 3 - M/L Horizontal)
• Tapers 1+2
• Axial stability
• Taper 3
• Increased proximal M/L dimension
• Designed for increased calcar loading
3
2
11
Zinc # DSEM/JRC/0417/0797
![Page 9: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/9.jpg)
C-STEM Triple Tapered Concept
9
• 3rd Taper behaves as an “Ovoid” wedge resisting the varus “fall over” seen with contemporary stem designs
• Load is shared
• medial to the anterior and posterior
• more even circumferential loading
• A-P shear force creates hoop stresses
• The wedged cross section results in lesser sub surface fatigue
Zinc # DSEM/JRC/0417/0797
![Page 10: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/10.jpg)
Summary of C-STEM original concept
10
• Proximal loading to protect and maintain femoral bone
• Improved axial and torsion stability1
• Reduces cement mantle stresses2
• Restoration of natural biomechanics
• Even cement mantle
• Optimal load transfer in the proximal femur resulting in positive postoperative bone remodelling1
1. Starke. G. An assessment of the C-STEM II femoral component. FRD/UCT Centre for research in
computational and applied Mechanics, University of Cape Town, South Africa
2. Spitze A. “The Triple-Tapered Stem.” Orthopeadic Technology Review, 2(4), March/April 2002:26-
27, 30.
Zinc # DSEM/JRC/0417/0797
![Page 11: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/11.jpg)
C-STEM original – the World Wide View
11
• Positives
• High acceptance of C-Stem principles
• Favourable response to report of positive bone re-modelling• Journal of Arthroplasty papers3
• Increased World Wide acceptance of polished tapered stems• market segment growing
3. Husby OS. A Randomised, Prospective, RSA Post Marketing Study Comparing SMARTSET™ HV
and PALACOS® R Bone Cement in THA, presented to the Norwegian Orthopaedic Association
(NOA), Oslo, Norway, October 27th/28th 2005.
Zinc # DSEM/JRC/0417/0797
![Page 12: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/12.jpg)
C-STEM original – the World Wide View
12
• Concerns• Consistent requests for higher offsets from some markets
• 9/10 taper was a barrier to acceptance in major markets
• Question mark over rotational stability4 (paper updated in 2014
which shows that C-Stem “didn’t” migrate - Continuous distal migration and internal rotation of the C-stem prosthesis without any adverse clinical effectsBone Joint J 2014;96-B:604–8. Received 28 November 2013;)
• Difficult to get the correct rotation as you cannot see the shoulder (cement covering)
4. Sundberg, M. “Movement patterns of the C-Stem femoral component”. J Bone Joint Surg [Br] 2005;87-B:1352-6.
Zinc # DSEM/JRC/0417/0797
![Page 13: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/13.jpg)
C-STEM AMT
13
• Same intra-medullary geometry
• Raised shoulder and broader M/L body
• 12/14 ‘articuleze’ mini-taper (AMT)
• Narrower A/P neck geometry
• Deep medial profile
• Greater differentiation between standard and high offset
• Continued to be made from Hi Nitrogen, cold forged Stainless Steel (Same as original C-STEM) C-STEM
9/10 Taper
C-STEM AMT
12/14 Taper
Zinc # DSEM/JRC/0417/0797
![Page 14: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/14.jpg)
Identical body sizes : use same
broaches as C-STEM
12/14 articuleze mini-taper (AMT)
Raised Lateral Shoulder
Size 4 HO Size 4
Geometry
Increased rotational stability5
14
5. Data on file: DHF A457 (Range of motion for C-STEM AMT)
Zinc # DSEM/JRC/0417/0797
![Page 15: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/15.jpg)
15
Zinc # DSEM/JRC/0417/0797
![Page 16: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/16.jpg)
Taper & Neck improvements
• Optimized 12/14 mini taper
• Completely captures head
• All head sizes and options available
• Less inventory
• Improved neck geometry
• Flattened A/P Geometry
• Designed to reduce A/P impingement
• Increased ROM possibility
• Proportionally Offset Anterior
Posterior
C-STEM
C-STEM AMT
16
Zinc # DSEM/JRC/0417/0797
![Page 17: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/17.jpg)
Biomechanics & offset
• 2 offsets per size – standard & high
• Direct lateralisation• Favors offset over length• No impact on leg length• Adds 6 mm to sizes 1 - 3• Adds 8 mm to sizes 4 - 8
• Constant 130 degree neck angle
• Proportional through size Standard
Offset
High
Offset
17
Zinc # DSEM/JRC/0417/0797
![Page 18: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/18.jpg)
Proximal-Distal Placement Options
• Can be implanted at three levels
• Provides 3 different leg lengths
• There are STD and high offset stems
• Multiple neck lengths depending on choice of modular head
Standard
Offset
High
Offset
18
Zinc # DSEM/JRC/0417/0797
![Page 19: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/19.jpg)
C-Stem AMT Line Extension & refresh
• Implant portfolio completion – 6 revision stems, 3 Asian and a CDH stem added to the range.
• Instrument upgrades
• Box osteotome
• Curved non-retaining inserter handle
• Depth marked broaches and trial necks
• New trial stems
• Tray upgrades
• InCement revision tray
• Core kit to serve 90%+ patients
• Streamlined kit to reduce COGs and increase hospital acceptance
19
Zinc # DSEM/JRC/0417/0797
![Page 20: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/20.jpg)
New additions to C-STEM AMT range
Size 2 & 3 180 mm long stems in std and high offset
Size 3 205 mm XL, 240 XL std offset stems
4 Small C-STEM AMT Implants - 1 CDH & 3 ‘A’ sizes
1570-24-095 C-STEM AMT CDH Standard Offset
1570-24-091 C-STEM AMT Size 1A Standard Offset
1570-24-092 C-STEM AMT Size 2A Standard Offset
1570-24-093 C-STEM AMT Size 3A Standard Offset
6 Revision C-STEM AMT Implants
1570-24-087 C-STEM AMT Long 2 Standard Offset
1570-24-088 C-STEM AMT Long 3 Standard Offset
1570-24-089 C-STEM AMT XL205 3 Standard Offset
1570-24-094 C-STEM AMT XL240 3 Standard Offset
1570-24-085 C-STEM AMT Long 2 High Offset
1570-24-086 C-STEM AMT Long 3 High Offset
20
Zinc # DSEM/JRC/0417/0797
![Page 21: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/21.jpg)
C-STEM Instrument additions
21
• Trial stems
• Ability to trial a stem during InCement procedure
• Ability to trial during revision surgery
• Simple to use height adjuster
• More intuitive use during surgery
• Easy placement
258003086 C STEM AMT STEM TRIAL 2 LONG S
258004086 C STEM AMT STEM TRIAL 2 LONG H
258003087 C STEM AMT STEM TRIAL 3 LONG S
258004087 C STEM AMT STEM TRIAL 3 LONG H
258005087 C STEM AMT STEM TRIAL 3 XL205
258006087 C STEM AMT STEM TRIAL SIZE 3 XL 240
258001010 C STEM AMT VERSION PIN
Zinc # DSEM/JRC/0417/0797
![Page 22: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/22.jpg)
C-STEM Instrument additions
22
• Improved depth markings on broach and trial necks
• Designed to improve ability of surgeon to gauge appropriate depth of insertion and therefore the most appropriate leg length
Zinc # DSEM/JRC/0417/0797
![Page 23: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/23.jpg)
C-STEM Instrument additions
23
• Modular box osteotome
• Reduces size and weight
• Curved non-retained inserter handle
• Benefits of original straight inserter
• Avoids greater trochanter during insertion
259807532 MODULAR BOX OSTEOTOME
252200502 STEM INTRODUCER (straight)
252200503 STEM INTRODUCER (curved/retained)
252200504 STEM INTRODUCER (curved/non-retained)
Zinc # DSEM/JRC/0417/0797
![Page 24: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/24.jpg)
C-STEM Instrument additionsImproved Introducer Handle
24
Zinc # DSEM/JRC/0417/0797
![Page 25: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/25.jpg)
Instruments (Pre 2017)Leg length adjuster
25
Zinc # DSEM/JRC/0417/0797
![Page 26: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/26.jpg)
Tray layout refresh
26
• Reduce our cost to serve our customer
• Improve proficiency of tray and instrument use in and out theatre
• Reduce the instrument sterilisation costs for our customer
• Reduce instrument and tray workflow pressure on hospital nursing staff
Core kit (90 kit) Extended kit (10 kit)
Revision kit InCement kit
Zinc # DSEM/JRC/0417/0797
![Page 27: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/27.jpg)
InCement Revision
27
DePuy Synthes InCement revision system is a clinically proven
conservative approach that reduces complexity, reduces risk of
fracture, bone loss, blood loss and surgery time and reduces cost6,7,8,9,
whilst utilising a 10A* ODEP rated primary cemented stem. This
system is provided for in a single tray reducing the number of trays
needed for a case whilst increasing the opportunity to target
competitor surgeons.
Key Value Proposition
6. Holt G, Hook S, Hubble M. Revision total hip arthroplasty: the femoral side using cemented implants. Int Orthop. 2011 Feb;35(2):267-73.
7. Duncan WW, Hubble MJW, Howell JR, Whitehouse SL, Timperley AJ, Gie GA. Revision of the cemented femoral stem using a cement-in-cement technique.
A five- to 15-year review. J Bone Joint Surg [Br] 2009;91-B:577-82.
8. Stefanovich-Lawbuary NS, Parry MC, Whitehouse MR, Blom AW. Cement in Cement Revision of the Femoral Component Using
a Collarless Triple Taper: A Midterm Clinical and Radiographic Assessment. J Arthroplasty. 2014 Oct;29(10):2002-6.
9. Morley JR, Blake SM, Hubble MJW, Timperley AJ, Gie GA, Howell JR. Preservation of the original femoral cement mantle during the management of infected cemented total hip
arthroplasty by twostage
revision. J Bone Joint Surg [Br]2012: 94B: 322-7.
Zinc # DSEM/JRC/0417/0797
![Page 28: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/28.jpg)
What is InCement Revision
28
What
• Utilise well fixed cement mantle
• Remove old stem
• Clean and re-cement new stem
Why
• Less expensive implants costs
• Quicker & easier to do in elderly
• Increasing Publications show improved results
• Fits with new tariff introductions
• One of the fastest growing revision areas
Supporting growth
Zinc # DSEM/JRC/0417/0797
![Page 29: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/29.jpg)
InCement Revision
29
• There is a growing trend for InCement Revisions
• Proportion of the existing cement mantle to be left in-situ
• The “Revision” stem (usually a primary size 1 or 2 Stdor HO) is then cemented within the existing mantle
• Cement mantle removal can result in
• Substantial blood loss
• Femoral perforation
• Femoral fracture
• Loss of bone stock
• Increase in operation time
• By avoiding cement removal the surgeon is able to reduce those problems associated with cement mantle removal
Zinc # DSEM/JRC/0417/0797
![Page 30: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/30.jpg)
InCement Revision
30
• Key InCement Revision steps are:
• Old stem removal
• Remove loose proximal cement
• Trial stem/head combination
• Cement in new stem
Stem Removal Check Cement Integrity Trialling
Cementation C-STEM AMT Introduction Final Reduction
Zinc # DSEM/JRC/0417/0797
![Page 31: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/31.jpg)
InCement Revision
31
• Independent/standalone tray for InCement only
• Contains the main instruments required for an InCement procedure
• Disposable chisels and handle
• Slap hammer
• Trial stems and heads
• Stem inserter & head impactor
• Able to target new & competitive customers
Zinc # DSEM/JRC/0417/0797
![Page 32: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/32.jpg)
Don’t sell one, sell them all
PORTFOLIO
32
Zinc # DSEM/JRC/0417/0797
![Page 33: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/33.jpg)
What’s our portfolio?
33
PREMIUM
C-STEM AMT/ C-STEM original
MARATHON XLPE Cemented Cup
HYBRID
C-STEM AMT
PINNACLE® Cementless Acetabular Cup
Latest ODEP ratings can be found at www.odep.org.uk
VALUE
CORAIL®
Cemented
ELITE Plus Ogee Cemented Cup
REVERSE HYBRID
CORAIL®
Cementless
MARATHON XLPE Cemented Cup
Zinc # DSEM/JRC/0417/0797
![Page 34: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/34.jpg)
How
34
Need to sell portfolio?
PREMIUM HYBRID REVERSE HYBRID
C-STEM AMT/ C-STEM originalMARATHON
CORAIL CementlessMARATHON
C-STEM AMTPINNACLE
A premium solution
for surgeons who
value cemented
constructs
Believe in our proven
cementless stem but
want cup positioning
and low wear of our
cemented cups
Want cementless
cup fixation but believe
cemented stems are a
better option than
cementless in some
patients
Zinc # DSEM/JRC/0417/0797
![Page 35: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/35.jpg)
C-STEM AMT Conclusions
• C-STEM AMT founded in C-STEM heritage
• C-STEM AMT system able to compete
• Visitation centres
• Key opinion leader group
• 10A* ODEP rating
35
Zinc # DSEM/JRC/0417/0797
![Page 36: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/36.jpg)
Post 2017
C-STEM™Surgical Technique
36
Zinc # DSEM/JRC/0417/0797
![Page 37: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/37.jpg)
Objectives – Understand:
• The sequence of steps in the C-STEM Surgical technique
• Good cement technique and its importance
37
Zinc # DSEM/JRC/0417/0797
![Page 38: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/38.jpg)
Pre-operative Templating
• Templates are provided to determine both Implant size & neck resection level
• Consideration should be given to restoration of leg length and soft tissue balance duringpre-op planning
38
Zinc # DSEM/JRC/0417/0797
![Page 39: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/39.jpg)
Neck Resection
• Once the femoral head is exposed, align the neck resection guide against the long axis of the femur.* Determine the resection level by aligning the top of the guide with the tip of the greater trochanter or by referencing a measured resection level above the lesser trochanter.
• Confirm the resection level with the preoperatively templated plan. Mark the resection line using diathermy. Resect the femoral head. The collarless stem enables proximal and distal adjustment regardless of neck resection level; however, orientation of the cut should be perpendicular to the neck axis in both planes in order to avoid impingement of the medial stem against the medial neck.
*Please note that the CDH stem has a CCD angle of 125° (a resection angle of 55°).The rest of the C-STEM AMT size range have a CCD angle of 130° (a resection angle of 50°)
39
Zinc # DSEM/JRC/0417/0797
![Page 40: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/40.jpg)
Opening the femoral canal
40
Clearing the Anatomical Calcar
• In order to achieve an optimal cement mantle, clear the anatomical calcar (the cortical condensation overlying the endosteal entry into the lesser trochanter) using an osteotome or curette. Avoid excavating the lesser trochanter.
Femoral Alignment
• Attach the Canal Probe to the T-Handle.
Introduce the probe into the femoral
canal,maintaining neutral orientation
• The C-STEM AMT Hip System is designed
as a broach-only system, to maximise the
strength of the bone / cement interface.
Zinc # DSEM/JRC/0417/0797
![Page 41: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/41.jpg)
Metaphyseal Preparation
Femoral Broaching
• Attach a broach – two sizes smaller than the size determined during pre-operative templating – to the broach handle. Carefully impact the broach down the long axis of the canal in neutral orientation.
• Diamond tooth broaches should not be introduced aggressively. When using the posterolateral approach, incorporate 5-15˚ of anteversion
41
Zinc # DSEM/JRC/0417/0797
![Page 42: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/42.jpg)
Broaching Levels
• Ensure that any remaining superolateral femoral neck is cleared to avoid varus stem placement.
• Sequentially increase the size of the broach until the final broach is fully seated in the femur with the upper surface of the broach level with the neck resection level, or at the level determined during pre-operative templating
• If the final seating position does not match the pre-operatively templated position, the leg length adaptors can be used to set the broach at neutral or +5 mm positions for trial reduction
42
Zinc # DSEM/JRC/0417/0797
![Page 43: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/43.jpg)
Calcar Planing
• Since the C-STEM AMT Stem is a collarless stem, it can be positioned proximally or distally to the neck cut. Therefore, calcar planing is not mandatory; however, it is advisable in order to facilitate seating the actual prosthesis to the same level as the broach. Position the centre hole of the planer over the broach trunnion and plane the bone until it is level with the proximal surface of the broach.
• Because the CDH stem has a CCD angle of 125° (rather than 130° like the rest of this range), calcar planing SHOULD NOT be used with the CDH broach.
43
Zinc # DSEM/JRC/0417/0797
![Page 44: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/44.jpg)
Trial Reduction
Femoral Neck Trial Assembly
• Attach the appropriate neck segment to the broach.
• If the femoral neck resection level is correct for proper leg length restoration, but there is still inadequate soft tissue abductor muscle tension, consider a high offset neck segment.
• Use a combination of neck segment and trial head sizes to restore joint stability with an adequate range of motion
Broach Removal
• Remove the broach using the broach handle. Clean the canal to remove loose cancellous bone using a curette.
44
Zinc # DSEM/JRC/0417/0797
![Page 45: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/45.jpg)
Cement Restriction
Inserting the Cement Restrictor
• Use pulsatile lavage to clear the femoral canal of debris and open the interstices of the bone.
• Use the stem restrictor trial based on the size determined from pre-operative templating to establish the correct size. Attach the correct size of trial cement restrictor to the cement restrictor inserter and insert the trial to the planned depth.
• Check that it is firmly seated in the canal.
• Remove the trial and replace it with the corresponding restrictor implant. Insert the PE cement restrictor implant at the same level as the restrictor trial
45
Zinc # DSEM/JRC/0417/0797
![Page 46: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/46.jpg)
Distal Centraliser
Attaching the Void Centraliser
• Using the centraliser trials, select the C-STEM void centraliser that corresponds to the diameter of the femoral canal (C-STEM Void Centralisers increase in 2 mm increments from 10 - 20 mm).
• After selecting the right size of centraliser, slide it firmly over the distal tip of the stem and push the end over the tip of the stem, observing the correct orientation of one of the fins with the lateral edge.
46
Zinc # DSEM/JRC/0417/0797
![Page 47: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/47.jpg)
Opening the femoral canal
• Start at the distal part of the femoral canal and inject the cement in a retrograde fashion, allowing the cement to push the nozzle gently back, until the canal is completely filled and the distal tip of the nozzle is clear of the canal.
• Continually inject cement during the period of Pressurisation. Use the Femoral Prep Kit curettes to remove excess bone cement. Implant insertion can begin when the cement can be pressed together without sticking to itself.
47
Zinc # DSEM/JRC/0417/0797
![Page 48: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/48.jpg)
DePuy Synthes Cement
The SMARTMIX CEMVAC Vacuum Mixing SystemThe SMARTMIX™ CEMVAC® Vacuum
Mixing System Prefilled with SmartSet
(G)HV Bone Cement
48
Zinc # DSEM/JRC/0417/0797
![Page 49: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/49.jpg)
Femoral Stem Implantation
• In terms of implantation depth, the stem is “neutrally” seated when the middle marking on the stem is level with the neck resection. The additional lines allow the implant to be raised or to increase or decrease leg length, without adjusting the offset.
• Introduce the implant in line with the long axis of the femur. Its entry point should be lateral, close to the greater trochanter.
• During stem insertion maintain thumb pressure on the cement at the medial femoral neck ensuring the stem is in the middle of the prepared cavity
49
Zinc # DSEM/JRC/0417/0797
![Page 50: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/50.jpg)
Femoral Head Impaction
50
• Once the cement has completely set, place the trial head on the implant and perform a final trial reduction.
• Remove the trial head and irrigate and thoroughly clean and dry the taper to remove any fluid or particulate debris.
• Twist and push the definitive head onto the taper using the head taper, then impact firmly with head impactor.
• Reduce the hip to carry out a final assessment of joint mechanics and stability.
Closure
• Closure is based on the surgeon’s preference and the individual case. The repair should be tested throughout the hip range of motion.
Zinc # DSEM/JRC/0417/0797
![Page 51: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/51.jpg)
Summary
51
• The sequence of steps in the C-STEM Surgical Technique
• Good cement technique and its importance
Zinc # DSEM/JRC/0417/0797
![Page 52: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/52.jpg)
Pre 2017
C-STEM™Surgical Technique
52
Zinc # DSEM/JRC/0417/0797
![Page 53: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/53.jpg)
Objectives – Understand:
• The sequence of steps in the C-STEM Surgical technique
• Good cement technique and its importance
53
Zinc # DSEM/JRC/0417/0797
![Page 54: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/54.jpg)
Pre-operative Templating
• Templates are provided to determine both Implant size & neck resection level
• Consideration should be given to restoration of leg length and soft tissue balance duringpre-op planning
54
Zinc # DSEM/JRC/0417/0797
![Page 55: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/55.jpg)
Neck Resection
• Once the femoral head is exposed, align the neck resection guide against the long axis of the femur.* Determine the resection level by aligning the top of the guide with the tip of the greater trochanter or by referencing a measured resection level above the lesser trochanter.
• Confirm the resection level with the preoperatively templated plan. Mark the resection line using diathermy. Resect the femoral head. The collarless stem enables proximal and distal adjustment regardless of neck resection level; however, orientation of the cut should be perpendicular to the neck axis in both planes in order to avoid impingement of the medial stem against the medial neck.
*Please note that the CDH stem has a CCD angle of 125° (a resection angle of 55°).The rest of the C-STEM AMT size range have a CCD angle of 130° (a resection angle of 50°)
55
Zinc # DSEM/JRC/0417/0797
![Page 56: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/56.jpg)
Clearing the Anatomical Calcar
• In order to achieve an optimal cement mantle, clear the anatomical calcar (the cortical condensation overlying the endosteal entry into the lesser trochanter) using an osteotome or curette. Avoid excavating the lesser trochanter.
Femoral Alignment
• Attach the Canal Probe to the T-Handle. Introduce the probe into the femoral canal,maintaining neutral orientation
• The C-STEM AMT Hip System is designed as a broach-only system, to maximise the strength of the bone / cement interface.
Opening the femoral canal
56
Zinc # DSEM/JRC/0417/0797
![Page 57: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/57.jpg)
Metaphyseal Preparation
Femoral Broaching
• Attach a broach – two sizes smaller than the size determined during pre-operative templating – to the broach handle. Carefully impact the broach down the long axis of the canal in neutral orientation.
• Diamond tooth broaches should not be introduced aggressively. When using the posterolateral approach, incorporate 5-15˚ of anteversion
57
Zinc # DSEM/JRC/0417/0797
![Page 58: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/58.jpg)
Broaching Levels
• Ensure that any remaining superolateral femoral neck is cleared to avoid varus stem placement.
• Sequentially increase the size of the broach until the final broach is fully seated in the femur with the upper surface of the broach level with the neck resection level, or at the level determined during pre-operative templating
• If the final seating position does not match the pre-operatively templated position, the leg length adaptors can be used to set the broach at neutral or +5 mm positions for trial reduction
58
Zinc # DSEM/JRC/0417/0797
![Page 59: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/59.jpg)
Calcar Planing
• Since the C-STEM AMT Stem is a collarless stem, it can be positioned proximally or distally to the neck cut. Therefore, calcar planing is not mandatory; however, it is advisable in order to facilitate seating the actual prosthesis to the same level as the broach. Position the centre hole of the planer over the broach trunnion and plane the bone until it is level with the proximal surface of the broach.
• Because the CDH stem has a CCD angle of 125° (rather than 130° like the rest of this range), calcar planing SHOULD NOT be used with the CDH broach.
59
Zinc # DSEM/JRC/0417/0797
![Page 60: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/60.jpg)
Trial Reduction
Femoral Neck Trial Assembly
• Attach the appropriate neck segment to the broach.
• If the femoral neck resection level is correct for proper leg length restoration, but there is still inadequate soft tissue abductor muscle tension, consider a high offset neck segment.
• Use a combination of neck segment and trial head sizes to restore joint stability with an adequate range of motion
Broach Removal
• Remove the broach using the broach handle. Clean the canal to remove loose cancellous bone using a curette.
60
Zinc # DSEM/JRC/0417/0797
![Page 61: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/61.jpg)
Cement Restriction
Inserting the Cement Restrictor
• Use pulsatile lavage to clear the femoral canal of debris and open the interstices of the bone.
• Use the stem restrictor trial based on the size determined from pre-operative templating to establish the correct size. Attach the correct size of trial cement restrictor to the cement restrictor inserter and insert the trial to the planned depth.
• Check that it is firmly seated in the canal.
• Remove the trial and replace it with the corresponding restrictor implant. Insert the PE cement restrictor implant at the same level as the restrictor trial
61
Zinc # DSEM/JRC/0417/0797
![Page 62: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/62.jpg)
Distal Centraliser
Attaching the Void Centraliser
• Using the centraliser trials, select the C-STEM void centraliser that corresponds to the diameter of the femoral canal (C-STEM Void Centralisers increase in 2 mm increments from 10 - 20 mm).
• After selecting the right size of centraliser, slide it firmly over the distal tip of the stem and push the end over the tip of the stem, observing the correct orientation of one of the fins with the lateral edge.
62
Zinc # DSEM/JRC/0417/0797
![Page 63: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/63.jpg)
Opening the femoral canal
• Start at the distal part of the femoral canal and inject the cement in a retrograde fashion, allowing the cement to push the nozzle gently back, until the canal is completely filled and the distal tip of the nozzle is clear of the canal.
• Continually inject cement during the period of Pressurisation. Use the Femoral Prep Kit curettes to remove excess bone cement. Implant insertion can begin when the cement can be pressed together without sticking to itself.
63
Zinc # DSEM/JRC/0417/0797
![Page 64: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/64.jpg)
DePuy Synthes Cement
The SMARTMIX CEMVAC Vacuum Mixing SystemThe SMARTMIX™ CEMVAC® Vacuum
Mixing System Prefilled with SmartSet
(G)HV Bone Cement
64
Zinc # DSEM/JRC/0417/0797
![Page 65: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/65.jpg)
Femoral Stem Implantation
• In terms of implantation depth, the stem is “neutrally” seated when the middle marking on the stem is level with the neck resection. The additional lines allow the implant to be raised or to increase or decrease leg length, without adjusting the offset.
• Introduce the implant in line with the long axis of the femur. Its entry point should be lateral, close to the greater trochanter.
• During stem insertion maintain thumb pressure on the cement at the medial femoral neck ensuring the stem is in the middle of the prepared cavity
65
Zinc # DSEM/JRC/0417/0797
![Page 66: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/66.jpg)
Femoral Head Impaction
66
• Once the cement has completely set, place the trial head on the implant and perform a final trial reduction.
• Remove the trial head and irrigate and thoroughly clean and dry the taper to remove any fluid or particulate debris.
• Twist and push the definitive head onto the taper using the head taper, then impact firmly with head impactor.
• Reduce the hip to carry out a final assessment of joint mechanics and stability.
Closure
• Closure is based on the surgeon’s preference and the individual case. The repair should be tested throughout the hip range of motion.
Zinc # DSEM/JRC/0417/0797
![Page 67: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/67.jpg)
Summary
67
• The sequence of steps in the C-STEM Surgical Technique
• Good cement technique and its importance
Zinc # DSEM/JRC/0417/0797
![Page 68: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/68.jpg)
MARATHON™ XLPE Cemented Cup
68
Zinc # DSEM/JRC/0417/0797
![Page 69: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/69.jpg)
Cemented Cup History
• Wrightington Hospital – Sir John Charnley
• 1962 – Charnley Cemented cup
• 1972 – LPW introduced to improve resistance to dislocation
• 1977 – PIJ- Flange to assist cement pressurisation
• 1982 – OGEE- Anatomic shaping of the flange
• 2008 – MARATHON XLPE - Improved wear performance10
10. Engh et al. A randomized prospective evaluation of outcomes after total hip arthroplasty using cross-
linked marathon and non-cross-linked Enduron polyethylene liners. Journal of Arthroplasty, 21, 2006.
69
Zinc # DSEM/JRC/0417/0797
![Page 70: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/70.jpg)
1962 – Charnley Cemented cup
70
Zinc # DSEM/JRC/0417/0797
![Page 71: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/71.jpg)
1972 – LPW introduced to improve resistance to dislocation
71
Zinc # DSEM/JRC/0417/0797
![Page 72: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/72.jpg)
1977 – PIJ - Flange to assist cement pressurisation
72
Zinc # DSEM/JRC/0417/0797
![Page 73: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/73.jpg)
1982 Ogee – Anatomic shaping of the flange
73
Zinc # DSEM/JRC/0417/0797
![Page 74: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/74.jpg)
1982 Ogee – Anatomic shaping of the flange
74
Zinc # DSEM/JRC/0417/0797
![Page 75: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/75.jpg)
MARATHON XLPE
• Developed by Dr Harry McKellop and introduced in 1998
• MARATHON XLPE liners available for DURALOC and then PINNACLE modular cup systems
• Engh reported 83% reduction in linear wear and 77% reduction volumetric wear at 10 yrscompared with ENDURON11
• 2008 MARATHON XLPE Cemented cups introduced after 10 year success in DURALOC and PINNACLE
11. Engh CA Jr, Hopper RH Jr, Huynh C, Ho H, Sritulanondha S, Engh CA Sr. A Prospective,
Randomized Study of Cross-Linked and Non–Cross-Linked Polyethylene for Total Hip Arthroplasty at
10-Year Follow-Up. J Arthroplasty. 2012;27(8 Suppl 1):2-7.e1
75
Zinc # DSEM/JRC/0417/0797
![Page 76: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/76.jpg)
What is MARATHON XLPE?
76
Gas Plasma
Sterilization
GUR 1050 bars Gamma
irradiation at 50 kGy
Remelting in vacuum at 155°C 24hr
Annealing 120°C 24hr
Component machining
Gas permeable packaging
Zinc # DSEM/JRC/0417/0797
![Page 77: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/77.jpg)
MARATHON XLPE - Features
• MARATHON XLPE cross linked polyethylene
• Trimmable PIJ flange
• Fixation interface identical to proven CHARNLEY/ELITE cup
• LPW feature
• X-Ray marker wire - marker wire is provided with the cup for assembly by the end user
• Straight forward instrumentation
77
Zinc # DSEM/JRC/0417/0797
![Page 78: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/78.jpg)
MARATHON XLPE - Range
available
78
Zinc # DSEM/JRC/0417/0797
![Page 79: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/79.jpg)
MARATHON XLPE Marker Wire
79
Zinc # DSEM/JRC/0417/0797
![Page 80: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/80.jpg)
MARATHON XLPE cup insertion video
80
• MARATHON XLPE insertion by Prof Martin stone
• DSEM-JRC-0115-0238a
• MARATHON XLPE discussion with Prof Martin Stone
• DSEM-JRC-0115-0238
Zinc # DSEM/JRC/0417/0797
![Page 81: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/81.jpg)
MARATHON XLPE Cement Pressurisation
81
Zinc # DSEM/JRC/0417/0797
![Page 82: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/82.jpg)
MARATHON XLPE Clinical data
82
• Clinical experience with MARATHON is good (ODEP 10A*). Cup survival is equivalent or better than standard ENDURON PE out to 7 years.
• Clinical wear performance confirms laboratory wear studies
• Engh et al reported a 83% reduction (linear wear) in wear of MARATHON compared to ENDURON at 10 years follow up and a reduced incidence of osteolysis [28mm CoCr head]10
• Hopper et al reported a 50% reduction (linear wear) at 2-3 years clinical follow up [28mm CoCr head]11
• Heisil et al showed a 70% reduction (volumetric) in patients when MARATHON was used as one half of a bilateral joint replacement (compared with enduron) [28mm CoCr head]12
• Horne and Devane showed Wear of MARATHON effectively dropped to zero after the first year (0.32mm wear at 4 years compared with 0.97mm wear for ENDURON) [28mm CoCR head]13
10. Engh et al. A randomized prospective evaluation of outcomes after total hip arthroplasty using cross-linked marathon and non-cross-linked Enduron polyethylene liners. Journal of
Arthroplasty, 21, 2006.
11. Hopper et al. Correlation between early and late wear rates in total hip arthroplasty with application to the performance of marathon cross-linked polyethylene liners. Journal of
Arthroplasty, 18, 2003
12. Heisel et al. In vivo wear of bilateral total hip replacements: conventional versus crosslinked polyethylene. Archives of Orthopaedic and Trauma surgery, 125(8) 2005.
13. Horne and Devane. A double Blind RCT of X-linked vs conventional PE in THA: A 2-4 year follow up. Proceedings of AAOS, 2007.
Zinc # DSEM/JRC/0417/0797
![Page 83: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/83.jpg)
MARATHON XLPE Summary
• MARATHON XLPE material
• Easy to cut flange
• Retains CHARNLEY features
• LPW
• Marker wire
• Fixation surface
• Straight forward instrumentation
83
Zinc # DSEM/JRC/0417/0797
![Page 84: Cemented Hip Portfolio - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · Cemented Hip Portfolio 1 ... J Arthroplasty. 2014 Oct;29(10)](https://reader030.vdocument.in/reader030/viewer/2022012311/5b31ce3b7f8b9aa0238b9692/html5/thumbnails/84.jpg)
Zinc# DSEM/JRC/0417/0797
84
Zinc # DSEM/JRC/0417/0797