Surgical Technique

CONTOUR™Acetabular Rings

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CONTOUR™ Acetabular Rings

CONTOUR Acetabular Rings can prove to be a most viable

surgical solution for acetabular defects in primary and

revision procedures. Used in conjunction with allograft

bone, the CONTOUR design protects the graft while

providing a stable base of fixation for the cement and the

polyethylene cup. In addition, CONTOUR Acetabular Rings

allow proper anatomical positioning of the polyethylene

socket independent of the metal ring.

Nota Bene

The technique description herein is made available to the healthcare professional to illustrate theauthors’ suggested treatment for the uncomplicated procedure. In the final analysis, the preferredtreatment is that which addresses the needs of the patient.

Surgical technique completedin conjunction with

Joseph Schatzker MD,BSc (Med.), FRCS (C)

Allan E. Gross, MD,FRCS (C)

Please see the Package Insert for a complete list of indications,contraindications, warnings, precautions, and other importantmedical information.

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Positioning of the patient

In primary cases, the patient may bepositioned either supine or in the lateraldecubitus position. All revisions are donewith the patient in the lateral decubitusposition.

Surgical exposureFor primary implantation of theReinforcement ring, the exposure is thesame as for a primary total hipreplacement.

The CONTOUR™ Acetabular Reconstructionring requires a more extensive exposurebecause access must be gained fromsuperoposteriorly down the posteriorcolumn to the ischium. Posterior columndefects require structural grafting moreoften than anterior column defects.Exposure of this magnitude necessitatesa trochanteric osteotomy, but it is ourexperience that an anterior trochantericslide, rather than a transverse trochantericosteotomy, is sufficient and provides a morestable fixation of the greater trochanter afterthe surgery.

GreatertrochanterIlium

Sciaticnerve

Posteriorcolumn

IschiumGluteusmaximus

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Preparation of the acetabulum

The previous implant must be removedwithout causing any further bone loss.Once the implant is removed, all cementand membrane must be carefully extracted.Great care should be exercised inremoving intrapelvic cement. A CT-scancombined with dye supplement to visualizethe great vessels and the ureter may berequired. In the absence of infection,cement may be left in its intrapelvicposition and allograft is then interposedbetween the cement and the CONTOUR™Reconstruction Ring.

It is extremely important to definecompletely the entire circumference ofthe acetabulum to be able to define adefect as contained or uncontained. Ifacetabular reamers are used, the outerdiameter of the implant should match orbe 2mm larger than the final reamer.

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Medial wall defects, particularly if extensive,are covered with cancellous allograftslices prepared from femoral heads. Theremainder of the defects are filled withmorsellized allograft bone. The morsellizedbone should be small chunks instead of aslurry of bone which would make impactionimpossible. In the case of uncontainedsegmental acetabular defects, bulk allograftmust be used. Although it is preferable touse true acetabular allograft bone, somedefects can be managed with male femoralheads.

Morsellized allograft bone is used to fillcavitary defects. It is firmly impacted withsmooth acetabular impaction domes.Reverse seat reamers can also be used,but these do not provide the same degree ofimpaction. Major medial wall deficienciesshould be managed with slices of allograftto provide containment of the morsellizedallograft bone used to fill the remainderof the defect. This prevents the morsellizedallograft bone from being impacted into thepelvis.

Preparation and implantationof the bone graft

Containedcavity defect

Morsellizedallograft boneimpacted intocavity defect

Globalcontainedcavity defectincludingmedial wall

Morsellizedallograft boneimpacted intoglobal cavitarydefect

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Preparation and implantationof the bone graft

If there is a major segmental defect, thismust be defined accurately by clearing allsoft tissue from the acetabular boundaries.Once the defect is defined, the structuralallograft is sculpted to fit the defect andthen held with two cancellous screws. Themost common reconstruction involves theposterior column. In this case, the screwsare usually directed superiorly into thedome. Structural allograft is often combinedwith morsellized allograft that is used to filladjacent cavitary defects.

Major columndefect

Restorationof bone stockby majorcolumn allograft

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Indications for the CONTOUR™Reinforcement RingThe CONTOUR Reinforcement Ring is usedwhere the bone deficits are such that thesurgeon can still get adequate supportfor the ring superoposteriorly andinferomedially against the host bone.The indications for this device are:

1. Primary hip replacement- Severe osteoporosis- Large acetabular erosions or cysts- Mild to moderate protrusio where the ringcan still be seated superoposteriorly andinferomedially against host bone

2. Revision arthroplasty of the hip- Contained cavitary defects in conjunctionwith morsellized allograft bone- For small segmental rim defects that donot involve the columns but may requirea small structural graft that can beprotected by the ring

Contraindications for CONTOURReinforcement Ring

1. Major segmental defects involving the domeor posterior column

2. Medial wall segmental defects3. Any bone defect that involves more than50% of the acetabulum (contained oruncontained)

It is extremely important that theReinforcement ring is supported by hostbone along its rim superoposteriorly andinferomedially. It must be seated firmlyagainst bone with no toggling. If thering is supported primarily againstmorsellized allograft bone, thedevice will obtain anchorage onlysuperoposteriorly and will fail becauseof the hinge�like forces that will beplaced upon it.

Reinforcement ringsurgical technique

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Reinforcement ring surgical technique

CONTOUR™ Reinforcement Ringinsertion

The CONTOUR Reinforcement Ring isfitted superiorly against the superior rimof the acetabulum, posteriorly againstthe posterior wall and column, andinferomedially against the floor of theacetabulum. The ring must have goodpurchase and support superiorly andposteriorly and it must rest inferomediallyagainst host bone and not on morsellizedallograft bone. It must have a firm seatand must not have any potential fortoggling. The CONTOUR ReinforcementRing has a threaded center hole for thethreaded cup positioner.

The reinforcement ring is secured withscrews that are directed into the domeof the acetabulum. It is best to start witha central screw which forces the ringupwards and medially in line with theresultant forces and in about 15-20° to thevertical axis of the body. At least threescrews should be inserted into this area ofthe dome. Screws can be inserted alongthe rim if necessary but must have thesame direction as those entering the planemore centrally. Screws should not bedirected anteriorly or medially because ofthe danger of penetration into the pelvisand risk to vital structures.

Acetabularscrewalignment

Reinforcementring insertion

AcetabularscrewalignmentA-P view

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Indications for the CONTOUR™Reconstruction RingThe CONTOUR Reconstruction Ring canbe used as long as there is supportsuperoposteriorly against the ilium andinferiorly against the ischium.

1. Large cavitary defects involving allquadrants of the acetabulum. This deviceis used in conjunction with morsellizedallograft bone. The ring is screwed tothe ilium and the dome, and must besupported by the posterior column andthe ischium.

2. Medial wall segmental defects where thisdevice can be used in conjunction withcancellous allograft slices and morsellizedbone.

3. Segmental defects that involve anterior orposterior column and involve more than50% of the acetabulum. The device isused in conjunction with a solid acetabularallograft.

4. Pelvic discontinuity may occur if there is adiscontinuity of both columns or a massiveglobal bone defect involving both columns.The pelvic discontinuity is stabilized bythe ring being fixed by screws to boththe ilium and ischium. The bone deficiencyis replaced with a structural graft (usuallyreplacing the posterior column). The graftis fixed superiorly to the ilium, and ifpossible, inferiorly to the ischium with6.5mm cancellous screws beforeapplication of the ring.

Reconstruction ringsurgical technique

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CONTOUR™ Reconstruction Ring insertion

Reconstructionring fixed to iliumand ischium

Reconstructionring withall-poly cupA-P view

The CONTOUR Reconstruction Ring isstabilized superoposteriorly by at leastthree screws in the superior flanges orthrough the ring into the dome. It should bebuttressed against the posterior column,the inferior rim of the acetabulum, andthe ischium, before screw insertion.

If a structural bulk allograft is being used,it is important to use screws in both thesuperior and inferior flanges to stabilizethe ring and bridge the allograft. If it isimpossible to gain good purchase of thescrews in the inferior flange sitting onthe ischium, it can be used as a buttressagainst the ischium or slotted into theischium.

As an alternative, the inferior flange can bebuttressed against the ischium with a screwbeing placed through the ring adjacent tothe flange and into the body of the ischium.

If there is a pelvic discontinuity, the inferiorflange should be screwed to the ischium. Ifthere is no pelvic discontinuity, the inferiorflange can be slotted into or buttressedagainst the ischium without screws.

Screws passing through the ring can alsobe used to add to the fixation of the solidallograft, but great care must be exercisedso that the screws do not penetrateanteriorly or medially.

It is important to contour this device veryclosely to the bone before placing thescrews. If the device is not contoured,tightening the screws either superiorlyor inferiorly causes the device to liftoff the bone.

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The ring must not be inserted too verticallyor the inferior rim will impinge on the neck ofthe femoral component, producing instabilityor loosening.

In summary, if the CONTOUR™ ReconstructionRing is used to reconstruct cavitary defectswhere stability of the ring can be gainedagainst the ilium and dome superiorly andthe posterior wall and column, then inferiorly,it is enough to buttress the ring against theinferior acetabular remnant or the ischium.If it is used in conjunction with a structuralacetabular allograft or in the presence of apelvic discontinuity, the inferior flange shouldbe fixed to the ischium by screws or slottedinto the ischium. If possible, at least threescrews should be used in the superior andone or two screws through the inferiorflanges.

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Cementing the polyethylene cupThe polyethylene cup is oriented relative tothe pelvis and the long axis of the patient.Do not reference the position of the ringwhen determining the proper position of thepolyethylene socket. Select the polyethylenesocket size that corresponds to, or is 2mmsmaller than, the inner diameter size of themetal ring.

Reconstruction ringsurgical technique

Globalcontainedcavitary defect

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CONTOUR Reconstruction Ring – ImplantsImplant Cat No OD ID Side7133-7150 50 46 Left7133-7156 56 52 Left7133-7162 62 58 Left7133-7168 68 64 Left7133-7174 74 70 Left7133-7250 50 46 Right7133-7256 56 52 Right7133-7262 62 58 Right7133-7268 68 64 Right7133-7274 74 70 Right

CONTOUR Reinforcement Ring – ImplantsImplant Cat No OD ID7133-7044 44 407133-7047 47 437133-7050 50 467133-7053 53 497133-7056 56 527133-7059 59 557133-7062 62 587133-7065 65 617133-7068 68 64

REFLECTION™ Spherical Head Screws6.5mmCat No Length7133-2515 15mm7133-2520 20mm7133-2525 25mm7133-2530 30mm7133-2535 35mm7133-2540 40mm7133-2545 45mm7133-2550 50mm7133-2560 60mm7133-2570 70mm

Catalog informationCONTOUR™ implants

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Catalog information

REFLECTION Cemented All Poly CupAll Poly PE All Poly XLPE OD ID7135-2240 7135-8001 40 mm 22 mm7135-2243 7135-8002 43 mm 22 mm7135-2246 7135-8003 46 mm 22 mm7135-2249 7135-8004 49 mm 22 mm7135-2252 7135-8005 52 mm 22 mm7135-2255 7135-8006 55 mm 22 mm7135-2258 7135-8007 58 mm 22 mm7135-2261 7135-8008 61 mm 22 mm

7135-2846 7135-8023 46 mm 28 mm7135-2849 7135-8024 49 mm 28 mm7135-2852 7135-8025 52 mm 28 mm7135-2855 7135-8026 55 mm 28 mm7135-2858 7135-8027 58 mm 28 mm7135-2861 7135-8028 61 mm 28 mmN/A 7135-8029 64 mm 28 mm

7135-3249 7135-8034 49 mm 32 mm7135-3252 7135-8035 52 mm 32 mm7135-3255 7135-8036 55 mm 32 mm7135-3258 7135-8037 58 mm 32 mm7135-3261 7135-8038 61 mm 32 mmN/A 7135-8039 64 mm 32 mm

N/A 7135-8065 52 mm 36 mmN/A 7135-8066 55 mm 36 mmN/A 7135-8067 58 mm 36 mmN/A 7135-8068 61 mm 36 mmN/A 7135-8069 64 mm 36 mm

REFLECTION™ Cemented All Poly Cup implants

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Catalog information

CONTOUR Reinforcement Ring – TrialsTrial Cat No OD ID7136-7044 44 407136-7047 47 437136-7050 50 467136-7053 53 497136-7056 56 527136-7059 59 557136-7062 62 587136-7065 65 617136-7068 68 64

CONTOUR Reconstruction Ring – TrialsTrial Cat No OD ID Side7136-7150 50 46 Left7136-7156 56 52 Left7136-7162 62 58 Left7136-7168 68 64 Left7136-7174 74 70 Left7136-7250 50 46 Right7136-7256 56 52 Right7136-7262 62 58 Right7136-7268 68 64 Right7136-7274 74 70 Right

CONTOUR Reinforcement Ring – TemplatesAcetateCat No 7138-0365

CONTOUR Reinforcement Ring – SampleCat No 7137-7056

CONTOUR Reconstruction Ring – TemplatesAcetateCat No 7138-0362

DigitalCat No 7138-0366

DigitalCat No 7138-0364

CONTOUR Reconstruction Ring – SampleCat No 7137-7156

CONTOUR™ trials

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Catalog information

REFLECTION Small Reamer/Trial TrayCat No 7136-2286

REFLECTION Primary Reamer TrayCat No 7136-2281

REFLECTION Larger Reamer/Trial TrayCat No 7136-2284

REFLECTION Reamer DomesSize

Cat No (mm)Standard Size Domes7136-2742 427136-2743 437136-2744 447136-2745 457136-2746 467136-2747 477136-2748 487136-2749 497136-2750 507136-2751 517136-2752 527136-2753 537136-2754 547136-2755 557136-2756 567136-2757 577136-2758 587136-2759 597136-2760 607136-2761 617136-2762 627136-2763 637136-2764 64

SizeCat No (mm)Small Size Domes7136-2738 387136-2739 397136-2740 407136-2741 41

Large Size Domes7136-2765 657136-2766 667136-2767 677136-2768 687136-2769 697136-2770 707136-2771 717136-2772 727136-2773 737136-2774 747136-2775 757136-2776 76

REFLECTION Reamer HandleCat No 7136-2279

Power Adapters (not included in set)Cat No Description7136-2781 Synthes7136-2782 Aesculap7136-2783 Hudson

REFLECTION™ reamer domes

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Catalog information

CONTOUR Compaction Dome TrayCat No 7136-7008

CONTOUR Compaction DomesCat No Description7136-7641 41mm7136-7644 44mm7136-7647 47mm7136-7650 50mm7136-7653 53mm7136-7656 56mm7136-7659 59mm7136-7662 62mm7136-7665 65mm7136-7668 68mm7136-7671 71mm7136-7674 74mm

REFLECTION™ Reamer HandleCat No 7136-2279

T-HandleCat No 7136-4006

CONTOUR™ compaction domes

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Catalog information

REFLECTION™ Positioner/ImpactorCat No 7136-2299

CONTOUR Flange BenderCat No 7136-7001

REFLECTION Screw Drill GuideCat No 7136-2919

Vice Grip PliersCat No 7136-7537

REFLECTION Screw ForcepsCat No 7136-2298

Flexible Screw DrillsCat No Length7136-2915 15mm7136-2925 25mm7136-2935 35mm7136-2950 50mm

Depth GaugeCat No 7136-2012

CONTOUR™ instruments

REFLECTION Ratchet HandleCat No 7136-2294

REFLECTION Ball Joint ScrewdriverCat No 7136-2295

REFLECTION™ Straight ScrewdriverCat No 7136-2293

X-BarCat No MT-2201

CONTOUR Instrument TrayCat No 7136-7003

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Catalog informationCONTOUR™ instruments

Straight Ball SpikeCat No 7117-0189

Cemented Cup PositionerCat No MT-2200

Cemented Cup Placement HeadsCat No SizeMT-2222 22 mmMT-2228 28 mmMT-2232 32 mm7136-7436 36 mm

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