Epoca Shoulder Arthroplasty System –Fracture. Hemi and total...

Epoca Shoulder ArthroplastySystem – Fracture. Hemi and total jointreplacement for fractures.

Technique Guide

Instruments and implants approved by the AO Foundation.

This publication is not intended fordistribution in the USA.

Introduction

Surgical Technique

Care and Maintenance

Product Information

Bibliography

Epoca Shoulder Arthroplasty System 2

AO Principles 4

Indications and Contraindications 5

Clinical Cases 6

Preoperative Planning 8

Patient Positioning 9

Hemiarthroplasty for Fractures 10

Implantation of a Glenoid Component 29

43

Implants 44

Special Implants 48

Instruments 49

59

Table of Contents

Epoca Shoulder Arthroplasty System – Fracture Technique Guide Synthes 1

Image intensifier control

WarningThis description alone does not provide sufficient background for direct use ofthe instrument set. Instruction by a surgeon experienced in handling theseinstruments is highly recommended.

Processing, Reprocessing, Care and MaintenanceFor general guidelines, function control and dismantling of multi-part instruments,as well as processing guidelines for implants, please contact your local salesrepresentative or refer to: www.synthes.com/reprocessingFor general information about reprocessing, care and maintenance of Synthesreusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) orrefer to: www.synthes.com/reprocessing

Epoca Shoulder Arthroplasty System.Anatomic reconstruction of the proximalhumerus.

The Epoca resurfacing head is intendedfor minimally invasive treatment ofearly stage arthritis or otherarthropathies with cartilage damage.– Thin surface allows for minimum

bone removal– Anatomic reconstruction of articulat-

ing surface– Stable and bone sparing crown

fixation– TiNb coated version for nickel

sensitive patients

Head

– Height proportional to radius– Anatomic design– Can be adjusted for medial

and posterior fit– TiNb coated version for nickel

sensitive patients

Stem

The Epoca Shoulder Arthroplasty sys-tem aims to restore glenohumeral kine-matics in fractures and degenerativecases. The Epoca implant facilitatesanatomic reconstruction of the proxi-mal humerus.– Anatomic design mimics contour of

the medial calcar and medullarycanal

– Non-protruding lateral design re-duces risk of damage to the insertionfacet of the supraspinatus tendon

– Medial and lateral holes in the stemallow for stable reattachment of thetuberosities

– Available in a variety of diametersand lengths, L and XL stems for revision

– Titanium for nickel sensitive patients

RH Resurfacing Head Stem for Fractures and Degenerative Conditions

2 Synthes Epoca Shoulder Arthroplasty System – Fracture Technique Guide

Eccenter Disc

– Allows medial and posterior offsetadjustments

– Independent adjustment of the headvs. shaft

– Press-fit assembly outside the patient

The Epoca shoulder prosthesis is intended for use as a hemi- or totalshoulder replacement– Ensures congruent glenohumeral

implant surfaces to achieve normalrange of motion

– Reduced size and beveled rim fornormal mobility and reduced risk ofimpingement

– Hybrid application with shell screws– Cementless application with metal-

back glenoid

The Epoca Reco glenoid reconstructiondevice is intended to reestablish a stable fulcrum in order to preventantero superior subluxation of thehumeral head.

Glenoid Reco Glenoid


Anatomic reduction– Anatomical implant-design preserves anatomical and

kinematic principles– Minimal resection preserves anatomical structures

Stable fixation– Implant design based on anatomical study leads to good

implant-bone-fixation– Stable osteosynthesis of the tuberosities in stable conjunc-

tion with stem-implant

Preservation of blood-supply– Anatomical reduction and osteosynthesis of the tuberosi-

ties in trauma case– Minimal resection preserves anatomical structures and

blood supply

Early mobilization– Anatomical design with maximum bone-preservation allow

early mobilzation– Combination of stable osteosynthesis and anatomical

implant allow early mobilization

AO Principles


Indications– Irreparable fractures of the proximal humerus– Posttraumatic conditions with advanced joint destruction – Failed previous osteosynthesisA glenoid component may be indicated in cases of cartilagedestruction or in case of an associated irreparable glenoidfracture where gleno-humeral stability is a concern.

Contraindications– Infections, acute or chronic, local or systemic– Severe muscular, neurological or vascular deficiencies,

which compromise the affected extremity– Destruction of bone or poor bone quality, which may

affect stability of the implant– Any concomitant disease which may compromise the func-

tion of the implant– Any other pathology which needs treatment priority

Conditions which can adversely affect joint replace-ment success– Severe osteoporosis– Severe deformities, congenital dislocation– Allergic reaction to one of the materials used– Local tumors of the bone– Systemic and metabolic disorders– History of infectious disease or falls– Drug or alcohol addiction and /or abuse– Obesity– High level of physical activity, involving shocks and shaking

in which the prosthesis is subject to pounding and /or excessive strains (e.g.: heavy physical labor, repetitive stressfrom sports, etc.)

Indications and Contraindications


Female patient, 65 years oldComminuted 4-part fracture with ischemic head, right shoulder

Clinical Case 1

AP view

Preoperative

Axillary view

Postoperative

AP view Axillary view


Female patient, 65 years oldComminuted 4-part fracture with ischemic head and osteoporosis, left shoulder

Clinical Case 2

AP view

AP view

Preoperative

Postoperative


Complete the preoperative radiographic assessment withstandard AP, lateral and axillary views. A CT scan is requiredwhen the axillary view is not optimal, i.e. when more infor-mation about the lesser tuberosity is required.

An AP view of the contralateral humerus is optional. It ishelpful to estimate the size of the prosthetic head and stem.

Place the template on the AP view of the contralateralhumerus to estimate the head and stem size. Then, draw theouter contour of the proximal humerus and the implant ontransparent paper or on an electronic support using a com-puter assisted planning tool.

Flip the image horizontally and superimpose it on the patho-logical side. Determine the required corrections.

Preoperative planning for glenoid replacementGlenoid replacement may be indicated in cases of anteriorfracture dislocations which are associated with significantglenoid fractures, such as Ideberg type II fractures. Whenplanning a glenoid replacement procedure, axial CT scanviews are recommended in order to assess the amount ofglenoid damage and the correction needed.

Additionally, a CT-based three-dimensional reconstruction ofthe glenoid (with the removal of the humeral head fromthe 3-D model) could help estimate the shape and size ofglenoid defects.

Preoperative Planning


Position the patient in a beach-chair position.

Avoid hyperextension and lateral inclination of the cervicalspine in order to prevent tension on the brachial plexus.

Ensure that the patient’s arm is freely extendable.

Ensure that a C-arm can be placed so that adequate imagescan be obtained when needed.

Patient Positioning


1Approach 1

Standard deltopectoral approachStart the incision over the acromioclavicular joint and extendit 8 cm inferior over the anterior deltoid, lateral to the del-topectoral groove. Alternatively, follow Langer’s skin tensionlines starting from the acromioclavicular joint.

Open the fascia over the deltopectoral groove and identifythe cephalic vein. Retract the deltoid with the cephalic veinlaterally, and the pectoralis major medially.

Incise the clavipectoral fascia.

Hemiarthroplasty for Fractures

2Expose fracture

Irrigate and remove the hematoma to expose the fracture.Check the vascularity of the humeral head and confirm thatjoint replacement is the optimal form of care.

Pass stay sutures through the infraspinatus tendon to aid manipulation of the greater tuberosity fragment.

Expose and transect the biceps tendon in its extraarticularpath. Suture the biceps tendon to the pectoralis major fascia.

Locate the split in the supraspinatus tendon induced bythe fracture. Enlarge the split in the supraspinatus tendon, asrequired, for access to the joint.

Retrieve the fractured humeral head and set it aside for lateruse. Examine the glenoid. Consider ORIF or glenoid replace-ment if there is a relevant fracture of the glenoid or glenoidrim.

1 see Hertel et al., 331–338.


3Prepare tuberosities for later fixation

Implant

02.401.000S Wire-Cable B 1.0 mm, with Crimp

Pass stay-sutures through the subscapularis, supraspinatus,and infraspinatus tendons.


Drill two holes in the greater tuberosity with a 2.0 mm drillbit. The two holes should be approximately aligned withthe medial and lateral perforations of the prosthetic stem.Drill the holes close to the point of transition from tendon tobone.

Using the wire portion of the wire-cable, pass the 1.0 mmwire-cables through the drill holes. Alternatively, cerclagewires or high strength sutures can be used. Park the wire- cables posteriorly, so that they do not interfere with the re-maining steps of the procedure.

Note: The wire portion of the wire-cable can be shortenedto the desired length.

Expose the shaft by extending, adducting, and externally rotating the humerus.

X

5Select trial head

Instruments

E5114-40– Trial Heads, sizes 40 to 54E5114-54

Osteotomize any remaining metaphyseal extensions to bettervisualize the head. Compare the retrieved humeral head withthe available trial heads. Choose the trial head that closelymatches the retrieved head. Save the humeral head for lateruse as bone graft.

Note: If the AP and lateral radii differ, choose an intermedi-ate trial head size.



4Determine stem height

Instrument

03.401.083 Ruler, length 250 mm, Stainless Steel

Measure the medial metaphyseal extension on the retrievedhead. This distance determines the precise height of thestem, i.e: how much the stem must protrude in respect tothe medial fracture line. Note the height for later reference.

6Open medullary canal and determine retrotorsion

Instruments

359.221 Combined Hammer

E5115-1 Retrotorsion Bar B 6.0 mm

E5115-2 Goniometer

E5112-6– Rasps, sizes 6 to 14 E5112-14

03.401.084 Curette, oval, with Toothing, length 300 mm

Probe and clean the medullary cavity with a sharp curette. Insert the size 6 rasp into the canal.

To check the rotational alignment, insert the 6.0 mm retro-torsion bar into the threaded hole of the rasp. Hold thegonio meter onto the lateral side of the retrotorsion bar. Forthe first rough adjustment, align the rasp to 25° retrotorsionwith reference to the axis of the forearm. This measurementreflects the median retrotorsion value for a normal popula-tion.1


1 see Hertel et al., 331–338.

8mm

Hammer in the rasp until proper seating is obtained. If therasp penetrates too deep into the medullary cavity, use thenext larger rasp size until the correct prosthetic height is ob-tained. Should you have difficulties fully inserting the chosenrasp, remove additional bone along the medial endostealregion using a sharp curette. This will allow the rasp to seatand self-lock a few millimeters deeper.

The pronounced calcar design provides the rasp and the implants with self-centering, self-rotating and self-locking ca-pabilities.

Confirm the retrotorsion by cross-checking against the bicipi-tal groove. The distance between the deepest point in thebicipital groove and the center line of the rasp should beapproximately 8 mm.2



2 see Hempfing et al., 460–463.

7Insert trial stem

Instruments


E5113-6– Trial Stems, sizes 6 to 14E5113-14

E5115-2 Goniometer

E5115-3 Slotted Hammer/Extractor


Attach the inserter/extractor to the selected trial stem. Applycontrolled light blows to the top of the inserter / extractorwith the hammer. Hammer until the trial stem protrudesabove the shaft, as determined in step 4.

To confirm the retrotorsion of the trial stem, insert the3.0 mm retrotorsion bar into the hole of the trial stem.

Use the goniometer to measure the retrotorsion.


8Attach trial eccenter disc

Instruments

E5115-4 /2 Screwdriver Epoca, width across 2.0 mm, for Trial Implants

E5117-20 Trial Eccenter Disc

Attach the trial eccenter disc to the trial stem.

Align the letter ‘A’ on the trial eccenter disc with the lateralline on the trial stem. This position reflects the normal (me-dian) offset.

Lock the trial eccenter disc using a 2.0 mm hex screwdriverin the proximal hole.



9Insert trial head

Instruments

E5114-40– Trial Heads, sizes 40 to 54E5114-54




Use a 2.0 mm hex screwdriver to back out the set screwsfrom the trial head in order to allow for correct seating.Be careful not to back out the set screws too far, as they mayfall out.

Mount the trial head on the trial eccenter disc. Align the ap-propriate marking on the trial head with the center line onthe trial stem (‘L’ for left humerus, ‘R’ for right humerus).

Lock the trial head in position by tightening the anterior setscrew. Verify that the offset is appropriate for the patient’sanatomy. The ideal position is reached when the head meetsthe medial calcar line with a continuous or unbroken line,i.e.: no overhang or medial step-off.

If the offset is not appropriate, adjust the anteroposterior position and /or the mediolateral offset. Loosen the trial ec-center disc with the 2.0 mm hex screwdriver. Use the2.5 mm hex screwdriver to rotate the trial eccenter disc untilthe desired head position is achieved.

Note: Should the screw in the trial head be missing, a screwfrom another trial head may be used instead.


For further adjustment, loosen the anterior set screw on thetrial head with the 2.0 mm hex screwdriver and manually rotate the trial head until the desired position is obtained.Lock the position by tightening the set screw.

Note: The 2.0 mm hex screwdriver is used for locking andunlocking the set screws, the 2.5 mm hex screwdriver is usedonly to rotate the eccenter disc.

Record the offset position of the trial head.



10Remove trial implants

Instruments


E5115-3 Slotted Hammer/Extractor



Once the offset position of the trial head is recorded, removethe trial head using the 2.0 mm hex screwdriver.

Record the offset position of the trial eccenter disc.

Important: Record the determined offset (number and letter) as these will be used to assemble the final implants.

Remove the trial eccenter disc using the 2.0 mm hex screw-driver. Mount the inserter / extractor onto the trial stem.Lightly tap against the inserter / extractor to back out the trialstem.

Note: To avoid possible damage to the thread, ensure thatthe inserter / extractor is fully threaded into the trial stem.


11Assemble implants

Instruments

E5115-5 /1 Press

E5115-5 /3 Eccenter / Impactor

E5115-5 /4 Torque Wrench for Press

E5115-5 /6– Holders for Press, sizes 6 to 14E5115-5 /14

Choose the stem holder that corresponds to the size of theshaft. Hold the half of the stem holder with two pegswith the etched side facing up. Orient the distal end of thestem toward the operator and slide the stem over the pegs.Slide the other half of the stem holder over the pegs. This as-sembly allows the stem to be firmly held in the press.

Important: Ensure that the etched side of the stem holder isfacing up. Improper assembly may cause jamming.

Position the eccenter on the stem. Align the letter recordedduring trial implantation (step 9) with the center line of thestem. Place the assembly in the press and place theeccenter / impactor over the eccenter. Make sure that the ec-center sits flush on the stem. Using the torque wrench, turnthe handle of the press clockwise in a controlled, slow mo-tion, until a click is heard, signifying the positive engagementof the eccenter and the stem.

Turn the torque wrench counterclockwise and remove theeccenter / impactor. Remove the stem-eccenter assemblyfrom the press.



Remove the implant from the press. Remove the stem holderand check for adequate seating of the head and the eccen-ter.

Note: No visible gap should be present between the base ofthe head and the humeral stem.

Place the head on the stem assembly. Align the recorded offset position with the lateral marking on the implant or thecontact line between the two halves of the stem holder.

Place the head and the stem eccenter assembly in the press.Compress components by turning the torque wrench clock-wise until a click is heard.




12Implant prosthesis

Choose the final implantation method according to the typeof stem being used (cemented /uncemented).

Instruments


E5115-2 Goniometer


E5115-7 Impactor

Mount the plastic liner onto the head impactor.

Remove any excess bone cement from the collar region before it sets to provide room for bone graft.

Fill the collar region with autogenous bone graft harvestedfrom the retrieved head to improve healing betweentuberosities and shaft.

Note: Follow the manufacturer’s instructions for preparation,injection and setting of the bone cement.

12aFinal implantation for cemented stems

Do a final irrigation of the medullary canal. Insert a cementrestrictor to prevent excess cement from flowing into the distal humerus.

Place a vent tube in the medullary canal. Dry the cavity. Injectcement into the canal. Remove the vent tube while the cement is being injected.

Ensure that the implant assembly is clean before inserting it.Check the final retrotorsion using the 3.0 mm retrotorsionbar.

Insert the implant, first manually, then using the head im-pactor until the predetermined anatomic prosthetic height isreached. The implant will be protruding as defined in steps 4and 7 of this procedure.

12bFinal implantation for pressfit, cementless stems

Introduce the prosthesis into the medullary canal. To confirmproper placement and orientation of the implant, use the3.0 mm retrotorsion bar and the goniometer to recheck theretrotorsion. Lightly tap on the head impactor with the hammer until the implant is fully seated.

The position must correspond to the predeterminedanatomic prosthetic height. If the implant’s position is toohigh, more bone rasping along the medial cortex is required.If the implant finds its stable position in a location that is toodistal, use a shaft one size larger. Alternatively, the smallershaft can be stabilized in the correct position using bonecement.

Note: The implant must protrude as defined in steps 4 and 7.

Fill the collar region with autogenous bone graft harvestedfrom the retrieved head to improve healing betweentuberosities and shaft.




13Pass wire-cables through stem/tuberosities

With the humeral head still in the anteriorly dislocated posi-tion, pass the wire-cables that were initially placed in step 3through the greater tuberosity / rotator cuff junction throughthe medial and lateral perforations of the stem.

10 mm

14Reduce the joint

Reduce the joint i.e. the prosthetic head to the glenoid andto the greater tuberosity. Pass the wire-cable through thelesser tuberosity.

Important: After passing the wire-cable through thetuberosities and stem, cut the wire portion of the wire-cableoff at the 10 mm intermediate section only.


Reduce the lesser tuberosity to the prosthesis. Use sutures toreadapt the split in the rotator cuff to obtain preliminary re-duction of the tuberosities. Avoid over-reduction of thegreater tuberosity, especially in a distal direction. The mostmedial insertion line of the supraspinatus must be flush withthe edge of the prosthetic head, not distal to it. Fill any voidunder the tuberosities with cancellous bone graft harvestedfrom the retrieved head. Use absorbable sutures for prelimi-nary reduction and adaptation of the relevant fragments.

Embrace and compress the tuberosities to the rectangularcross section of the shaft to obtain rotational stability.

Pass the end of the distal cable through the crimp and repeatthe step with the proximal cable.


15Apply wire tightener and crimping pliers

Instruments

E5014-04 Crimping Pliers

E5014-05 Wire Tightener for Cerclage

Tension the cables manually but do not tighten them toomuch. Hold the distal cable and apply the wire tightener.

Open the cable tightening nut and pass the cable. Tightenthe nut so that the cable is fix. Before fully tightening, applythe crimping pliers over the crimp.

Note: Do not tighten the cable too much before applyingthe crimping pliers. Once the cable is fully tightened, apply-ing the crimping pliers will be difficult.


16Tighten and crimp cables

Instruments



Fully tighten the cable with the wire tightener. Crimp the cable using the pliers.

Repeat this step for the proximal cable.

Note: To prevent deformation of the tuberosities, be sure tonot over-tension the cables. When using embracing cables,additional devascularizing vertical sutures between shaft andtuberosities are not necessary. The use of embracing cablesrequires a tenotomy and tenodesis of the biceps tendon.



17Cut the cable ends

Instrument

E5014-06 Cutting Pliers for Cerclage

Using the cutting pliers, cut the ends of the cable while hold-ing the cable.

Repeat this step for the proximal cable.


A glenoid component may be indicated in cases where thereis associated cartilage damage to the glenoid or where thereare irreparable glenoid fractures in which gleno-humeral sta-bility is a concern.

Note: The size of the glenoid implant is determined by thesize of the humeral head component.

Implantation of a GlenoidComponent

1Approach and exposure

Adequate exposure of the glenoid is essential for implanta-tion. Exposure must permit the use of straight instrumentssuch as reamers and drill bits. In fractures, exposure of theglenoid generally follows the space between the tuberosities.

Introduce a tear-drop ring retractor (or another instrumentsuch as a Fukuda Ring Retractor) to displace the greatertuberosity in a posterior and inferior direction.

Remove any remnants of the cartilage.


Implantation of a Glenoid Component


2Locate center point

Locate the true center of the glenoid, which is slightly infe-rior to the midpoint of Saller’s line (vertical line dividing theglenoid into anterior and posterior halves). This is the slip-page point of the humeral head during concentric motion.

3Ream glenoid

Instruments

292.260 Kirschner Wire B 2.5 mm, length 280 mm

03.401.085 Guide Extension Epoca, rigid, with Quick Coupling

E5211-4L Drill Guide, left

E5211-4R Drill Guide, right

03.401.128 Reamer Epoca B 28 mm, for Glenoid, with Quick Coupling


The shape of the drill guide matches the shape of the gle-noid implant. Determine the desired anatomic position of theglenoid implant by placing the drill guide (left or right) onthe glenoid. The central hole of the drill guide should coverthe center point located in step 2. Hold the drill guide in thecorrected position. Introduce the 2.5 mm Kirschner wire andre-check the positioning.




Assemble the smallest reamer (28 mm) onto the rigid guideextension.

Note: Ensure the reamer and the rigid guide extension arecoaxially aligned during assembly. Check that the reamer isproperly attached to the rigid guide extension.

Couple the assembly to power equipment. If there is suffi-cient exposure, place the reamer assembly over the Kirschnerwire, position the reamer firmly against the glenoid, andream.

If there is not enough exposure to be able to slide the reamerover the Kirschner wire, remove the Kirschner wire. Placethe reamer assembly on the glenoid, then reintroduce theKirschner wire through the assembly into the previouslydrilled central hole, and ream.

OptionalAlternatively, free-hand reaming is possible without the useof guide wires. The reamer produces a uniformly concavesurface, which is independent of the size of the glenoid.

Ream clockwise at high speed with steady light pressure.Windows in the reamer allow for visualization of the glenoidand the extent of reaming. During the reaming process, cor-rect the retro- or anteversion while preserving as much densesubchondral bone as possible.

Warnings:– Too much axial pressure on the reamer while reaming

weak or osteopenic bone may lead to overreaming.– While retracting the reamer, ensure that it does not detach

from the rigid guide extension.

Notes:– The reamer B 28 mm can be used for glenoids for head

B 40/42, 44 and 46. For larger glenoid sizes (48 and big-ger) continue reaming with the reamer B 32 mm to gainsuperior and inferior extension of the prepared surface.

– The drop shape of the drop-shaped ring retractors (avail-able in the General Shoulder Instruments Set 01.401.039)facilitate glenoid reaming by creating sufficient and com-fortable working space for the reamer.

– To facilitate cleaning of the reamers, place them in waterimmediately following usage.

4Prepare for trial glenoid

Instruments

292.260 Kirschner Wire B 2.5 mm, length 280 mm

E5211-4L Drill Guide, left

E5211-4R Drill Guide, right

E5211-6K Drill Bit B 7.4 mm, length 150 mm, for Glenoid and Shell Screw

E5211-6L Drill Bit B 7.4 mm, length 200 mm, for Glenoid and Shell Screw

If the Kirschner wire has been removed, reinsert it. Reintro-duce the drill guide (left or right) over the Kirschner wire. Rotate the drill guide until anatomic alignment is obtained.

Note: Use the insertion point of the biceps tendon as alandmark to determine the alignment of the longitudinal axisof the glenoid. It is recommended to position the inferiorhole slightly posterior and the superior hole slightly anteriorto Saller’s Line. Bone stock is typically better in this location.

Using the shorter (150 mm) drill bit, drill the distal hole first.The depth of the drill hole depends on the planned implanttype.


19 mm *

21 mm *

21 mm *



4aCemented all-poly glenoid

For cemented all-poly glenoid, drill to a depth of 19 mm.

4cPressfit metalback glenoid

For pressfit metalback glenoid, drill to a depth of 21 mm.

4bHybrid glenoid with shell screws

For shell screw 10 mm, drill to a depth of 21 mm.For shell screw 15 mm, drill to a depth of 26 mm.For shell screw 20 mm, drill to a depth of 31 mm.

The smallest (10 mm) shell screw is the standard implant.Longer versions are typically used when bone defects such ascomminuted anterior glenoid rim fractures require bridging.

Remove the Jacobs chuck but leave the drill bit in situ to sta-bilize the drill guide while drilling the second hole. Preparethe proximal hole using the long drill bit (200 mm). Removethe drill bits, Kirschner wire and drill guide.

*mm depth includes the height of the drill guide

5Introduce trial glenoid

Instruments

E5211-8E Holding Forceps for Trial Glenoid

E5213-42– Trial Glenoids, size 42 to 54E5213-54

Select the trial glenoid that matches the sizeof the humeral head.

Trial Glenoids

Head size 40 42 44 46 48 50 52 54

Trial size 40/42 40/42 44/46 44 /46 48/50 48/50 52/54 52/54

Art. No. E5213–42 E5213–42 E5213–46 E5213–46 E5213–50 E5213–50 E5213–54 E5213–54




Use the trial glenoid holding forceps to insert the trial gle-noid. Check the fit of the trial implant and ensure that therear surface of the trial fits firmly to the reamed surface ofthe glenoid. If not, additional reaming of the glenoid is re-quired. Alternatively, gaps may be filled with autogenousbone graft.

In case of a comminuted anterior glenoid rim fracture, theglenoid implant is stabilized by 15 or 20 mm shell screwswhile the fracture fragment can be reduced and fixed with asimple osteosuture.

Note: A simple suture loop to readapt the radial labral tearoccurring at the 2 o’clock position is often sufficient.

6Implant glenoid component

Instruments


E5211-8 Holding Forceps for Glenoid

F017-4.5 Screwdriver, hexagonal, width across 4.5 mm

F017-2.5 Screwdriver, hexagonal, width across 2.5 mm

E5211-10 Glenoid Impactor

E5221-1 Metalback Impactor

E5221-2 Drill Sleeve 2.5 (22)

E5221-3 Drill Bit B 2.5 mm

03.401.081 Tap for Epoca Shell Screws, length 200 mm

03.401.082 Insertion Guide for Epoca Shell Screws

03.019.005 Handle with Quick Coupling, length 150 mm

Ensure that the plastic impactor liner is mounted on theglenoid impactor.

Option A. Cemented all-poly glenoidClean and dry the drilled cavities. Consider using a suctiondevice introduced through the base of the coracoid processto evacuate undesired fluids. Introduce a small amount ofbone cement (methylmethacrylate) into the two drilled cavi-ties (0.15 ml in each cavity) using a 1 ml syringe.

Note: Avoid overflow of the cement onto the faceplate ofthe glenoid as this will lead to a thin and brittle cement layer.Consult the manufacturer’s instructions for proper bone ce-ment usage.




Mount the glenoid implant on the special holding forcepsand introduce the implant in the correct orientation (the nar-row part facing up). Introduce the glenoid implant and seat itinto its final position with light hammer taps on the glenoidimpactor.

Option B. Hybrid glenoid (with shell screws)Position the insertion guide for the shell screws over theguide wire.

Optional (in cases of dense or sclerotic bone)Align the insertion guide with the pre-drilled holes and man-ually tap using the tap for Epoca Shell Screws.

Note: The color coding on the tap corresponds to the shellscrew lengths (10 mm = green, 15 mm = blue, 20 mm = yel-low).


Insert the previously selected shell screws (see step 5) withthe long, 4.5 mm, hexagonal screwdriver.

The shell screw should be slightly below the surface of thebone.

Note: The shell screws can be inserted with or without theuse of the insertion guide for Epoca Shell Screws.



Place the glenoid implant in position using the glenoid hold-ing forceps. Set the glenoid implant into place using thehammer and glenoid impactor.

Introduce a small amount of bone cement (0.13 ml methyl-methacrylate) into each shell screw using a 1 ml syringe.

Note: Avoid overflow of the cement onto the faceplate ofthe glenoid, as this will lead to a thin and brittle cementlayer. Consult the manufacturer’s instructions for bone ce-ment usage.

Option C. Pressfit metalback glenoidPlace the metalback glenoid implant in position using themetalback impactor. Lightly tap the glenoid implant intoplace using the hammer and glenoid impactor.

Note: The metalback glenoid can be fixed with 3.5 mm cor-tex screws at the bottom of the pegs for additional stability.

OptionalAdditional screw fixation depends upon surgeons’ intraoper-ative judgment and preference. For this purpose, a specialaiming drill guide is available. Introduce the cylindrical drillguide in the cylindrical metal-back peg and drill with a2.5 mm drill bit. Measure the screw length and introduce astandard 3.5 mm cortical screw.




Place the glenoid implant in position using the glenoid hold-ing forceps. Set the glenoid implant into place using thehammer and glenoid impactor.

7Complete implantation of humeral component

Remove the humeral retractors and expose the proximalhumerus. Complete implantation of a standard humeralcomponent.

E5115-5/1 Press Epoca

519.970 Oil Dispenser with Synthes Special Oil, 50 ml

Note: The Epoca Press requires autoclavable oil prior to use.To ensure proper performance, oil the following locationsand repeat as necessary until a noticeable smooth actuationof the screw mechanism is achieved.

Failure to apply oil prior to use may cause undesired performance and lack of calibrated force upon the implantassembly.

Note: The autoclavable oil is purchased separately.

For best results turn the press with torque wrench clockwiseand counterclockwise until smoother movement is noticed.

Care and Maintenance





Humeral Stem, uncemented– Titanium alloy (TAV) with Ti+HA coating– Also for Nickel sensitive Patients

Art. No. Size (mm) Length (mm)

5528-6/11 6 115

5528-8/12 8 120

5528-10/12 10 125

5528-12/13 12 130

5528-14/13 14 135

Implants(all Implants are sterile packed)

Humeral Stem, cemented– Stainless Steel

Art. No. Size (mm) Length (mm)

5614-6/11 6 115

5614-8/12 8 120

5614-10/12 10 125

5614-12/13 12 130

5614-14/13 14 135

Titanium Eccenter– Titanium alloy (TAV)

Art. No. Usage

5413-20/5 Standard

Head– Stainless Steel

Art. No. B (mm) Height (mm)

5311–40/15 40 15.00

5311–42/15 42 15.75

5311–44/16 44 16.50

5311–46/17 46 17.25

5311–48/18 48 18.00

5311–50/18 50 18.75

5311–52/19 52 19.50

5311–54/20 54 20.25

5311–56/21 56 21.00 optional

5311–58/22 58 21.75 optional

Glenoid– UHMW polyethylene– Can be used as stand alone component or in combination

with Shell Screws or Metalback component

Art. No. For Head B (mm)

5213–42 40 and 42

5213–44 44

5213–46 46

5213–48 48

5213–50 50

5213–52 52

5213–54 54

5213–56 56 optional

5213–58 58 optional


Implants


Shell Screws for hybrid Glenoid – Titanium alloy (TAV)– For use with Polyethylene Glenoid component

Art. No. Length (mm) Glenoid

5114-9/10 10 5213-42 to 5213-58

5114-9/15 15 5213-42 to 5213-58

5114-9/20 20 5213-42 to 5213-58

Metalback component for cementless Glenoid – Titanium alloy (TAV)– For use with Polyethylene Glenoid

Art. No. Size Glenoid

5118-42 40 + 42 5213-42

5118-46 44 + 46 5213-44 / 5213-46

5118-50 48 + 50 5213-48 / 5213-50

5118-54 52 + 54 5213-52 / 5213-54

Cortex Screw B 3.5 mm– Optional for use with Metalback Glenoid

Art. No. Length (mm)

404.010S 10

404.012S 12

404.014S 14

404.016S 16

404.018S 18

404.020S 20

404.022S 22

404.024S 24

404.026S 26

404.028S 28

404.030S 30

Tubercable– Stainless Steel– For Tubercula Refixation in Trauma surgery

Art. No. B (mm)

9014-6/50 1.0


Wire-cable

02.401.000S Wire-Cable B 1.0 mm, with Crimp


Head for Allergy Patients– Stainless Steel, with TiNb coating

Art. No. B (mm) Height (mm)

5321–40/15 40 15.00

5321–42/15 42 15.75

5321–44/16 44 16.50

5321–46/17 46 17.25

5321–48/18 48 18.00

5321–50/18 50 18.75

5321–52/19 52 19.50

5321–54/20 54 20.25

5321–56/21 56 21.00 optional

5321–58/22 58 21.75 optional

Special Implants(all Implants are sterile packed)

Stem for Allergy Patients, sterile– See Humeral Stem, uncemented (Titanium alloy TAV)– Art. No. 5528-6/11 to 5528-14/13

Instruments


E5112-1 Starter Rasp Epoca, size 6

E5115-1 Retrotorsion Bar Epoca B 6.0 mm

E5115-2 Goniometer Epoca


01.401.110 Epoca Humerus: Stem instruments

68.401.112 Modular Tray for Humeral Stem Epoca, Trial Instruments, size 1/1, without Contents, Vario Case System

68.401.113 Modular Tray for Humeral Stem Epoca, Rasp Instruments, size 1/1, without Contents, Vario Case System

Note: The instrument set 01.401.110 also contains theempty additional modular tray 68.401.111.

E5112-6 Rasp Epoca, size 6





E5115-3 Slotted Hammer/Extractor Epoca

E5113-6 Trial Stem Epoca, size 6





E5115-6 Retrotorsion Bar Epoca B 3.0 mm

E5115-4/2 Screwdriver Epoca, width across 2.0 mm, for Trial Implants

E5115-4/3 Screwdriver Epoca, width across 2.5 mm, for Trial Implants

Instruments


E5117-20 Trial Eccenter Disc Epoca

E5114-40 Trial Head Epoca, size 40



E5114-46 Trial Head Epoca, size 46E5114-48 Trial Head Epoca, size 48




E5114-56 Trial Head Epoca, size 56 (optional)

E5114-58 Trial Head Epoca, size 58 (optional)

E5115-8/38 Humeral Cover Epoca B 38 mm, for Trial Stem



E5115-7 Impactor Epoca


03.401.083 Ruler, length 250 mm, Stainless Steel(optional)

03.401.084 Curette, oval, with Toothing, length 300 mm (optional)

E5115-5/4 Torque Wrench Epoca, for Press

E5115-5/1 Press Epoca

E5115-5/6 Holder Epoca for size 6, for Press





E5115-5/3 Eccenter/Impactor Epoca


Instruments

01.401.120 Epoca Humerus: Press instruments

68.401.032 Vario Case for Epoca Humerus Press Instruments

E5211-4L Drill Guide Epoca, left

E5211-4R Drill Guide Epoca, right

292.260 Kirschner Wire B 2.5 mm with trocar tip, length 280 mm, Stainless Steel

03.401.085 Guide Extension Epoca, rigid, with Quick Coupling


01.401.130 Instruments Epoca Glenoid

68.401.131 Modular Tray for Epoca Glenoid, Insertion Instruments, size 1/1, without Contents, Vario Case System

68.401.132 Modular Tray for Epoca Glenoid, Preparation Instruments, size 1/1, without Contents, Vario Case System

E5211-6L Drill Bit Epoca B 7.4 mm, length 200 mm,for Glenoid and Shell Screw

E5211-6K Drill Bit Epoca B 7.4 mm, length 150 mm,for Glenoid and Shell Screw

E5211-8E Holding Forceps Epoca for Trial Glenoid


Instruments

03.401.128 Reamer Epoca B 28 mm, for Glenoid,with Quick Coupling

03.401.132 Reamer Epoca B 32 mm, for Glenoid,with Quick Coupling

03.401.081 Tap for Epoca Shell Screws, length 200 mm

03.401.082 Insertion Guide for Epoca Shell Screws

03.019.005 Handle with Quick Coupling, length 150 mm

E5213-42 Trial Glenoid Epoca, size 42




F017-4.5 Screwdriver Epoca, hexagonal, width across 4.5 mm

E5221-1 Metalback Impactor Epoca


E5211-8 Holding Forceps Epoca for Glenoid

E5211-10 Glenoid Impactor Epoca


Instruments

E5221-2 Drill Sleeve Epoca 2.5 (22)

E5221-3 Drill Bit Epoca B 2.5 mm

F017-2.5 Screwdriver, hexagonal, Epoca, width across 2.5 mm

338.080 DHS/DCS T-Handle with Quick Coupling(optional)


Additional instruments

03.401.086 Adapter for Quick Coupling to EpocaReamer Thread

Spare parts

E5114-1 Spare Screws for Trial Head Epoca

E5115-7P Impactor Head Epoca

E5211-10P Synthetic Headpiece for Impactor for Glenoid

E5211-3 Wrench Epoca, width across 10


E5014-06 Cutting Pliers for Cerclage

Cerclage Instruments



Instruments

Notes:– Ordering information for the General Shoulder Instruments

Sets can be found in the brochure 036.000.823.– Ordering information for the Epoca Revision Instruments

can be found in the technique guide 036.001.070.

Stanley Hoppenfeld and Piet deBoer, Surgical Exposures inOrthopaedics–The Anatomic Approach, Third Edition, 2003,pp. 2–8.

Hertel R, Knothe U, Ballmer FT. Geometry of the proximalhumerus and implications for prosthetic design. J ShoulderElbow Surg. 2002;11(4):331-8.

Hempfing A, Leunig M, Ballmer FT, Hertel R. Surgical land-marks to determine humeral head retrotorsion for hemi-arthroplasty in fractures. J Shoulder Elbow Surg.2001;10(5):460-3.

Bibliography


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Synthes GmbHEimattstrasse 3CH-4436 Oberdorfwww.depuysynthes.com

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Synthes GmbHEimattstrasse 3CH-4436 Oberdorfwww.depuysynthes.com

This publication is not intended for distribution in the USA.

All surgical techniques are available as PDF files atwww.synthes.com/lit

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