CHARNLEY - Forsiden |...

CHARNLEY ®,

THE WORLD’S

MOST SUCCESSFUL

HIP IMPLANT

S u r g i c a l T e c h n i q u e

CHARNLEY®

The principles of low frictional

torque arthroplasty laid down by

Sir John Charnley in the early

1950’s, based on the 22.225mm

diameter femoral head, have

proved remarkably reliable.1

Long term results for Charnley®

implants, achieved by surgeons

working in centres worldwide,

continue to set the standard by

which all other implants must

be judged.2

Today’s Charnley® hip is the result

of a thirty year learning curve -

with each new development

setting higher and higher

standards in design, materials and

manufacturing.

A range of twenty six femoral sizes

provides the surgeon with a stem

choice to suit every patient, and

comprehensive instrumentation

designed to assure accuracy,

assists the surgeon to produce

consistent, reliable clinical results.

The 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.

AP view

2

The pre-operative preparation and surgical approach have been described by:Mr MH Stone M Phil FRCS (Ed), Mr D McDonald FRCS and Dr OS Husby MD.

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.

The lateral approachIn 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.

The posterior approachIn 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.

Patient positioning

Surgical Technique

The 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.

The 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.

Lateral approach

Posterior approach

3

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.

Split the fascia lata distally from the

greater trochanter, in line with its

fibres. 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.

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.

The Charnley® initial incision

retractor is inserted with the C-Arm

concave towards the head. 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.

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.

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 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.

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.

Lateral approach

Posterior approach

4

A blunt nosed retractor is placed over

the anterior lip of the joint capsule.

Radially incise the anterior capsule,

and excise the anterior flap.

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.

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. This is then attached to an

artery forcep.

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. 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.

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.

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.

Further exposure is achieved by

dividing the abductor muscles in line

with their fibres, using blunt

dissection.

A continuous flap is opened, from the

abductors to the quadriceps. This will

be reattached on completion of the

procedure.

5

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.

NB. 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.

Femoral initiation

Entry point to the femur at the 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.

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.Entry point too anterior

and medial.

Correctly aligned stem Malaligned stem


Posterior viewStem aligned centrally in the canal

Posterior viewStem in varus


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

6

Prosthesis

catalogue Distal reamernumber Description 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

9623-54-000 Long Neck 1 Long Stem 12

9623-52-000 Long Neck 2 12

9623-53-000 Long Neck 2 Extra Heavy 12

9623-55-000 Long Neck 2 Long Stem 12

9623-59-000 3/4 Neck 12

9623-60-000 CDH 12

9624-17-000 SNS35 11

9624-22-000 Magnum 40 13

9624-23-000 Magnum 45 14

9624-24-000 CD Extra Small 11

9624-18-000 Straight Thick Stem 12

9623-46-000 Flanged 35 12

9624-16-000 Flanged 40 Long Stem 12

9624-20-000 Extra Heavy Flanged 40 Long Stem 12

9623-62-000 Extra Small 11

Reaming guide

Attach the Excel™ canal probe to the ‘T’ handle and

introduce the probe into the femoral canal in line with

the femur.

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).

Canal reaming

7

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. 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.

NB. 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.

Acetabular preparation

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.

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.

Femoral neck resection

8

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.

NB. Care should be taken to avoid the 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.

Using the trial as a guide, cut the flange of the definitive

cup to match.

Lavage and clear the acetabulum of debris.

Acetabular sizing

9

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.

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.

Femoral canal preparation

Attach the cup to the cup introducer. Introduce the

cement into the acetabular bed and insert the cup.

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.

Cup implantation

10˚ of anteversion

Long axis of the patient

Shaft of the introducer

parallel to the superior and

inferior illiac spines.

10

When the final broach is seated at the resection line,

fit the trial head onto the neck of the broach and reduce

the hip.

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.

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.

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.

Broaching

11

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.

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.

Stem implantation

Cement Cement

Prosthesis Broach restrictor restrictor

description description size depth

Flanged 40 F40 12 135

Extra Heavy Flanged 40 F40EH 12 135

Roundback 40 RB40 12 135

Roundback 40 Narrow RB40N 11 135

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

Long Neck 2 L2 12 135

Long Neck 2 Extra Heavy LN2EH 12 135

Long Neck 1 Long Stem LN1LS 12 200

Long Neck 2 Long Stem LN2LS 12 205

3/4 Neck 3/4N 12 115

CDH CDH 12 130

SNS35 SNS35 11 135

Magnum 40 M40 13 135

Magnum 45 M45 14 155

CDH Extra Small CDHES 11 130

Standard Thick Stem SNS35 11 135

Resection Stem N/A

15” Stem 40 N/A

Flanged 35 SNS35 11 135

Flanged 40 Long Stem FL40 12 190

Extra Heavy Flanged 40

Long Stem EHFL40 12 190

Extra Small CDHES 11 140

Cement restrictor depths

❊

These measurements are taken from the medial edge of the neckosteotomy and allow for 20mm of cement distal to the tip of theprosthesis. If a bone block is to be used, this distance may be variedaccording to surgeon preference.

In these instances, increased reaming depth is required to accommodate the longer stem length.

The recommended broach should be used as a rasp to prepare thefemur and a trial implant is used to assess joint function and stability.

Dimensions in millimetres.

❊

✶

✪

✪

✪

✪

✪

✶

✶

✶

12

Acetabular Implants

Charnley®

9650-22-040 Charnley® Std Cup 22.225/40

9650-22-043 Charnley® Std Cup 22.225/43

9650-22-047 Charnley® Std Cup 22.225/47

9650-22-050 Charnley® Std Cup 22.225/50

9650-22-053 Charnley® Std Cup 22.225/53

9651-22-038 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





9623-69-000 Charnley® Flanged Cup Std Small

9623-23-000 Charnley® Flanged Cup Std Large

9623-80-000 Charnley® Flanged Cup Offset Bore

9653-22-040 Charnley® Ogee® Cup 22.225/40





9624-10-000 Charnley® Ogee® Cup Std Small

9624-09-000 Charnley® Ogee® Cup Std Large

Acetabular Instruments

2440-30-000 Grater Shaft with Hudson Fitting

2440-38-000 Acetabular Reamer 38mm












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

9622-41-000 Trimming Scissors

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

13

14

Charnley® Base BroachingInstrument Set

Base Tray

9624-63-000 Charnley® Tray Base and Lid

9620-40-000 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™ FemoralInstrument Set

Top Tray

9624-65-000 Charnley® Tray Excel™ Insert

9620-45-000 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

2001-43-000 Excel™ IM Initiator

2354-10-000 Muller Awl Reamer with Hudson End

2105-12-000 Canal Reamer 10




2002-25-000 Anteversion Osteotome Medium

2001-65-000 Excel™ Femoral Head Impactor

Alternative Top Tray Instrument Set

Charnley® BroachingInstrument Set

Top Tray

9624-64-000 Charnley® Tray Broaching Insert

9629-00-000 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

9611-33-000 Restrictor Trial Introducer

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



9623-47-000 Charnley® Extra Heavy Flanged 45

9623-49-000 Charnley® Long Neck 1

9623-50-000 Charnley® Long Neck 1 Extra Heavy

9623-52-000 Charnley® Long Neck 2

9623-53-000 Charnley® Long Neck 2 Extra Heavy

9623-54-000 Charnley® Long Neck 1 Long Stem

9623-55-000 Charnley® Long Neck 2 Long Stem

9623-59-000 Charnley® 3/4 Neck

9623-60-000 Charnley® CDH

9623-62-000 Charnley® Extra Small

9623-63-000 Charnley® 15” Stem 40

9623-64-000 Charnley® Resection Stem

9624-16-000 Charnley® Flanged 40 Long Stem

9624-17-000 Charnley® SNS 35

9624-18-000 Charnley® Straight Thick Stem 35

9624-20-000 Charnley® Extra Heavy Flanged 40 Long Stem

9624-22-000 Charnley® Magnum 40

9624-23-000 Charnley® Magnum 45

9624-24-000 Charnley® CDH Extra Small

5460-10-000 Cement Restrictor Size 1







Ordering Information

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

Cat No: 9061-79-000

Charnley® and Ogee® are registered trademarks and Elite™ is a trademark of DePuy International Ltd. Excel™ is a trademark of DePuy Orthopaedics, Inc.

© 2003 DePuy International Limited. All rights reserved.

References:

1. Kabo MJ, Gebhard J, Loren G, Amstutz H. In Vivo Wear of Polyethylene

Acetabular Components. J Bone Joint Surg (Br), 75-B, 254-8, 1993.

2. Kavanagh B, Wallrichs S, Dewitz M, Berry D, Currier B, Ilstrup D,

Coventry M. Charnley Low Friction Arthroplasty of the Hip. J of Arthrop,

9, No 3, 1994.

0086

This publication is not intended for distribution in the USA

CHARNLEY - Forsiden |...

Documents

Transcript of CHARNLEY - Forsiden |...